Associations between periodontitis and serum anti-malondialdehyde-acetaldehyde antibody concentrations in rheumatoid arthritis: A case-control study

BACKGROUND

Malondialdehyde-acetaldehyde (MAA) adducts lead to generation of anti-MAA autoantibodies and have been independently identified in inflamed periodontal and rheumatoid arthritis (RA) tissues. This study evaluates serum samples from RA cases and osteoarthritis (OA) controls to quantify associations between periodontal clinical measures, alveolar bone loss (ABL), and anti-Porphyromonas gingivalis, anti-Prevotella intermedia, and anti-Fusobacterium nucleatum antibody concentrations with anti-MAA antibody concentrations.

METHODS

Participants (n = 284 RA cases, n = 330 OA controls) underwent periodontal clinical assessments and ABL measurements. Serum immunoglobulin (Ig) A, IgG, and IgM anti-MAA and serum IgG antibacterial antibody concentrations were quantified by enzyme-linked immunosorbent assay (ELISA). Analyses utilized simple linear regression and multivariable adjusted models.

RESULTS

No significant associations of periodontal clinical measures with serum anti-MAA were found. Moderate (p = 0.038 and p = 0.036, respectively) and high ABL (p = 0.012 and p = 0.014, respectively) in RA cases (but not in OA) were positively associated with IgG and IgM anti-MAA. Anti-P. gingivalis and anti-P. intermedia antibody concentrations were positively associated with IgA (p = 0.001 for both), IgG (p = 0.007 and p = 0.034, respectively), and IgM anti-MAA antibody concentrations (p < 0.001 and p = 0.020, respectively), while anti-F. nucleatum was positively associated with IgG anti-MAA (p = 0.042), findings that were similar across groups.

CONCLUSIONS

A positive association was demonstrated between ABL and serum IgG and IgM anti-MAA antibody concentrations that was unique to RA and not observed in OA. Serum anti-P. gingivalis, anti-P. intermedia, and anti-F. nucleatum antibody concentrations displayed significant associations with anti-MAA antibody in both groups. These findings suggest MAA may play a role in the interrelationship between the periodontium and RA.

Evaluation of a Human Trafficking Educational Intervention for Nursing Professionals

BACKGROUND

Human trafficking (HT) is a serious public health issue. Survivors of HT seek medical care. Health care professionals may be inadequately trained to identify and support survivors. This study evaluated improvements in nurses' knowledge after a professional development workshop on HT.

METHOD

Pre- and postevaluation surveys assessed nurses' self-reported changes in perceived knowledge of HT and its vulnerability factors, the health impact of HT, strategies for identification and assessment of HT, and response to and follow-up of HT.

RESULTS

After the workshop, participants showed significant improvement in perceived knowledge of all measures, regardless of hours of previous training and years of practice.

CONCLUSION

Perceived knowledge of HT identification and response can be improved through training of nurses, regardless of hours of previous training and years of practice. [J Contin Educ Nurs. 2024;55(1):26-32.].

Serum antibodies to periodontal pathogens prior to rheumatoid arthritis diagnosis: A case-control study

OBJECTIVES

1) To quantify the association between anti-Porphyromonas gingivalis serum antibody concentrations and the risk of developing rheumatoid arthritis (RA), and 2) to quantify the associations among RA cases between anti-P. gingivalis serum antibody concentrations and RA-specific autoantibodies. Additional anti-bacterial antibodies evaluated included anti-Fusobacterium nucleatum and anti-Prevotella intermedia.

METHODS

Serum samples were acquired pre- and post- RA diagnosis from the U.S. Department of Defense Serum Repository (n = 214 cases, 210 matched controls). Using separate mixed-models, the timing of elevations of anti-P. gingivalis, anti-P. intermedia, and anti-F. nucleatum antibody concentrations relative to RA diagnosis were compared in RA cases versus controls. Associations were determined between serum anti-CCP2, ACPA fine specificities (vimentin, histone, and alpha-enolase), and IgA, IgG, and IgM RF in pre-RA diagnosis samples and anti-bacterial antibodies using mixed-effects linear regression models.

RESULTS

No compelling evidence of case-control divergence in serum anti-P. gingivalis, anti-F. nucleatum, and anti-P. intermedia was observed. Among RA cases, including all pre-diagnosis serum samples, anti-P. intermedia was significantly positively associated with anti-CCP2, ACPA fine specificities targeting vimentin, histone, alpha-enolase, and IgA RF (p<0.001), IgG RF (p = 0.049), and IgM RF (p = 0.004), while anti-P. gingivalis and anti-F. nucleatum were not.

CONCLUSIONS

No longitudinal elevations of anti-bacterial serum antibody concentrations were observed in RA patients prior to RA diagnosis compared to controls. However, anti-P. intermedia displayed significant associations with RA autoantibody concentrations prior to RA diagnosis, suggesting a potential role of this organism in progression towards clinically-detectable RA.

EUS-guided versus percutaneous liver biopsy: A comprehensive review and meta-analysis of outcomes

EUS-guided liver biopsy (EUS-LB) has gained momentum in recent years, especially with availability of newer needle designs. Given the emerging comparative data on EUS-LB with second-generation needles and percutaneous LB (PC-LB), we conducted a systematic review and meta-analysis to compare the safety and efficacy of the two techniques. We searched multiple databases from inception through November 2021 to identify studies comparing outcomes of EUS-LB and PC-LB. Pooled estimates were calculated using a random-effects model, and the results were expressed in terms of pooled proportions and odds ratio (OR) along with relevant 95% confidence intervals (CIs). Five studies with 748 patients were included in the final analysis. EUS-LB was performed in 276 patients and PC-LB in 472 patients. Across all studies, PC-LB had an overall higher diagnostic accuracy than EUS-LB, 98.6% confidence interval (CI: 94.7-99.7) versus 88.3% (49.6-98.3), OR: 1.65, P = 0.04. On assessing data from randomized controlled trials, there was no difference between the two. While pooled diagnostic adequacy and overall adverse events were not significantly different between PC-LB and EUS-LB, the former was superior in terms of the mean number of complete portal tracts (CPT) and total specimen length. PC-LB and EUS-LB produce similar results. PC-LB allows obtaining longer samples and more CPT. Further studies are needed to see if these trends hold up as more providers begin to perform EUS-LB.

2067. Missed Opportunities for Confirmatory HIV Testing at a Midwestern Medical Center

Background

The currently recommended HIV testing algorithm begins with a 4th generation antigen/antibody (Ag/Ab) combination immunoassay, which allows for early detection of HIV. However, this assay’s high sensitivity can result in false positives that must be distinguished from acute infections via an HIV nucleic acid test (NAT). At our medical center, HIV NATs are recommended in the lab report for anyone with a positive p24Ag component on the screening assay, but they are not done reflexively by the lab as it requires a different blood tube. Thus, difficulties arise in obtaining the NAT, such as providers failing to order the test or patients failing to return for another blood draw, jeopardizing the diagnosis of early HIV.

Methods

We conducted a retrospective chart review of adult patients at a Midwest academic medical center with a positive p24Ag on the HIV-1/2 Ag/Ab combination assay between Jan. 1, 2017 and Feb. 21, 2021. We assessed if appropriate confirmatory testing was performed, identified barriers to missed opportunities for confirmatory testing, and used t-tests and Fisher’s exact tests to evaluate differences between those who did and did not receive confirmatory testing.

Results

Of 37 people with a positive p24Ag on the HIV Ag/Ab immunoassay, 6 (17%) did not have an HIV NAT performed within 30 days of their positive screening test. Of these 6 cases, the ordering provider did not acknowledge the need for a confirmatory test in 3 cases, the patient did not return for the test in 1 case, and other factors prevented follow-up in 2 cases. Of those who had an HIV NAT ordered, 7 (23%) had a positive HIV NAT. Younger age was significantly associated with completion of appropriate confirmatory testing (p=0.05), but other factors including sex, race, insurance status, having a primary care provider, specialty of ordering provider, encounter location, and test indication were not.

Conclusion

Our review identified multiple missed opportunities for confirmatory HIV testing following a positive p24Ag component on the HIV screening test. Provider lack of knowledge/awareness of the need for appropriate testing was the most common barrier. A quality improvement initiative will be undertaken to minimize future risk of missed opportunities for confirmatory testing.

Disclosures

Paul D. Fey, PhD, BioFire: Advisor/Consultant|BioFire: Grant/Research Support|Merck: Grant/Research Support Sara H. Bares, MD, Gilead Sciences: Expert Testimony|GSK ViiV Healthcare: Grant/Research Support|Janssen: Grant/Research Support.

1962. Perceptions of the COVID-19 Vaccine within the Sudanese-American Community

Background

One of the primary issues affecting COVID-19 vaccine uptake in high-income countries is vaccine hesitancy, which is prevalent in people from different countries of origin. Characterizing vaccine uptake in immigrant and refugee populations in the US could provide a unique window into both local and global health behaviors. The goal of this project is to characterize Sudanese American perspectives on the COVID-19 vaccine.

Methods

We conducted an anonymous, online, anonymous, cross-sectional survey directed toward Sudanese Americans, with survey development guided by principles from the Vaccine Examination Scale. The survey was distributed in both English and Arabic and included questions about vaccination history, motives for getting the vaccination, reasons for vaccine hesitancy, and barriers to vaccination. Fisher’s exact tests were used to analyze evaluate possible associations between vaccine uptake and sources of information on the vaccine and social media use, respectively. Data analysis was conducted using STATA SE v17.0 (StataCorp, College Station, TX).

Results

A total of 108 survey responses were received; 4 were excluded for failing to meet inclusion criteria. A total of 92% received at least one dose of COVID-19 vaccine, with the primary motivation being to protect oneself (62%). Only 8 had not been vaccinated and, of those, 2 were willing to take the vaccine. Of the 6 unwilling to take the vaccine, the most cited reason was a belief that it had not been studied enough. Of the 14 possible hesitancy responses, 9 were selected at least once.

When asked about their primary source of information on COVID-19, 44% used government websites, followed by mass media (22%), social media (12%) and health personnel (11%). Using Fisher’s exact tests, no statistically significant conclusions were drawn between vaccine uptake and primary source of information (P = .097) or specific types of social media.

Conclusion

Vaccine uptake among our survey population (92%) was much higher than that of the US (77%) or Sudanese population (11%). Overall motivators for vaccine hesitancy and vaccine uptake varied and no specific correlations were found to be associated to vaccine uptake. Future research should evaluate high levels of vaccine uptake in this community.

Disclosures

All Authors: No reported disclosures.

Liver resection after Y-90 radioembolization: a systematic review and meta-analysis of perioperative morbidity and mortality

BACKGROUND

Data on morbidity and mortality following liver resection after radioembolization (Y90) are limited and controversial. Therefore, the perioperative morbidity and mortality of liver resections after Y90 treatment were investigated with systematic review and meta-analysis.

METHODS

A PubMed search was conducted to identify studies of liver resection after previous Y90 treatment. Systematic review and meta-analysis for perioperative morbidity and mortality were perfomed using the 2009 PRISMA guidelines and STATA 16.1 software.

RESULTS

A total of 16 studies reporting on 276 patients who underwent liver resection after Y90 met the inclusion criteria and were included in the meta-analysis. Meta-analysis of 30-day mortality rates yielded pooled mortality of 0.5% (95% CI 0.0-3.2%). Six studies (155 patients) reported a pooled 90-day mortality of 3.0% (95% CI 0.3-7.4%). The median time to resection after Y90 ranged from 2 to 12.5 months in various studies. In all studies where the median resection was undertaken eight or more months after Y90, zero 30-day mortality was reported. A meta-analysis of overall grade 3 or higher morbidity noted a rate of 26% (95% CI 16-37%).

CONCLUSIONS

Liver resection after Y90 may be safe in very well selected patients. Delaying resection after Y90 may further decrease mortality.

Investigating changes in disease activity as a mediator of cardiovascular risk reduction with methotrexate use in rheumatoid arthritis

OBJECTIVE

Examine the association of methotrexate (MTX) use with cardiovascular disease (CVD) in rheumatoid arthritis (RA) using marginal structural models (MSM) and determine if CVD risk is mediated through modification of disease activity.

METHODS

We identified incident CVD events (coronary artery disease (CAD), stroke, heart failure (HF) hospitalisation, CVD death) within a multicentre, prospective cohort of US Veterans with RA. A 28-joint Disease Activity Score with C-reactive protein (DAS28-CRP) was collected at regular visits and medication exposures were determined by linking to pharmacy dispensing data. MSMs were used to estimate the treatment effect of MTX on risk of incident CVD, accounting for time-varying confounders between receiving MTX and CVD events. A mediation analysis was performed to estimate the indirect effects of methotrexate on CVD risk through modification of RA disease activity.

RESULTS

Among 2044 RA patients (90% male, mean age 63.9 years, baseline DAS28-CRP 3.6), there were 378 incident CVD events. Using MSM, MTX use was associated with a 24% reduced risk of composite CVD events (HR 0.76, 95% CI 0.58 to 0.99) including a 57% reduction in HF hospitalisations (HR 0.43, 95% CI 0.24 to 0.77). Individual associations with CAD, stroke and CVD death were not statistically significant. In mediation analyses, there was no evidence of indirect effects of MTX on CVD risk through disease activity modification (HR 1.03, 95% CI 0.80 to 1.32).

CONCLUSIONS

MTX use in RA was associated with a reduced risk of CVD events, particularly HF-related hospitalisations. These associations were not mediated through reductions in RA disease activity, suggesting alternative MTX-related mechanisms may modify CVD risk in this population.

Performance of a commercially available multiplex platform in the assessment of circulating cytokines and chemokines in patients with rheumatoid arthritis and osteoarthritis

BACKGROUND/OBJECTIVE

Cytokines and chemokines (cytokines) are central to rheumatoid arthritis (RA) pathogenesis, with increasing use of multiplex immunoassays in clinical/research settings. Rheumatoid factor (RF) may interfere with assay outcomes by nonspecifically binding detection analytes. We evaluated the performance of a commercially available multiplex platform, including assessment of the impact of RF depletion.

METHODS

Forty-five cytokines were tested using Meso Scale Discovery V-PLEX™ and samples from 40 RA and 40 osteoarthritis (OA) patients. Select samples were depleted of RF using a commercial binder. Performance was assessed using intra-assay coefficients of variation (CV), intraclass correlation coefficients (ICC), percent change following RF depletion, and disease discrimination. Values above or below quantification thresholds were imputed.

RESULTS

Of the 45 cytokines analyzed, 31 yielded CVs <10%; none demonstrated CVs >30%. ICCs universally exceeded 0.85 with the exception of eight analytes. RF depletion altered cytokine values by <15% for 40 analytes with larger changes (>30%) only seen for one analyte. Twenty-three cytokines differed significantly based on measurement in plasma vs. serum. Three analytes were higher in the serum of RA vs. OA (IL-10, IP-10, TNFα), and none were significantly greater in OA vs. RA. Seventeen analytes required imputation for >50% of the samples tested, primarily related to concentrations below the lower limit of quantification threshold.

CONCLUSION

The results from this commercially available multiplex assay were generally highly reproducible and interference induced by RF only meaningfully impacted the quantification of five of the analytes examined.

942. Lung Cancer Screening in at-risk patients with HIV in a Midwestern Clinic

Background

Patients with HIV (PWH) have an increased risk of lung cancer compared to the general population. In 2013, the U.S. Preventive Services Task Force (USPSTF) released their lung cancer screening (LCS) guidelines for the general population. The objective of this study is to evaluate the frequency of and factors associated with LCS using computed tomography in at-risk PWH.

Methods

A retrospective chart review of patients 55-80 years old seen at a Midwestern HIV Clinic between July 1, 2016 to June 30, 2018 was conducted. Demographic, clinical, laboratory, and referral for LCS information were collected. Descriptive statistics and logistic regression models were used for analysis.

Results

We reviewed 347 patients, out of whom 91 were excluded for the following reasons: never smoked (8), deceased (38), pack history unknown (39), and prior lung cancer diagnosis (6). Mean (sd, range) for age was 61 (5.0, 55-78). A total of 256 patients were included in the analysis, out of whom 104 (41%) met the USPSTF criteria. No effect was identified for demographic information including race, ethnicity, gender, or insurance status on LCS referral. LCS referral was made for 22 out of 256 patients (9%) (13% of patients who met the USPSTF criteria and 5% of those who did not). Patients who received tobacco cessation counseling (OR 7.83, P=0.047) and with hepatitis C infection (OR 4.32, P=0.002) were more likely to receive LCS referral. Out of those who received LCS referral, 12/22 (55%) completed the referral. Patients with hepatitis C infection were more likely to complete LCS referral (OR 8, P=0.038).

Conclusion

Only 13% of patients who met USPSTF criteria were referred for LCS. Patients who received tobacco cessation counseling were more likely to receive a referral. Patients with hepatitis C infection were more likely to receive and complete LCS referral. Quality improvement efforts to improve rates of LCS in PWH are needed. Future prospective studies should examine the factors associated with LCS in PWH.

Disclosures

Sara H. Bares, MD, Gilead Sciences (Grant/Research Support)

Applying SLICC and ACR/EULAR systemic lupus erythematosus classification criteria in a cohort of patients with undifferentiated connective tissue disease

BACKGROUND/OBJECTIVE

New classification criteria for SLE have recently been developed. How these criteria affect the classification of patients with the SLE-mimicking condition UCTD is poorly understood. This study investigated the reclassification of UCTD patients using newly derived SLE criteria.

METHODS

Patients with UCTD were identified within a single academic medical center using ICD9/10 codes. Medical record review was performed to confirm UCTD diagnosis and identify disease features present at diagnosis. The SLICC and ACR/EULAR criteria were applied, after which we compared the proportion of patients reclassified as SLE and determined which disease features were associated with reclassification.

RESULTS

A total of 129 patients were included in the study. When applying the SLICC and ACR/EULAR criteria, 18 (14.0%) and 26 patients (20.2%) were reclassified as SLE. Comparison with McNemar's test trended toward statistical significance (p = 0.057). Cohen's kappa coefficient was 0.62 (p < 0.001), indicating substantial agreement between these criteria. Disease features associated with reclassification as SLE were renal involvement, leukopenia, thrombocytopenia, anti- dsDNA antibody, hypocomplementemia, non-scarring alopecia (SLICC), and arthritis (ACR/EULAR).

CONCLUSIONS

Both the SLICC and ACR/EULAR criteria exhibit increased SLE classification. These newer classification criteria could be used to increase the number of SLE patients in future clinical studies.

Incidental Findings on Brain MRI in People with HIV Infection

BACKGROUND

Incidental findings are a well-known complication of imaging studies done for both diagnostic and research purposes. Little is known about the rates and types of incidental findings found on brain MRI in patients with HIV infection, who may be at risk for HIV-Associated Neurocognitive Disorders (HAND).

METHODS

The parent study included 108 adults with HIV infection and 125 demographically-matched uninfected controls who completed MRI and neuropsychological testing. Incidental findings were classified by the study team as vascular, neoplastic, congenital, other neurologic, or non-neurologic. Categorical measures were compared using Pearson chi-square tests; continuous measures were compared using t-tests.

RESULTS

Among participants with HIV infection, 36/108 (33%) had incidental findings compared to 33/125 (26%) controls (p = 0.248). Rates of incidental findings were significantly correlated with increasing age in both participants with HIV infection (p = 0.013) and controls (p = 0.022). We found no correlation between presence of incidental findings and sex or race/ethnicity among either cohort, and no correlation with CD4 count or HAND status for the HIV-infected cohort.

CONCLUSIONS

Incidental findings were common in both participants with HIV infection and controls, at higher rates than previously reported in healthy populations. There was no significant difference in prevalence between the groups.

Step width variability as a discriminator of age-related gait changes

BACKGROUND

There is scientific evidence that older adults aged 65 and over walk with increased step width variability which has been associated with risk of falling. However, there are presently no threshold levels that define the optimal reference range of step width variability. Thus, the purpose of our study was to estimate the optimal reference range for identifying older adults with normative and excessive step width variability.

METHODS

We searched systematically the BMC, Cochrane Library, EBSCO, Frontiers, IEEE, PubMed, Scopus, SpringerLink, Web of Science, Wiley, and PROQUEST databases until September 2018, and included the studies that measured step width variability in both younger and older adults during walking at self-selected speed. Data were pooled in meta-analysis, and standardized mean differences (SMD) with 95% confidence intervals (CI) were calculated. A single-decision threshold method based on the Youden index, and a two-decision threshold method based on the uncertain interval method were used to identify the optimal threshold levels (PROSPERO registration: CRD42018107079).

RESULTS

Ten studies were retrieved (older adults = 304; younger adults = 219). Step width variability was higher in older than in younger adults (SMD = 1.15, 95% CI = 0.60; 1.70; t = 4.72, p = 0.001). The single-decision method set the threshold level for excessive step width variability at 2.14 cm. For the two-decision method, step width variability values above the upper threshold level of 2.50 cm were considered excessive, while step width variability values below the lower threshold level of 1.97 cm were considered within the optimal reference range.

CONCLUSION

Step width variability is higher in older adults than in younger adults, with step width variability values above the upper threshold level of 2.50 cm to be considered as excessive. This information could potentially impact rehabilitation technology design for devices targeting lateral stability during walking.

1256. Contemporary Evaluation of Racial/Ethnic Disparities in Survival and Disease Progression among People with HIV in the US Midwest

Background

Combating HIV-related disparities is a major goal of the 2020 National HIV/AIDS Strategy. However, research on HIV disparities has primarily been conducted in urban settings. A 1997–2007 study of people with HIV (PWH) at our clinic noted significantly increased mortality among high-risk non-Hispanic (NH) Black PWH (73%) compared with NH Whites (88%). This study evaluated demographic disparities in survival and disease progression in a large Midwest clinical cohort.

Methods

We retrospectively reviewed records of 1,396 PWH receiving treatment at an HIV Clinic in Omaha, Nebraska from 2012 through 2017. We included patients over 19 years old with diagnosed HIV, a minimum of two visits, and no lapse in care >2 years. Patients were stratified into low-risk (CD4 >100 cells/mm³ and HIV viral load <250,000 copies/mL) and high-risk (all others) groups. Cox proportional hazard models and Kaplan–Meier curves with log-rank tests compared patient demographics and mortality. Generalized estimating equations modeled change in CD4 count over time.

Results

No significant difference in mortality was noted across race/ethnicity categories (P = 0.286). Several clinical and demographic characteristics, including CD4 counts <500 cells/mm³, were significantly associated with increased mortality (Figure 1). Compared with NH Whites, mean CD4 counts (Figure 2) were significantly lower for NH Blacks (P = 0.001), Hispanics (P = 0.006), and Others (P = 0.013). High-risk status was associated with mortality (P < 0.001), but no significant differences in mortality were noted across race/ethnicity categories after stratifying for patient risk status (Figures 3 and 4).

Conclusion

Significant racial/ethnic disparities in HIV disease progression among PWH at a Midwest HIV Clinic persist. However, in contrast to the 1997–2007 study, disparities in survival were not observed among high-risk PWH. As our patient demographics are essentially the same, the reduction of this disparity suggests needed investigation of whether these changes are the result of better antiretroviral efficacy or if social determinants of health in the region have improved. Systems-level interventions are needed to ensure all PWH benefit from continuing advances in HIV research and care.

Disclosures

All authors: No reported disclosures.

368. Incidental Findings on Brain MRI in People Living with HIV

Background

HIV infection is associated with an array of neurocognitive changes, collectively referred to as HIV-Associated Neurocognitive Disorder (HAND). These changes have been the subject of a great deal of study, often including structural MRI of the brain. Incidental findings (IF) are a well-known complication of imaging studies done for both diagnostic and research indications, and can pose important ethical and clinical dilemmas. Little is known about the rates and types of IF found on brain MRI in patients with HIV infection. We identified and characterized such findings in participants who participated in a study of neurophysiological markers of HAND.

Methods

The parent study included 108 HIV-infected adults and 125 demographically matched uninfected controls without cognitive impairment who had undergone T1-weighted structural brain MRI for research purposes. Demographic and diagnostic data were abstracted from the research records. Each MRI study was read by the same neuroradiologist, blind to the participant’s HIV status. IF were classified as vascular, neoplastic, congenital, other neurologic, or non-neurologic. Categorical measures were compared using Pearson chi-square tests while continuous measures were compared using t-tests.

Results

Among HIV-infected participants, 36/108 (33.3%) had IF compared with 33/125 (26.4%) of controls (P = 0.248). Rates of IF were significantly correlated with increased age in both HIV-infected and control participants. We found no correlation among presence or absence of IF and sex, race/ethnicity, or CD4 count and HAND status for the HIV-infected cohort. The most common categories were neurologic (27), followed by non-neurologic (8), vascular (6), and neoplastic (2) (Table 1).

Conclusion

If were common in both HIV-infected participants and controls, at higher rates than previously reported, possibly because of increased sensitivity of MRI machines over time. Surprisingly, we found no significant difference between the groups and no correlation with HAND status or CD4 count. Age was the only factor correlated with rates of IF in either HIV-infected participants or controls. To our knowledge, this study is the first of its kind to characterize incidental findings in HIV-infected patients.

Disclosures

All authors: No reported disclosures.

The Likelihood of Self-reporting Balance Problems in Those With Advanced Chronic Kidney Disease, Slow Gait Speed, or Low Vitamin D

OBJECTIVE

The purpose of this study was to determine the prevalence of vitamin D (25(OH)D) and balance deficits in persons with chronic kidney disease (CKD) and the likelihood of self-reporting balance and falling problems, measured gait speed in persons with kidney disease, and low levels of vitamin D and albumin.

DESIGN

Analysis of the National Health and Nutrition Examination Survey 1999-2004 data set.

SUBJECTS

The study included 8,554 subjects aged >40 years who were categorized into CKD stages based on the glomerular filtration rate (normal kidney function and stages 1 and 2 served as the control group, and stages 3 and 4/5 served as the CKD groups).

MAIN OUTCOME MEASURES

Measured 25(OH)D levels, timed 20-feet walk, Romberg standing balance task, and self-reported balance and falling issues.

RESULTS

The prevalence of balance deficits was found to be high in this CKD sample, with fail rates increasing with kidney disease severity. Similarly, when examining the relationship between CKD stage and the measurement of balance, fail rates (impaired balance) increased and gait speed decreased with kidney disease severity. In addition, the likelihood of self-reporting a balance and falling problem in the past year was higher in persons who had advanced CKD, were of older age, were of female sex, were with former or current smoking status, had lower 25(OH)D levels, and had lower albumin levels. Similarly, the likelihood of having a 20-feet walk time of more than 8 seconds was associated with those who were older, had higher body mass index, and had lower levels of 25(OH)D and albumin.

CONCLUSION

The unique finding of this study is that increased reporting of balance and falling issues (both perceived and measured) and slower gait were found in persons with increased CKD severity and lower 25(OH)D status.

Midwest pharmacists' familiarity, experience, and willingness to provide pre-exposure prophylaxis (PrEP) for HIV

Introduction

Pharmacist provision of pre-exposure prophylaxis (PrEP) through collaborative practice agreements with physicians could expand access to people at risk for HIV. We characterized pharmacists’ familiarity with and willingness to provide PrEP services in Nebraska and Iowa.

Methods

An invitation to complete an 18-question survey was emailed to 1,140 pharmacists in Nebraska and Iowa in June and July of 2016. Descriptive analyses and Pearson chi-square tests were used to determine to what extent demographics, familiarity and experience were associated with respondent willingness to provide PrEP. Wilcoxon rank-sum tests compared ages and years of experience between groups of respondents.

Results

One hundred forty pharmacists (12.3%) responded. Less than half were familiar with the use of PrEP (42%) or the CDC guidelines for its use (25%). Respondents who were older (p = .015) and in practice longer (p = .005) were less likely to be familiar with PrEP. Overall, 54% indicated they were fairly or very likely to provide PrEP services as part of a collaborative practice agreement and after additional training. While familiarity with PrEP use or guidelines did not affect respondents’ willingness to provide PrEP, respondents were more likely to provide PrEP with prior experience counseling HIV-infected patients on antiretroviral therapy (OR 2.43; p = 0.023) or PrEP (OR 4.67; p = 0.013), and with prior HIV-related continuing education (OR 2.77; p = 0.032).

Conclusions

Pharmacist respondents in Nebraska and Iowa had limited familiarity and experience with PrEP, but most indicated willingness to provide PrEP through collaborative practice agreements after additional training. Provision of PrEP-focused continuing education may lead to increased willingness to participate in PrEP programs.

A pharmacist-led medication switch protocol in an academic HIV clinic: patient knowledge and satisfaction

Background

Tenofovir alafenamide (TAF) is associated with less renal and bone toxicity compared with tenofovir disoproxil (TDF). TAF's recent FDA approval has spurred HIV providers to consider switching antiretroviral therapy (ART) regimens containing TDF to TAF to minimize long term risks. Patient views on the process of such medication switches have not been explored.

Methods

Patients taking elvitegravir/cobicistat/emtricitabine/tenofovir disoproxil fumarate (E/C/F/TDF) following the Food and Drug Administration’s (FDA) approval of elvitegravir/cobicistat/emtricitabine/tenofovir alafenamide (E/C/F/TAF) received medication education from an HIV pharmacist prior to switching to the tenofovir alafenamide (TAF) formulation. Patients were asked to complete a cross-sectional survey assessing satisfaction with the switch process and knowledge about the new medication 4 to 8 weeks post-switch.

Results

Sixty five patients completed the switch and 57 (88%) completed a follow-up survey. Most (86%) reported understanding why the switch was made, while 91% correctly identified that TAF is associated with reduced renal toxicity, and 73% correctly identified that TAF is associated with reduced bone toxicity. No statistically significant difference was found in satisfaction with or understanding of why the medication switch was made when assessed by sex, age, race, or education, but there was a trend toward significance in the distribution of answers based on education level with those with a high school diploma, General Educational Development (GED) or less being more likely to be satisfied with the medication switch (p = 0.074).

Conclusions

Education from an ambulatory clinic-based HIV pharmacist resulted in high rates of patient satisfaction and understanding of the switch from TDF to TAF-containing ART.

Electronic supplementary material

The online version of this article (10.1186/s12879-018-3226-2) contains supplementary material, which is available to authorized users.

Association of Distinct Fine Specificities of Anti-Citrullinated Peptide Antibodies With Elevated Immune Responses to Prevotella intermedia in a Subgroup of Patients With Rheumatoid Arthritis and Periodontitis

Objective

In addition to the long‐established link with smoking, periodontitis (PD) is a risk factor for rheumatoid arthritis (RA). This study was undertaken to elucidate the mechanism by which PD could induce antibodies to citrullinated peptides (ACPAs), by examining the antibody response to a novel citrullinated peptide of cytokeratin 13 (CK‐13) identified in gingival crevicular fluid (GCF), and comparing the response to 4 other citrullinated peptides in patients with RA who were well‐characterized for PD and smoking.

Methods

The citrullinomes of GCF and periodontal tissue from patients with PD were mapped by mass spectrometry. ACPAs of CK13 (cCK13), tenascin‐C (cTNC5), vimentin (cVIM), α‐enolase (CEP‐1), and fibrinogen β (cFIBβ) were examined by enzyme‐linked immunosorbent assay in patients with RA (n = 287) and patients with osteoarthritis (n = 330), and cross‐reactivity was assessed by inhibition assays.

Results

A novel citrullinated peptide cCK13‐1 (₄₄₄TSNASGR‐Cit‐TSDV‐Cit‐RP₄₅₈) identified in GCF exhibited elevated antibody responses in RA patients (24%). Anti–cCK13‐1 antibody levels correlated with anti–cTNC5 antibody levels, and absorption experiments confirmed this was not due to cross‐reactivity. Only anti–cCK13‐1 and anti‐cTNC5 were associated with antibodies to the periodontal pathogen Prevotella intermedia (P = 0.05 and P = 0.001, respectively), but not with antibodies to Porphyromonas gingivalis arginine gingipains. Levels of antibodies to CEP‐1, cFIBβ, and cVIM correlated with each other, and with smoking and shared epitope risk factors in RA.

Conclusion

This study identifies 2 groups of ACPA fine specificities associated with different RA risk factors. One is predominantly linked to smoking and shared epitope, and the other links anti–cTNC5 and cCK13‐1 to infection with the periodontal pathogen P intermedia.

Enrichment of malondialdehyde-acetaldehyde antibody in the rheumatoid arthritis joint

Objective

To characterize the expression of malondialdehdye-acetaldehyde (MAA) adducts and anti-MAA antibody in articular tissues and serum of patients with RA.

Methods

Paired sera and SF were examined from 29 RA and 13 OA patients. Anti-MAA antibody, RF, ACPA and total immunoglobulin were quantified. SF-serum measures were compared within and between disease groups. The presence and co-localization of MAA, citrulline and select leukocyte antigens in RA and OA synovial tissues were examined using immunohistochemistry.

Results

Circulating and SF anti-MAA antibody concentrations were higher in RA vs OA by 1.5- to 5-fold. IgG (P < 0.001), IgM (P = 0.006) and IgA (P = 0.036) anti-MAA antibodies were higher in paired RA SF than serum, differences not observed for total immunoglobulin, RF or ACPA. In RA synovial tissues, co-localization of MAA with citrulline and CD19+ or CD27+ B cells was demonstrated and was much higher in magnitude than MAA or citrulline co-localization with T cells, monocytes, macrophages or dendritic cells (P < 0.01).

Conclusion

Anti-MAA antibodies are present in higher concentrations in the RA joint compared with sera, a finding not observed for other disease-related autoantibodies. Co-localization of MAA and citrulline with mature B cells, coupled with the local enrichment of anti-MAA immune responses, implicates MAA-adduct formation in local autoantibody production.

Salivary and serum procalcitonin and C-reactive protein as biomarkers of periodontitis in United States veterans with osteoarthritis or rheumatoid arthritis

Serum procalcitonin (ProCT) is elevated in response to bacterial infections, whereas high sensitivity C-reactive protein (hsCRP) is a nonspecific inflammatory marker that is increased by excess adipose tissue. We examined the efficacy of ProCT and hsCRP as biomarkers of periodontitis in the saliva and serum of patients with arthritis, which is characterized by variable levels of systemic inflammation that potentially can confound the interpretation of inflammatory biomarkers. Blood and unstimulated whole saliva were collected from 33 patients with rheumatoid arthritis (RA) and 50 with osteoarthritis (OA). Periodontal status was assessed by full mouth examination and patients were categorized as having no/mild, moderate or severe periodontitis by standard parameters. Salivary and serum ProCT and hsCRP concentrations were compared. BMI, diabetes, anti-inflammatory medications and smoking status were ascertained from the patient records. Differences between OA and RA in proportionate numbers of patients were compared for race, gender, diabetes, adiposity and smoking status. Serum ProCT was significantly higher in arthritis patients with moderate to severe and severe periodontitis compared with no/mild periodontitis patients. There were no significant differences in salivary ProCT or salivary or serum hsCRP in RA patients related to periodontitis category. Most of the OA and RA patients were middle aged or older, 28.9% were diabetic, 78.3% were overweight or obese, and slightly more than half were either current or past smokers. The OA and RA groups differed by race, but not gender; blacks and males were predominant in both groups. The OA and RA groups did not differ in terms of controlled or uncontrolled diabetes, smoking status or BMI. The RA patients had been prescribed more anti-inflammatory medication than the OA patients. Our results demonstrate that circulating ProCT is a more discriminative biomarker for periodontitis than serum hsCRP in patients with underlying arthritis. Any elevation in salivary and serum hsCRP due to periodontitis apparently was overshadowed by differences among these patients in factors that influence CRP, such as the extent of inflammation between RA and OA, the extent of adipose tissue, the use of anti- inflammatory medications and smoking status. Although our study showed no differences in salivary ProCT related to severity of periodontitis, this biomarker also may be useful with further refinement.

Performance of self-reported measures for periodontitis in rheumatoid arthritis and osteoarthritis

BACKGROUND

This study evaluates the performance of self-report against the reference standard of clinically defined periodontitis in patients with rheumatoid arthritis (RA) and osteoarthritis (OA) after accounting for factors associated with periodontitis.

METHODS

Six self-report periodontitis questions were evaluated in patients with RA and OA. Questions were validated against a reference standard of severe and moderate-to-severe periodontitis based on full-mouth examination. Multivariable logistic regression was used to evaluate the performance of: 1) self-report alone; 2) age, sex, education, and smoking status; and 3) a combination of the above. Model performance was assessed using the c-statistic. Convergent validity of self-reported "bone loss/deep pockets" and "loose teeth" was assessed; associations of self-report with RA disease characteristics were explored.

RESULTS

Self-report performed similarly in RA and OA, with individual question specificity for periodontitis ≥ 68% and sensitivity from 9.8% to 45%. Question-only models yielded c-statistics of 0.66 to 0.72, whereas risk factor-only models yielded c-statistics of 0.74 to 0.79. The highest-performing models incorporated both self-report questions and periodontitis risk factors, with c-statistics ≥ 0.79. Greater radiographic alveolar bone loss was observed among participants reporting "bone loss/deep pockets" (P < 0.001) and "loose teeth" (P < 0.001). Among patients with RA, "loose teeth," but not other self-report items, was associated with rheumatoid factor positivity (P = 0.047) and higher disease activity (P < 0.001).

CONCLUSIONS

Patient self-report, when combined with other risk factors, performs well in identifying periodontitis among patients with RA and OA. Self-report questions related to alveolar bone loss exhibit excellent convergent validity in these patient subsets.

Identification of an immunodominant peptide from citrullinated tenascin-C as a major target for autoantibodies in rheumatoid arthritis

Objectives

We investigated whether citrullinated tenascin-C (cTNC), an extracellular matrix protein expressed at high levels in the joints of patients with rheumatoid arthritis (RA), is a target for the autoantibodies in RA.

Methods

Citrullinated sites were mapped by mass spectrometry in the fibrinogen-like globe (FBG) domain of tenascin-C treated with peptidylarginine deiminases (PAD) 2 and 4. Antibodies to cyclic peptides containing citrullinated sites were screened in sera from patients with RA by ELISA. Potential cross-reactivity with well-established anticitrullinated protein antibody (ACPA) epitopes was tested by inhibition assays. The autoantibody response to one immunodominant cTNC peptide was then analysed in 101 pre-RA sera (median 7 years before onset) and two large independent RA cohorts.

Results

Nine arginine residues within FBG were citrullinated by PAD2 and PAD4. Two immunodominant peptides cTNC1 (VFLRRKNG-cit-ENFYQNW) and cTNC5 (EHSIQFAEMKL-cit-PSNF-cit-NLEG-cit-cit-KR) were identified. Antibodies to both showed limited cross-reactivity with ACPA epitopes from α-enolase, vimentin and fibrinogen, and no reactivity with citrullinated fibrinogen peptides sharing sequence homology with FBG. cTNC5 antibodies were detected in 18% of pre-RA sera, and in 47% of 1985 Swedish patients with RA and 51% of 287 North American patients with RA. The specificity was 98% compared with 160 healthy controls and 330 patients with osteoarthritis.

Conclusions

There are multiple citrullination sites in the FBG domain of tenascin-C. Among these, one epitope is recognised by autoantibodies that are detected years before disease onset, and which may serve as a useful biomarker to identify ACPA-positive patients with high sensitivity and specificity in established disease.

Does how much a resident teaches impact performance? A comparison of preclinical teaching hours to pathology residents' in-service examination scores

BACKGROUND

While others have studied the effects of resident teaching on medical student performance, few have examined the benefits to the resident educator. Our study compared the quantity of pathology residents' didactic teaching with their performance on in-service examinations.

METHODS

The academic records of anatomic/clinical pathology residents over 10 years were reviewed. Scores on step I of the United States Medical Licensing Examination (USMLE(®)), the annual percentile on the in-service examination, and preclinical teaching hours for each resident were obtained.

RESULTS

Average annual teaching hours showed a weak positive correlation with mean in-service examination performance. Those below the 50th percentile had a lower number of teaching hours (average 7.8) than above the 50th percentile (mean 10.4, P=0.01). The incremental positive association between the two metrics increased by year in training and was strongest among senior residents, even controlling for USMLE performance (P<0.01).

CONCLUSION

There is an association between the amount of pathology residents' preclinical educational activity and their mean performance on in-service examinations.

Gout-related health care utilization in US emergency departments, 2006 through 2008

OBJECTIVE

To characterize gout-related emergency department (ED) utilization using a nationally representative sample and to examine factors associated with the frequency and charges of gout-related ED visits.

METHODS

Using the National Emergency Department Sample data from 2006-2008, the weighted national frequency of gout visits was calculated along with the median ED charge and total national ED-related charges. Associations of several patient- and facility-level factors were examined with the occurrence of gout visits using multivariable logistic regression and with ED-related charges using multivariable linear regression.

RESULTS

Gout was the primary indication for 168,410 ED visits in 2006, 171,743 visits in 2007, and 174,823 visits in 2008, accounting for ∼0.2% of all visits annually and generating ED charges of more than $128 million in 2006, $144 million in 2007, and $166 million in 2008. Age, male sex, household income <$39,000, private insurance, and hospital locations in nonmetropolitan areas and the southern US were associated with an increased propensity for ED utilization in gout. Higher ED-related charges for gout were associated with female sex, age, a higher number of coded diagnoses, and a metropolitan residence.

CONCLUSION

Gout accounts for a substantial proportion of ED visits, leading to significant health care charges. Effective strategies to reduce gout burden in EDs could potentially benefit by targeting groups characterized by factors demonstrated to be related to a higher ED utilization in gout as identified by our study.

Long-acting parenteral nanoformulated antiretroviral therapy: interest and attitudes of HIV-infected patients

AIM

To gauge patient interest in receiving long-acting injectable nanoformulated antiretroviral therapy.

METHODS

Four hundred adult HIV-infected patients currently prescribed antiretroviral therapy were surveyed. χ(2) tests were used for comparisons of interest across groups.

RESULTS

Respondents were 68% male and 53% African-American, with a mean age of 47 years. Overall, 73% of patients indicated that they would definitely or probably try injectable nanoformulated antiretroviral therapy; 61% with weekly dosing; 72% every 2 weekly; and 84% monthly. In total, 48% indicated that they were very concerned about the possible side effects and 35% were very concerned about needle use.

CONCLUSION

The majority of respondents indicated that they definitely or probably would try parenteral nanoformulated antiretroviral therapy.

Prospective study of posttraumatic stress disorder and disease activity outcomes in US veterans with rheumatoid arthritis

OBJECTIVE

To examine the relationship between posttraumatic stress disorder (PTSD) and disease activity in US veterans with rheumatoid arthritis (RA).

METHODS

US veterans with RA were enrolled in a longitudinal observational study and were categorized as having PTSD, other anxiety/depression disorders, or neither of these psychiatric diagnoses using administrative codes. Generalized linear mixed-effects models were used to examine the associations of the diagnostic groups with outcomes measured over a mean followup period of 3.0 years.

RESULTS

At enrollment, 1,522 patients had a mean age of 63 years, they were primarily men (91%), and a majority (78%) reported white race. A diagnosis of PTSD was observed in 178 patients (11.7%), and other anxiety/depression diagnoses (excluding PTSD) were found in 360 patients (23.7%). The presence of a PTSD diagnosis was independently associated with higher values of self-reported pain, physical impairment, tender joint count, and worse patient global well-being scores compared to patients with no psychiatric diagnosis. There were no significant group differences in swollen joint count, erythrocyte sedimentation rate, or Disease Activity Score in 28 joints. There were no differences between any outcomes comparing those with PTSD and those with other anxiety/depression diagnoses.

CONCLUSION

In this RA cohort, the diagnosis of PTSD was associated with worse patient-reported outcomes and tender joint counts, but not with other physician- or laboratory-based measures of disease activity. These results suggest that PTSD, along with other anxiety/depression disorders, may affect RA disease activity assessments that rely on patient-reported outcomes and the resulting treatment decisions.

Serum cotinine as a biomarker of tobacco exposure and the association with treatment response in early rheumatoid arthritis

OBJECTIVE

Cigarette smoking has emerged as a risk factor for the development of rheumatoid arthritis (RA). Recent studies have suggested that cigarette smoking may lead to lower treatment response rates with methotrexate (MTX) and some biologic agents in RA. Knowledge of whether tobacco exposure reduces treatment efficacy is important, since smoking could represent a modifiable factor in optimizing RA treatment.

METHODS

The study participants included patients with early RA (<3 years in duration) enrolled in the Treatment of Early Aggressive Rheumatoid Arthritis study, a randomized, blinded, placebo-controlled clinical trial comparing early intensive therapy (MTX + etanercept or MTX + hydroxychloroquine + sulfasalazine triple therapy) versus initial treatment with MTX with step-up to MTX + etanercept or to triple therapy if the disease was still active at 24 weeks. Serum cotinine was measured using a commercially available enzyme-linked immunosorbent assay at baseline and at 48 weeks, with detectable concentrations at both visits serving as an indicator of smoking status. The mean Disease Activity Score in 28 joints (DAS28) was compared by smoking status, adjusting for baseline disease activity.

RESULTS

Of the 412 subjects included in the analysis, 293 (71%) were categorized as nonsmokers and 119 (29%) as current smokers. There were no differences in the mean DAS28 score between 48 and 102 weeks based on smoking status for the overall group (P = 0.881) or by specific treatment assignment.

CONCLUSION

Among patients enrolled in a large randomized controlled trial of early RA with poor prognostic factors, smoking status did not impact treatment responses for those receiving early combination or initial MTX with step-up therapy at 24 weeks if the disease was still active.