Use of Recommended Neurodiagnostic Evaluation Among Patients With Drug-Resistant Epilepsy

Importance

Interdisciplinary practice parameters recommend that patients with drug-resistant epilepsy (DRE) undergo comprehensive neurodiagnostic evaluation, including presurgical assessment. Reporting from specialized centers suggests long delays to referral and underuse of surgery; however, longitudinal data are limited to characterize neurodiagnostic evaluation among patients with DRE in more diverse US settings and populations.

Objective

To examine the rate and factors associated with neurodiagnostic studies and comprehensive evaluation among patients with DRE within 3 US cohorts.

Design, Setting, and Participants

A retrospective cross-sectional study was conducted using the Observational Medical Outcomes Partnership Common Data Model including US multistate Medicaid data, commercial claims data, and Columbia University Medical Center (CUMC) electronic health record data. Patients meeting a validated computable phenotype algorithm for DRE between January 1, 2015, and April 1, 2020, were included. No eligible participants were excluded.

Exposure

Demographic and clinical variables were queried.

Main Outcomes and Measures

The proportion of patients receiving a composite proxy for comprehensive neurodiagnostic evaluation, including (1) magnetic resonance or other advanced brain imaging, (2) video electroencephalography, and (3) neuropsychological evaluation within 2 years of meeting the inclusion criteria.

Results

A total of 33 542 patients with DRE were included in the Medicaid cohort, 22 496 in the commercial insurance cohort, and 2741 in the CUMC database. A total of 31 516 patients (53.6%) were women. The proportion of patients meeting the comprehensive evaluation main outcome in the Medicaid cohort was 4.5% (n = 1520); in the commercial insurance cohort, 8.0% (n = 1796); and in the CUMC cohort, 14.3% (n = 393). Video electroencephalography (24.9% Medicaid, 28.4% commercial, 63.2% CUMC) and magnetic resonance imaging of the brain (35.6% Medicaid, 43.4% commercial, 52.6% CUMC) were performed more regularly than neuropsychological evaluation (13.0% Medicaid, 16.6% commercial, 19.2% CUMC) or advanced imaging (3.2% Medicaid, 5.4% commercial, 13.1% CUMC). Factors independently associated with greater odds of evaluation across all 3 data sets included the number of inpatient and outpatient nonemergency epilepsy visits and focal rather than generalized epilepsy.

Conclusions and Relevance

The findings of this study suggest there is a gap in the use of diagnostic studies to evaluate patients with DRE. Care setting, insurance type, frequency of nonemergency visits, and epilepsy type are all associated with evaluation. A common data model can be used to measure adherence with best practices across a variety of observational data sources.

Clinical outcomes among initial survivors of cryptogenic new-onset refractory status epilepsy (NORSE)

OBJECTIVE

New-onset refractory status epilepticus (NORSE) is a rare but severe clinical syndrome. Despite rigorous evaluation, the underlying cause is unknown in 30%-50% of patients and treatment strategies are largely empirical. The aim of this study was to describe clinical outcomes in a cohort of well-phenotyped, thoroughly investigated patients who survived the initial phase of cryptogenic NORSE managed in specialist centers.

METHODS

Well-characterized cases of cryptogenic NORSE were identified through the EPIGEN and Critical Care EEG Monitoring Research Consortia (CCEMRC) during the period 2005-2019. Treating epileptologists reported on post-NORSE survival rates and sequelae in patients after discharge from hospital. Among survivors >6 months post-discharge, we report the rates and severity of active epilepsy, global disability, vocational, and global cognitive and mental health outcomes. We attempt to identify determinants of outcome.

RESULTS

Among 48 patients who survived the acute phase of NORSE to the point of discharge from hospital, 9 had died at last follow-up, of whom 7 died within 6 months of discharge from the tertiary care center. The remaining 39 patients had high rates of active epilepsy as well as vocational, cognitive, and psychiatric comorbidities. The epilepsy was usually multifocal and typically drug resistant. Only a minority of patients had a good functional outcome. Therapeutic interventions were heterogenous during the acute phase of the illness. There was no clear relationship between the nature of treatment and clinical outcomes.

SIGNIFICANCE

Among survivors of cryptogenic NORSE, longer-term outcomes in most patients were life altering and often catastrophic. Treatment remains empirical and variable. There is a pressing need to understand the etiology of cryptogenic NORSE and to develop tailored treatment strategies.

Low household income increases the risk of tuberculosis recurrence: a retrospective nationwide cohort study in South Korea

OBJECTIVES

We assessed the impact of household income on tuberculosis (TB) recurrence and the long-term impact of TB on household income.

STUDY DESIGN

This was a retrospective nationwide cohort study of patients with drug-susceptible TB (DS-TB) and TB recurrence.

METHODS

Using the South Korean national TB cohort database, we identified a sub-set cohort of patients with newly diagnosed drug-susceptible TB between 2013 and 2016 and tracked their TB recurrence and longitudinal income data from 2007 to 2018. Income levels were evaluated as 'Medical aid' and quintile categories. To assess risk factors associated with TB recurrence, we used a sub-distribution hazard model, adjusting for the competing risks of death.

RESULTS

Of 66,690 patients successfully treated with DS-TB, 2095 (3.1 %) experienced recurrence during a median follow-up of 39 months. The incidence of TB recurrence was 982.1/100,000 person-years, with 50.3 % of the recurrences occurring within 1 year of treatment completion. The risk of TB recurrence increased with decreasing income levels, with the highest risk observed in the lowest income group. The effect of income on TB recurrence was prominent in males but not in females. Overall, patients with TB recurrence experienced a linear decline in income levels, compared with those without recurrence.

CONCLUSIONS

Household income during the initial TB episode was an important risk factor for TB recurrence, particularly in males.

Whole Regional Lymph Node Area Delineation with Deep Learning Model for Total Marrow and Lymphoid Irradiation

PURPOSE/OBJECTIVE(S)

Total body irradiation (TBI) has been performed for conditioning before hematopoietic stem cell transplantation. However, TBI can be related to diverse adverse events including radiation pneumonitis and cataract. Efforts to reduce these events include the total marrow irradiation (TMI) and total marrow and lymphoid irradiation (TMLI). Compared to TMI, TMLI requires more target delineations with lymph nodes which can be labor-intensive and time-consuming. However, with the TMI plans, the coverage to lymph node might be lower than TMLI and its clinical significance is unknown. In the current study, we aimed to develop a deep learning model for automatic delineation of whole regional lymph nodes area and assess the dose coverage of lymph nodes with TMI plans.

MATERIALS/METHODS

Whole regional lymph nodes (cervical, axillary, mediastinal, para-aortic, common iliac, external iliac, internal iliac, obturator, presacral, inguinal lymph nodes) were manually contoured by 3 radiation oncologists in 26 patients having whole body computed tomography (CT) images. Twenty patients were designated as the training/validation set and 6 patients as the testing set, and model was developed using the 'nnUNET' framework. The trained model was evaluated with dice coefficient score (DCS), precision, and recall. In addition, dose coverage of the automatically or manually delineated lymph nodes in TMI plans was calculated.

RESULTS

The mean value of DCS, precision, and recall of the trained model was 0.76, 0.81, and 0.74, respectively. Dose parameters for manually delineated lymph nodes in previously treated TMI plans showed the mean value of V100% (the percentage of volume receiving 100% of the prescribed dose), V95%, and V90% to be 46.50%, 62.12%, and 73.68%, respectively. The highest V90% was observed in presacral (93.61%), axillary (90.40%), obturator (88.78%), and internal iliac lymph nodes (84.67%). In contrast, the lowest V90% was identified in inguinal (47.95%), cervical (61.69%), and para-aortic (65.75%) and external iliac lymph nodes (68.97%). For automatically delineated lymph nodes, the mean value of V100%, V95%, and V90% of TMI plan was 38.35%, 55.06%, and 67.84%, respectively. The difference with dose coverage of lymph node between delineated manually and automatically was not statistically significant.

CONCLUSION

Automatic delineation of lymph node using deep learning showed the potential to reduce the labor-intensive process of TMLI. When treated with TMI, the coverage of inguinal, cervical, para-aortic and external iliac lymph nodes was lower than expected.

Mapping the Anatomical Distribution of MRI-Identified Locoregional Recurrence following Robotic-Assisted Laparoscopic Prostatectomy for Prostate Adenocarcinoma

PURPOSE/OBJECTIVE(S)

The pattern of locoregional recurrence specifically after robotic-assisted laparoscopic prostatectomy (RALP) for prostate adenocarcinoma is still unknown. In this study, we reviewed pelvic magnetic resonance images (MRI) after postoperative biochemical recurrence (BCR) and drew a map of locoregional recurrence to support evidence of determining the optimal target volume of salvage radiotherapy in a post-RALP BCR scenario.

MATERIALS/METHODS

We have retrospectively searched 7,583 prostate adenocarcinoma patients who have received RALP in our institution between January 2010 and December 2021, and found a pool of highly selected patients with gross tumor recurrence confirmed by post-BCR pelvic MRIs and did not have other histories of malignancy. BCR was defined as the serum PSA more or equal to 0.2 ng/mL, or three consecutive increases. Patients with serum PSA nadir more or equal to 0.2 ng/mL on the 90th postoperative day (POD 90) were excluded to guarantee successful tumor removal. We have reviewed serum PSA levels using R codes, MRI and pathological reports using Excel, and descriptive statistics using SPSS 25. The gross lesions were contoured on the correlating MRIs using MIM Maestro 7.1. The RT structure DICOM files were merged into a map using MATLAB 2022b. In addition, we have conducted Fisher exacted test, Mann-Whitney U test, and logistic regression to identify risk factors for regional recurrence.

RESULTS

A total of 173 patients were identified with locoregional recurrence from post-BCR pelvic MRIs, and 139 (80.3%) patients were in the high-risk group or very-high-risk group according to the NCCN guidelines: 57 (32.9%) patients with histological grade group 5, 50 (28.9%) patients with initial PSA over 20 ng/mL, 114 (65.9%) patients with extracapsular extension, 55 (31.8%) patients with seminal vesicle invasion, and 15 (9%) patients with pN1. The median follow-up was 4.7 (IQR 2.8-6.9) years for pelvic MRIs and 5.8 (IQR 4.0-8.6) years for serum PSA. The BCF survival was median of 10.7 (IQR 4.6-19.1) months, and the locoregional recurrence-free survival was median of 24.6 (IQR 9.7-49.4) months for this subgroup of patients. At first locoregional recurrence, 148 (85.5%) patients were local only, 20 (11.6%) patients were regional only, and 5 (2.9%) patients were both local and regional. Out of the 25 patients with regional recurrence, the incidence of gross tumor recurrence differed by nodal sites: 3 (12%) in perirectal space, 5 (20%) in internal iliac, 7 (28%) in obturator, 13 (52%) in external iliac, and 6 (24%) in common iliac lymph nodes.

CONCLUSION

We have found 173 patients and were able to map reliable gross tumor recurrence sites after RALP and confirmed by pelvic MRIs following BCR. The map supports evidence of using the existing consensus pelvic clinical target volume of salvage radiotherapy, in a post-RALP BCR scenario.

Management of epilepsy with eyelid myoclonia: Results of an international expert consensus panel

OBJECTIVE

There are limited data about the treatment and management of epilepsy with eyelid myoclonia (EEM). The objective of this study was to determine areas of consensus among an international panel of experts for the management of EEM (formerly known as Jeavons syndrome).

METHODS

An international steering committee was convened of physicians and patients/caregivers with expertise in EEM. This committee summarized the current literature and identified an international panel of experts (comprising 25 physicians and five patients/caregivers). This panel participated in a modified Delphi process, including three rounds of surveys to determine areas of consensus for the treatment, other areas of management, and prognosis for EEM.

RESULTS

There was a strong consensus for valproic acid as the first-line treatment, with levetiracetam or lamotrigine as preferable alternatives for women of childbearing age. There was a moderate consensus that ethosuximide and clobazam are also efficacious. There was a strong consensus to avoid sodium channel-blocking medications, except for lamotrigine, as they may worsen seizure control. There was consensus that seizures typically persist into adulthood, with remission occurring in <50% of patients. There was less agreement about other areas of management, including dietary therapy, lens therapy, candidacy for driving, and outcome.

SIGNIFICANCE

This international expert panel identified multiple areas of consensus regarding the optimal management of EEM. These areas of consensus may inform clinical practice to improve the management of EEM. In addition, multiple areas with less agreement were identified, which highlight topics for further research.

Knowledge and beliefs about epilepsy genetics among Hispanic and non-Hispanic patients

OBJECTIVE

Hispanics continue to face challenges when trying to access health care, including epilepsy care and genetic-related health care services. This study examined epilepsy genetic knowledge and beliefs in this historically underserved population.

METHODS

Questionnaires were completed by 641 adults with epilepsy without identified cause, of whom 122 self-identified as Hispanic or Latino and 519 as non-Hispanic. Participants were asked about their views on the contribution of genetics to the cause of their epilepsy ("genetic attribution"), optimism for advancements in epilepsy genetic research ("genetic optimism"), basic genetic knowledge, and epilepsy-specific genetic knowledge. Generalized linear models were used to compare the two groups in the means of quantitative measures and percents answered correctly for individual genetic knowledge items. Analyses were adjusted for age, sex, education, religion, family history of epilepsy, and time since last seizure.

RESULTS

Hispanics did not differ from non-Hispanics in genetic attribution, genetic optimism, or number of six basic genetic knowledge items answered correctly. The number of nine epilepsy-specific genetic knowledge items answered correctly was significantly lower for Hispanics than non-Hispanics (adjusted mean = 6.0 vs. 6.7, p < .001). After adjustment for education and other potential mediators, the proportion answered correctly was significantly lower for Hispanics than non-Hispanics for only two items related to family history and penetrance of epilepsy-related genes. Only 54% of Hispanics and 61% of non-Hispanics answered correctly that "If a person has epilepsy, his or her relatives have an increased chance of getting epilepsy."

SIGNIFICANCE

Despite large differences in sociodemographic variables including education, most attitudes and beliefs about genetics were similar in Hispanics and non-Hispanics. Epilepsy-specific genetic knowledge was lower among Hispanics than non-Hispanics, and this difference was mostly mediated by differences in demographic variables. Genetic counseling should address key concepts related to epilepsy genetics to ensure they are well understood by both Hispanic and non-Hispanic patients.

Clinical presentation and evaluation of epilepsy with eyelid myoclonia: Results of an international expert consensus panel

OBJECTIVE

The objective of this study was to determine areas of consensus among an international panel of experts for the clinical presentation and diagnosis of epilepsy with eyelid myoclonia (EEM; formerly known as Jeavons syndrome) to improve a timely diagnosis.

METHODS

An international steering committee was convened of physicians and patients/caregivers with expertise in EEM. This committee summarized the current literature and identified an international panel of experts (comprising 25 physicians and five patients/caregivers). This international expert panel participated in a modified Delphi process, including three rounds of surveys to determine areas of consensus for the diagnosis of EEM.

RESULTS

There was a strong consensus that EEM is a female predominant generalized epilepsy syndrome with onset between 3 and 12 years of age and that eyelid myoclonia must be present to make the diagnosis. There was a strong consensus that eyelid myoclonia may go unrecognized for years prior to an epilepsy diagnosis. There was consensus that generalized tonic-clonic and absence seizures are typically or occasionally seen in patients. There was a consensus that atonic or focal seizures should lead to the consideration of reclassification or alternate diagnoses. There was a strong consensus that electroencephalography is required, whereas magnetic resonance imaging is not required for diagnosis. There was a strong consensus to perform genetic testing (either epilepsy gene panel or whole exome sequencing) when one or a combination of factors was present: family history of epilepsy, intellectual disability, or drug-resistant epilepsy.

SIGNIFICANCE

This international expert panel identified multiple areas of consensus regarding the presentation and evaluation of EEM. These areas of consensus may be used to inform clinical practice to shorten the time to the appropriate diagnosis.

Association of antiseizure medication adherence with illness perceptions in adults with epilepsy

OBJECTIVE

We assessed the relationship of epilepsy illness perceptions to antiseizure medication (ASM) adherence.

METHODS

Surveys were completed by 644 adult patients with epilepsy of unknown cause. We used the Morisky Medication Adherence Scale-8 (MMAS-8) to define "high" adherence (score = 8) and "low-medium" adherence (score < 8). We evaluated epilepsy illness perceptions using seven items from the Brief Illness Perception Questionnaire (BIPQ), each scored from 0-10, measuring participants' views of the overall effect of epilepsy on their lives, how long it would last, how much control they had over their epilepsy, the effectiveness of their treatment, level of concern about epilepsy, level of understanding of epilepsy, and emotional impact of epilepsy. We investigated the association of each BIPQ item with medication adherence using logistic regression models that controlled for potential confounders (age, race/ethnicity, income, and time since the last seizure).

RESULTS

One hundred forty-nine patients (23%) gave responses indicating high adherence. In the adjusted models, for each 1-unit increase in participants' BIPQ item scores, the odds of high adherence increased by 17% for understanding of their epilepsy (OR = 1.17, 95% CI 1.07-1.27, p < 0.001), decreased by 11% for overall life impact of epilepsy (OR = 0.89, 95% CI 0.82-0.97, p = 0.01) and decreased by 6% for emotional impact of epilepsy (OR = 0.94, 95% CI 0.86-0.99, p = 0.03). No other illness perception was associated with high adherence. Depression, anxiety, and stigma mediated the inverse relationships of high adherence to the overall life impact of epilepsy and the emotional impact of epilepsy. These measures did not mediate the relationship of high adherence to the perceived understanding of epilepsy.

CONCLUSION

These results indicate that a greater perceived understanding of epilepsy is independently associated with high ASM adherence. Programs aimed at improving patients' understanding of their epilepsy may help improve medication adherence.

A comprehensive narrative review of epilepsy with eyelid myoclonia

Epilepsy with eyelid myoclonia (EEM) is a generalized epilepsy syndrome with childhood-onset and 2:1 female predominance that consists of: 1. eyelid myoclonia with or without absence seizures, 2. eye closure induced seizures or EEG paroxysms, 3. clinical or EEG photosensitivity. While eyelid myoclonia is the disease hallmark, other seizure types, including absence seizures and generalized tonic-clonic seizures, may be present. It is thought to have a genetic etiology, and around one-third of patients may have a positive family history of epilepsy. Recently, specific genetic mutations have been recognized in a minority patients, including in SYNGAP1, NEXMIF, RORB, and CHD2 genes. There are no randomized controlled trials in EEM, and the management literature is largely restricted to small retrospective studies. Broad-spectrum antiseizure medications such as valproate, levetiracetam, lamotrigine, and benzodiazepines are typically used. Seizures typically persist into adulthood, and drug-resistant epilepsy is reported in over 50%.

Rare Genetic Variation and Outcome of Surgery for Mesial Temporal Lobe Epilepsy

OBJECTIVE

Genetic factors have long been debated as a cause of failure of surgery for mesial temporal lobe epilepsy (MTLE). We investigated whether rare genetic variation influences seizure outcomes of MTLE surgery.

METHODS

We performed an international, multicenter, whole exome sequencing study of patients who underwent surgery for drug-resistant, unilateral MTLE with normal magnetic resonance imaging (MRI) or MRI evidence of hippocampal sclerosis and ≥2-year postsurgical follow-up. Patients with either sustained seizure freedom (favorable outcome) or ongoing uncontrolled seizures since surgery (unfavorable outcome) were included. Exomes of controls without epilepsy were also included. Gene set burden analyses were carried out to identify genes with significant enrichment of rare deleterious variants in patients compared to controls.

RESULTS

Nine centers from 3 continents contributed 206 patients operated for drug-resistant unilateral MTLE, of whom 196 (149 with favorable outcome and 47 with unfavorable outcome) were included after stringent quality control. Compared to 8,718 controls, MTLE cases carried a higher burden of ultrarare missense variants in constrained genes that are intolerant to loss-of-function (LoF) variants (odds ratio [OR] = 2.6, 95% confidence interval [CI] = 1.9-3.5, p = 1.3E-09) and in genes encoding voltage-gated cation channels (OR = 2.4, 95% CI = 1.4-3.8, p = 2.7E-04). Proportions of subjects with such variants were comparable between patients with favorable outcome and those with unfavorable outcome, with no significant between-group differences.

INTERPRETATION

Rare variation contributes to the genetic architecture of MTLE, but does not appear to have a major role in failure of MTLE surgery. These findings can be incorporated into presurgical decision-making and counseling. ANN NEUROL 2022.

Differences in elective epilepsy monitoring unit admission rates by race/ethnicity and primary payer in New Jersey

Elective admission to the epilepsy monitoring unit (EMU) is an essential service provided by epilepsy centers, particularly for those with drug-resistant epilepsy. Given previously characterized racial and socioeconomic healthcare disparities in the management of epilepsy, we sought to understand access and utilization of this service in New Jersey (NJ). We examined epilepsy hospitalizations in NJ between 2014 and 2016 using state inpatient and emergency department (ED) databases. We stratified admissions by race/ethnicity and primary payer and used these to estimate and compare (1) admission rates per capita in NJ, as well as (2) admission rates per number of ED visits for each group. Patients without insurance underwent elective EMU admission at the lowest rates across all racial/ethnic groups and payer types studied. Black patients with Medicaid and private insurance were admitted at disproportionately low rates relative to their number of ED visits. Hispanic/Latino and Asian/Pacific Islanders with private insurance, Hispanic/Latinos with Medicaid, and Asian/Pacific Islanders with Medicare were also admitted at low rates per capita within each respective payer category. Future studies should focus on addressing causal factors driving healthcare disparities in epilepsy, particularly for patients without adequate health insurance coverage and those who have been historically underserved by the healthcare system.

Tracking Multisite Seizure Propagation Using Ictal High-Gamma Activity

PURPOSE

Spatial patterns of long-range seizure propagation in epileptic networks have not been well characterized. Here, we use ictal high-gamma activity (HGA) as a proxy of intense neuronal population firing to map the spatial evolution of seizure recruitment.

METHODS

Ictal HGA (80-150 Hz) was analyzed in 13 patients with 72 seizures recorded by stereotactic depth electrodes, using previously validated methods. Distinct spatial clusters of channels with the ictal high-gamma signature were identified, and seizure hubs were defined as stereotypically recruited nonoverlapping clusters. Clusters correlated with asynchronous seizure terminations to provide supportive evidence for independent seizure activity at these sites. The spatial overlap between seizure hubs and interictal ripples was compared.

RESULTS

Ictal HGA was detected in 71% of seizures and 10% of implanted contacts, enabling tracking of contiguous and noncontiguous seizure recruitment. Multiple seizure hubs were identified in 54% of cases, including 43% of patients thought preoperatively to have unifocal epilepsy. Noncontiguous recruitment was associated with asynchronous seizure termination (odds ratio = 19.7; p = 0.029). Interictal ripples demonstrated greater spatial overlap with ictal HGA in cases with single seizure hubs compared with those with multiple hubs (100% vs. 66% per patient; p = 0.03).

CONCLUSIONS

Ictal HGA may serve as a useful adjunctive biomarker to distinguish contiguous seizure spread from propagation to remote seizure sites. High-gamma sites were found to cluster in stereotyped seizure hubs rather than being broadly distributed. Multiple hubs were common even in cases that were considered unifocal.

Search for Dark Matter Axions with CAST-CAPP

The CAST-CAPP axion haloscope, operating at CERN inside the CAST dipole magnet, has searched for axions in the 19.74 μeV to 22.47 μeV mass range. The detection concept follows the Sikivie haloscope principle, where Dark Matter axions convert into photons within a resonator immersed in a magnetic field. The CAST-CAPP resonator is an array of four individual rectangular cavities inserted in a strong dipole magnet, phase-matched to maximize the detection sensitivity. Here we report on the data acquired for 4124 h from 2019 to 2021. Each cavity is equipped with a fast frequency tuning mechanism of 10 MHz/ min between 4.774 GHz and 5.434 GHz. In the present work, we exclude axion-photon couplings for virialized galactic axions down to g_aγγ = 8 × 10⁻¹⁴ GeV⁻¹ at the 90% confidence level. The here implemented phase-matching technique also allows for future large-scale upgrades.

Haloscopes aim at detecting axions by converting them into photons using high-quality resonant cavities, where the cavity resonance should be tuned with the unknown axion mass. Here, the authors improve exclusion limits using four phase-matched resonant cavities and a fast frequency scanning technique.

The association between cardiovascular risk factors and coronary CT angiography findings for predicting obstructive coronary artery disease in Korean patients with stable chest pain

Background/Introduction

The 2019 European Society of Cardiology (ESC) guidelines currently recommend the use of coronary computed tomography angiography (CCTA) as the initial test for diagnosing coronary artery disease (CAD) in symptomatic patients in whom obstructive CAD cannot be excluded by clinical assessment alone.

Purpose

The purpose of this study is to identify the prevalence of obstructive CAD in patients with stable chest pain, and the correlation between several clinical cardiovascular disease (CVD) risk factors and CCTA findings presented by Coronary Artery Disease Reporting and Data System (CAD-RADS).

Methods

The present study is a single-center retrospective cross-sectional study. A total of 1,892 patients with stable chest pain who underwent CCTA were enrolled in this study. Diamond-Forrester classification, Framingham risk score (FRS), atherosclerotic CVD (ASCVD) 10-year risk score, coronary artery calcium score (CACS) and CAD-RADS category were obtained from every patient.

Results

Among 1,892 patients (mean age, 60.5±8.6 years; men, 59.3%), 356 (18.8%) had obstructive CAD according to CCTA. Patients with high and intermediate ASCVD 10-year risk score had 2.59 times (aOR 2.59, 95% CI; 1.58 to 4.23) and 1.66 times (aOR 1.66, 95% CI; 1.04 to 2.65) higher odds of having obstructive CAD than patients with low ASCVD 10-year risk score, respectively (adjusted for Diamond-Forrester classification and CACS group). Higher ASCVD risk scores were significantly associated with higher CAD-RADS category (p&lt;0.001), and patients with CAD-RADS category 3 had ASCVD 10-year risk score of 20.1±12.7. CACS showed the highest discrimination in presence of obstructive CAD, followed by ASCVD 10-year risk score, FRS, and Diamond-Forrester classification (AUC: 0.821 [95% CI; 0.797–0.845]; 0.711 [95% CI; 0.683–0.740]; 0.675 [95% CI; 0.646–0.704]; 0.600 [95% CI; 0.569–0.632], respectively).

Conclusion

This is the first study of CCTA findings in stable chest pain patients in Korea. The prevalence of obstructive CAD in patients with stable chest pain was 18.8%. Higher ASCVD score is significantly associated with presence of obstructive CAD and higher CAD-RADS category. As coronary stenosis of 50%-69% had a mean ASCVD score of 20.1, we should consider CCTA for identifying obstructive CAD in patients with ASCVD score over 20 with stable chest pain.

Funding Acknowledgement

Type of funding sources: None.

Epilepsy, Vascular Risk Factors, and Cognitive Decline in Older Adults: The Cardiovascular Health Study

Objective:

Recent studies have shown that global cognitive ability tends to decline faster over time in older adults (≥65 years) with epilepsy compared with older adults without epilepsy. Scarce data exist about the role of vascular risk factors (VRFs) on cognitive course in epilepsy. We assessed whether the associations of individual VRFs with cognitive trajectory differed depending on the presence of prevalent epilepsy.

Methods:

The Cardiovascular Health Study is a population-based longitudinal cohort study of 5,888 US adults aged ≥65 years. Cognitive function was assessed annually with Modified Mini-

Mental State Exam (3MS; global cognitive ability) and Digit Symbol Substitution Test (DSST; information processing speed). We used linear mixed models to estimate the individual and joint associations of epilepsy and VRFs with cognitive decline by modeling epilepsy × VRF interactions one by one, each adjusted for all other VRFs considered, including demographics, health behaviors, clinical characteristics, and comorbid diagnoses. From these models, we estimated excess mean cognitive decline due to interaction of epilepsy with each VRF.

Results:

We observed excess mean decline in global cognitive ability (3MS) due to interactions of epilepsy with hypertension (6.6 points greater mean 8-year decline than expected if no interaction; 95% CI: 1.3, 12.0) and with abstaining from alcohol (5.8 points greater than expected; 95% CI: 0.3, 11.3). We also observed excess mean decline in information processing speed (DSST) due to interactions of epilepsy with prior stroke (18.1 points greater mean 9-year decline than expected; 95% CI: 7.6, 28.5), with abstaining from alcohol (6.1 points greater than expected; 95% CI: 2.5, 9.8), and with higher triglyceride levels (2.4 points greater than expected per standard deviation; 95% CI: 0.4, 4.3).

Conclusion:

Associations of some VRFs with cognitive decline in older adults are stronger in the presence of epilepsy, suggesting a need for greater attention to vascular protection for preserving brain health in older adults with epilepsy.

Reproduction and genetic causal attribution of epilepsy

OBJECTIVE

This study addresses the contribution of genetics-related concerns to reduced childbearing among people with epilepsy.

METHODS

Surveys were completed by 606 adult patients with epilepsy of unknown cause at our medical center. Poisson regression analysis was used to assess the relations of number of offspring to: (1) genetic attribution (GA: participants' belief that genetics was a cause of their epilepsy), assessed via a novel scale developed from four survey items (Cronbach's alpha = .89), (2) participants' estimates of epilepsy risk in the child of a parent with epilepsy (1%, 5%-10%, 25%, and 50%-100%), and (3) participants' reports of the influence on their reproductive decisions of "the chance of having a child with epilepsy" (none/weak/moderate, strong/very strong). Analyses were adjusted for age, education, race/ethnicity, religion, type of epilepsy (generalized, focal, and both/unclassifiable), and age at epilepsy onset (<10, 10-19, and ≥20 years).

RESULTS

Among participants 18-45 years of age, the number of offspring decreased significantly with increasing GA (highest vs lowest GA quartile rate ratio [RR] = .5, p < .001), and increasing estimated epilepsy risk in offspring (with 5%-10% as referent because it is closest to the true value, RR for 25%: .7, p = .05; RR for 50%-100%: .6, p = .03). Number of offspring was not related to the reported influence of "the chance of having a child with epilepsy" on reproductive decisions. Among participants >45 years of age, the number of offspring did not differ significantly according to GA quartile or estimated offspring epilepsy risk. However, those reporting a strong/very strong influence on their reproductive decisions of "the chance of having a child with epilepsy" had only 60% as many offspring as others.

SIGNIFICANCE

These findings suggest that overestimating the risk of epilepsy in offspring can have important consequences for people with epilepsy. Patient and provider education about recurrence risks and genetic testing options to clarify risks are critical, given their potential influence on reproductive decisions.

POS1443 IDENTIFYING THE NEW EMERGENCE OF RACIAL DISPARITIES IN GOUT OVER THE PAST 3 DECADES – US NATIONAL SURVEY AND PROSPECTIVE COHORT DATA

Background

Several studies published after 2010 reported a higher frequency of gout and hyperuricemia among US Blacks than Whites.1-4 However, Blacks (in the US and Africa) were previously thought to suffer gout less often than Whites.5 We hypothesized that the racial disparity in Blacks emerged over the past several decades, with flipped prevalence between the two races.

Objectives

To assess trends in racial differences in gout prevalence in the US using both national survey and cohort study data over the past 3 decades.

Methods

Using data from the NHANES (National Health and Nutrition Examination Survey) III (1988-1994) and latest decade (2007-2016), and data from 5 examination periods in the ARIC (Atherosclerosis Risk in Communities) Study between 1988 through 2013, we compared age- and sex-adjusted prevalences and odds ratios (OR) to determine the trend of racial differences in gout prevalence between Blacks and Whites. A time-race interaction term was used to assess differences in the rate of change between the two races.

Results

Among Whites, the sex- and age-standardised prevalence of gout in the NHANES rose from 2.8% (95% CI: 2.4 to 3.2) in 1988-94 to 3.7% (3.2 to 4.1) in 2007/16. Prevalence of gout among Blacks was lower than Whites in 1988-94 (2.6% [2.2 to 3.0]) but rose more sharply over the subsequent decades (p for race-time interaction=0.003), and in 2007/16 came to exceed that of Whites (5.0% [4.4 to 5.6]).

Corresponding age-sex-adjusted ORs for gout in Blacks vs. Whites were 0.93 (0.73 to 1.17) in 1988-94, increasing to 1.46 (1.22 to 1.74) in 2007/16 (Table 1). This disproportionate rise in gout prevalence among Blacks tended to be more prominent among women (OR 1.81 [1.29 to 2.53]) than men (OR 1.26 [1.02 to 1.55]; p for race-time interactions of 0.002 and 0.01, respectively). Similar trends were observed in the ARIC cohort, where the OR for gout among Blacks vs. Whites rose progressively from 0.82 (0.65 to 1.02) in 1987-89 to 1.81 (1.49 to 2.19) in 2011-13.

Table 1.

Temporal Trend of Racial Disparity in Gout Prevalence in NHANES Survey and the ARIC Study Cohort, overall and by sex

Odds Ratio (95% CI) for Gout Among Blacks vs. WhitesOVERALLNHANES1988-19942007-2016Age- and sex-adjusted0.93(0.73 to 1.17)1.46(1.22 to 1.74)ARICVisit 1: 1987-89Visit 2: 1990-92Visit 3: 1993-95Visit 4: 1996-98Visit 5: 2011-13Age- and sex-adjusted0.82(0.65 to 1.02)0.99(0.81 to 1.22)1.24(1.03 to 1.50)1.60(1.35 to 1.90)1.81(1.49 to 2.19)WOMENNHANES1988-19942007-2016Age-adjusted0.98(0.65 to 1.47)1.81(1.29 to 2.53)ARICVisit 1: 1987-89Visit 2: 1990-92Visit 3: 1993-95Visit 4: 1996-98Visit 5: 2011-13Age-adjusted0.92(0.64 to 1.32)1.14(0.82 to 1.59)1.45 (1.07 to 1.96)1.89 (1.45 to 2.46)2.28(1.73 to 3.01)MENNHANES1988-19942007-2016Age-adjusted0.91(0.68 to 1.21)1.26 (1.02 to 1.55)ARICVisit 1: 1987-89Visit 2: 1990-92Visit 3: 1993-95Visit 4: 1996-98Visit 5: 2011-13Age-adjusted0.73 (0.54 to 0.97)0.87 (0.66 to 1.14)1.03(0.79 to 1.33)1.29(1.02 to 1.64)1.34(1.00 to 1.78)

Conclusion

Gout prevalence tended to be lower in Blacks than Whites until late 80’s, then rose and surpassed that of Whites over the past several decades. These trends closely parallel the worsening obesity epidemic during this period,6 particularly in Blacks, partly due to enhanced Western lifestyle. Gout risk genetic profile change would not contribute to this emergence of racial differences, particularly among the same individuals in ARIC, although it remains to be clarified whether Blacks carry genetic profiles that enhance the effect of lifestyle risk factors for gout.

References

[1]PMID 22225548 (2012)

[2]PMID 24330409 (2013)

[3]PMID 24335384 (2014)

[4]PMID: 30618180 (2019)

[5]NEJM PMID: 15014177

[6]JAMA PMID: 12365955

Disclosure of Interests

Natalie McCormick: None declared, Leo Lu: None declared, Chio Yokose: None declared, Amit Joshi: None declared, Yuqing Zhang: None declared, Hyon Choi Consultant of: Ironwood, Selecta, Horizon, Takeda, Kowa, and Vaxart., Grant/research support from: Ironwood and Horizon

POS0280 EXCESS RISK OF ALL-CAUSE AND CARDIOVASCULAR MORTALITY IN FEMALES WITH GOUT – A PROSPECTIVE COHORT STUDY OF 105,502 WOMEN

Background

Despite the disproportionately worsening disease burden of female gout in recent years1 and its frequent associations with key cardiovascular risk factors (more often than male gout2,3), there remains a paucity of specific data about female gout, particularly about its impact on mortality and fatal coronary heart disease (CHD).

Objectives

To prospectively examine the relation of female gout and risk of all-cause and cardiovascular and coronary heart disease-specific deaths.

Methods

Using data from the Nurses’ Health Study (NHS), an ongoing prospective cohort study in which female nurses in the United States completed detailed mailed questionnaires regarding their medical history, lifestyle, and other risk factors at baseline and every two years thereafter, we prospectively analyzed the relation between gout status at baseline and during the follow-up period and the risk of all-cause and cardiovascular mortality using Cox proportional hazards regression to adjust for cardiovascular risk factors such as comorbidities, body mass index, postmenopausal status, medication use, and dietary factors.

Results

The analysis included 105,502 women without gout and 1602 women with gout. Women with gout at baseline in 1982 tended to be older (mean age 54 vs. 50 years), and more likely to report a history of hypertension (44% vs. 22%), hypercholesterolemia (17% vs. 8%), and diabetes (11% vs. 6%). During 24 years of follow-up, we documented 15,255 deaths from all causes, including 3,128 deaths from cardiovascular disease (CVD) and 1,405 deaths from coronary heart disease (CHD). Compared to women without history of gout or CHD at baseline, the multivariable relative risks (RRs) among women with history of gout at baseline were 1.33 (95% CI, 1.21 to 1.46) for total mortality, 1.40 (95% CI, 1.17 to 1.67) for CVD deaths, and 1.49 (95% CI, 1.17 to 1.91) for fatal CHD (Table 1). The corresponding RRs for gout at baseline and during the follow-up were 1.33 (95% CI, 1.23 to 1.44), 1.43 (95% CI, 1.24 to 1.66), and 1.34 (95% CI, 1.08 to 1.66), respectively.

Table 1.

Relative Risks of Death from All-Causes, Cardiovascular Disease, and Coronary Heart Disease According to Gout Status at Baseline in 1982 in the Nurses’ Health Study

No CHDNo GoutGoutDeaths from all causesCases, n14,810445Age-adjusted RR (95% CI)1.01.58 (1.43, 1.73)Multivariable-adjusted* RR (95% CI)1.01.33 (1.21, 1.46)All cardiovascular deathsCases, n3,001127Age-adjusted RR (95% CI)1.02.06 (1.72, 2.46)Multivariable-adjusted* RR (95% CI)1.01.40 (1.17, 1.67)Fatal CHDCases, n1,33570Age-adjusted RR (95% CI)1.02.53 (1.99, 3.22)Multivariable-adjusted* RR (95% CI)1.01.49 (1.17, 1.91)

*Adjusted for age (continuous), history of hypertension, history of hypercholesterolemia, history of diabetes, aspirin use (yes, no), diuretic use (yes, no), smoking (never, past, current <15, current ≥15 cigarettes/day), body mass index (<23, 23-24.9, 25-29.9, 30-34.9, ≥35), physical activity (quintile), alcohol intake (nondrinker, <5, 5-9, 10-29, ≥30g/day), family history of MI (yes, no), menopausal status (premenopause, post menopause), hormone replacement therapy use (premenopause, never user, current user, past user). total energy intake (quintile), trans fat (quintile), dietary cholesterol (quintile), protein (quintile), linoleic fatty acid (quintile), and ratio of polyunsaturated fat/saturated fat.

CHD = coronary heart disease; CI = confidence interval; RR = relative risk.

Conclusion

These prospective data indicate that women with gout have a higher risk of all-cause mortality, which is primarily driven by higher risk of CVD deaths. These findings closely agree with the UK general population data of both sexes that showed unclosing mortality gap over the past two decades.4 Together, these findings provide support for rigorous cardiovascular risk factor modification specifically in female gout to help curtail the rising disease burden of gout worldwide.1

References

[1]Xia et al., PMID 31624843

[2]Puig et al., PMID 2012455

[3]Harrold et al., PMID 16644784

[4]Fisher et al., PMID 28122760

Disclosure of Interests

Chio Yokose: None declared, Natalie McCormick: None declared, Na Lu: None declared, Amit Joshi: None declared, Gary Curhan Consultant of: AstraZeneca, Allena Pharmaceuticals, Shire/Takeda, Dicerna, and Orfan, Grant/research support from: Decibel Therapeutics, Employee of: Chief Medical Officer at OM1, Inc., Hyon Choi Consultant of: Ironwood, Selecta, Horizon, Takeda, Kowa, and Vaxart, Grant/research support from: Ironwood and Horizon

POS0155 WHAT DRIVES RACIAL DISPARITIES IN GOUT IN THE US? – POPULATION-BASED, SEX-SPECIFIC, CASUAL MEDIATION ANALYSIS

Background

Traditionally viewed as a disease of White men, global frequency and disability burden of female gout are rising disproportionately to male gout.1 Moreover, emerging US cohort data suggest gout and hyperuricemia impart larger burdens on Black adults than Whites.2 These racial disparities may be largely attributable to differences in non-genetic, mainly modifiable gout risk factors e.g., BMI, diet,3,4 and chronic kidney disease (CKD). However, national-level, general population data on racial differences in burden of gout, and potential mediators, are lacking.

Objectives

To determine and quantify sex-specific mediators of racial disparities in gout prevalence among a nationally representative sample of US adults.

Methods

Using recent decadal data (2007-2016) on physician-diagnosed gout and hyperuricemia from the National Health and Nutrition Examination Survey, we compared contemporary sex- and race-specific prevalences and conducted sequential causal mediation analysis (adjusting for upstream mediators following causal pathways)5 to determine the proportion of the racial differences attributable to 7 potentially mediating social and clinical factors (see DAG in Figure 1): low education, poverty, body mass index (BMI), alcohol, poor quality diet (poor DASH adherence), diuretic use, and CKD (eGFR <60 mL/min, using the latest equations that do not include a coefficient for Black race6, per National Kidney Foundation and American Society of Nephrology recommendations.7)

Results

Age standardised prevalence of gout was 3.5% and 2.0% in Black and White women, respectively (age-adjusted OR =1.8 [95% CI: 1.3 to 2.5]), and 7.0% and 5.4% in Black and White men (age-adjusted OR =1.3 [1.0 to 1.6]). Most risk factors were more frequent/elevated in Blacks than Whites, except alcohol consumption, which was lower in Blacks (both sexes). BMI levels and poverty were higher in Black women, but similar between Black and White men.

Largest mediating factor of excess gout cases among Black women was excess BMI, accounting for 56% of the racial difference (independent of education, poverty, diet, and alcohol), followed by CKD (24%), poverty (17%), and poor diet (12%) (see Table 1).

Table 1.

Indirect (mediation) effects of potential mediators, using sequential mediation analysis, for the association between Black race and odds of gout in US women and men.

WOMENMENEffect Estimate (OR), 95% CIProportion Mediated, %Effect Estimate (OR), 95% CIProportion Mediated, %Indirect (Mediation) EffectEducation (high school or less)1.01 (0.98 to 1.03)2.4%1.01 (0.98 to 1.03)3.3%Poverty1.07 (1.04 to 1.10)16.9%1.00 (0.99 to 1.00)0.53%Alcohol consumption (# drinks/week, continuous)0.99 (0.96 to 1.01)-3.4%0.99 (0.98 to 1.00)-4.5%DASH diet score (continuous; higher scores = ↓ adherence)1.05 (0.96 to 1.01)12.0%1.05 (1.01 to 1.10)19.8%Body mass index (continuous)1.25 (1.14 to 1.37)55.9%1.03 (1.02 to 1.04)11.9%Diuretic use1.03 (1.01 to 1.05)7.6%1.04 (1.02 to 1.06)14.2%Chronic kidney disease1.10 (1.04 to 1.16)23.9%1.12 (1.08 to 1.17)45.6%Direct Effect0.94 (0.68 to 1.30)a−15.2%1.02 (0.83 to 1.26)b9.2%Total Effect1.49 (1.12 to 1.98)100%1.29 (1.05 to 1.57)100%

DASH=Dietary Approaches to Stop Hypertension;

ap=0.52,

bp=0.83

Among men, CKD was the largest mediator (46%), followed by poor diet (20%) and diuretic use (14%). BMI (12%) and poverty (0.5%) mediated smaller proportions of the racial difference among men compared to women. Mediators of racial differences in hyperuricemia closely agreed with gout results.

Conclusion

Contrasting with historical views, gout is more frequent among Black adults in the US than their White counterparts, especially women (two-times greater in Black women vs. White). Culturally informed efforts to reduce these disparities should focus on excess adiposity, diet quality, and kidney disease while recognising the impact of poverty in female gout.

References

[1]Xia; PMID 31624843

[2]PMID 24335384

[3]Rai BMJ PMID 28487277

[4]Yokose JAMA IM (2022)

[5]VanderWeele; PMID 25580377

[6]NEJM PMID 34554658

[7]JASN PMID 34556489

Disclosure of Interests

Natalie McCormick: None declared, Leo Lu: None declared, Chio Yokose: None declared, Amit Joshi: None declared, Tony Merriman: None declared, Kenneth Saag Consultant of: Arthrosi, Atom Bioscience, Horizon Therapeutics, LG Pharma, Mallinkrodt, SOBI, Takeda, Grant/research support from: Horizon Therapeutics, SOBI, Shanton, Yuqing Zhang: None declared, Hyon Choi Consultant of: Ironwood, Selecta, Horizon, Takeda, Kowa, and Vaxart.

Grant/research support from: Ironwood, Horizon

OP0166 CHRONIC KIDNEY DISEASE AND AMPLIFICATION OF SERUM URATE IMPACT ON GOUT RISK: POPULATION-BASED STUDY OF > 450,000 UK BIOBANK PARTICIPANTS

Background

Serum urate (SU) is a necessary causal factor for development of gout, while chronic kidney disease (CKD) is associated with increased inflammatory biomarkers, cytokines, and reduced AMPK activity levels. Furthermore, CKD has been found to be associated with an increased risk of incident gout, even beyond (i.e., independent of) SU levels. As such, the impact of SU may be enhanced by presence of CKD, but this hypothesis has not been evaluated.

Objectives

To prospectively examine whether CKD modifies the relation between SU levels and risk of incident gout.

Methods

We conducted a prospective cohort analysis of UK Biobank participants with urate and creatinine levels available from baseline blood samples (2006-2010), and no prior diagnosis of gout or urate lowering therapy use. CKD Stage ≥ 3 status (eGFR <60 mL/min) was determined from latest CKD-Epi equations (NEJM 2021; JASN 2021).1,2 Incident cases of gout were ascertained from linked hospitalisation, primary care, and death records. Participants were followed from baseline up to 10 years or until gout diagnosis, death, or end of study period (Dec 31/19).

We calculated 10-year cumulative incidence of gout according to baseline SU category and CKD status and evaluated their individual and joint impact on gout risk using multivariable Cox proportional hazards models.

We further assessed for additive and multiplicative interactions3 between levels of SU and inverted eGFR, on a standardized continuous scale per SD.

Results

We included 458,244 individuals (45% male, mean age 56.5 years), of whom 6,559 had CKD at baseline, and documented 5,847 cases of incident gout over 4,442,866 person-years.

10-year cumulative incidence of gout ranged from 0.2% (baseline SU < 5 mg/dL) to 33% (baseline SU ≥ 10 mg/dL), and in each category incidence was higher for those with CKD than without (Table 1; Figure 1-left), Multivariable hazard ratio (HR) for the joint effect of CKD and highest SU level (≥ 10 mg/dL), compared to non-CKD and lowest SU (<5mg/dL), was 242 (95% CI: 189 to 309) (Figure 1-right).

Table 1.

Cumulative incidence and hazard ratio (HR) of incident gout according to baseline serum urate levels and CKD status

CKD Stage ≥ 3Hyperuricemia (Dichotomous)Serum urate, mg/dL<55.0 to < 6.06.0 to < 7.07.0 to < 8.08.0 to < 9.09.0 to < 10.0≥10<7.0≥7.0N cases6152895150104874943610-Year Cumulative Incidence0.6%1.1%1.7%7.6%19.1%28.0%42.0%1.2%16.6%Incidence Rate Ratio1.0 (Ref)1.72.712.333.856.1107.71.0 (Ref)15.2No CKDSerum urate, mg/dL<55.0 to < 6.06.0 to < 7.07.0 to < 8.08.0 to < 9.09.0 to < 10.0≥10<7.0≥7.0N cases393446105617691251363841,8953,46710-Year Cumulative Incidence,0.2%0.4%1.4%6.0%15.6%23.5%27.5%0.5%8.8%Incidence Rate Ratio1.0 (Ref)2.18.034.696.9155.9198.81.0 (Ref)20.2Joint Effect of Serum Urate and CKDSerum urate, mg/dL<55.0 to < 6.06.0 to < 7.07.0 to < 8.08.0 to < 9.09.0 to < 10.0≥10<7.0≥7.0Age-, Sex-, and Race- Adjusted HRNo CKD1.0 (Ref)1.97.029.883.0133.3170.31.0 (Ref)15.7CKD3.25.17.834.193.3155.9302.32.530.5Fully adjusted HR*No CKD1.0 (Ref)1.86.425.869.4108.7132.91.0 (Ref)12.5CKD3.14.76.828.975.2121.1241.82.322.4

*Adjusted for age, sex, race, body mass index, hypertension, diuretic use, smoking, and consumption of alcohol, coffee, meat, fish, poultry, and milk.

There was a significant additive interaction between continuous SU and eGFR (relative excess risk due to interaction=0.16 [0.09 to 0.24], p < 0.001), with HRs of 3.7 (3.6 to 3.8) per SD increase of SU, 1.2 (1.2 to 1.3) per SD increase of inverted eGFR, and 4.1 (3.9 to 4.2) for their joint effect. Their multiplicative interaction was also significant (p < 0.001).

Conclusion

These large prospective cohort data suggest CKD presence enhances the effect of elevated SU levels on risk of incident gout. They support roles of CKD-associated factors beyond SU in developing gout, such as reduced AMPK activity levels and altered inflammatory factors in CKD, which warrant further investigation.

References

[1]PMID 34554658

[2]PMID 34556489

[3]ARD (2021) PMID 34857519

Disclosure of Interests

Natalie McCormick: None declared, Leo Lu: None declared, Chio Yokose: None declared, Amit Joshi: None declared, Yuqing Zhang: None declared, Hyon Choi Consultant of: Ironwood, Selecta, Horizon, Takeda, Kowa, and Vaxart., Grant/research support from: Ironwood and Horizon

POS0276 TRADITION VS INNOVATION! CONVENTIONAL RADIOGRAPHY AND ULTRASOUND IN THE DIAGNOSIS OF CPPD: INSTRUCTIONS FOR USE

Background

Conventional radiography (CR) is widely used as the first-line investigation for calcium pyrophosphate deposition (CPPD) disease, given its widespread use and the low cost. Next to it a series of advanced imaging techniques have been evaluated for accuracy and reliability. Among them, ultrasound (US) has been thoroughly tested and demonstrated to be accurate and reliable for CPPD diagnosis. However, even if there are data on the diagnostic accuracy of US and CR alone, it is not clear if performing both diagnostic tests and in which sequential order provides an added value for the diagnosis of CPPD.

Objectives

The aim of this study was to assess which diagnostic test performs better for the diagnosis of CPPD and if a combination of the two exams provides an additional value.

Methods

This is an ancillary study of the criterion validity of US in CPPD study1. Consecutive patients with knee osteoarthritis requiring total joint replacement were enrolled in 8 centres. Participants underwent US and CR of the affected knee prior to surgery. US was performed by experienced sonographers following the same scanning protocol described in the main study, while CR were performed in weight bearing AP and lateral views and were read by 2 experienced radiologists that reached a consensus on the presence/absence of CPPD. The evaluation of CPPD at the level of menisci and hyaline cartilage (HC) was based on the OMERACT definitions for US and on the new definitions developed by the ACR/EULAR CPPD classification criteria working group for CR [paper under submission]. Patients were classified as having CPPD considering histological examination as reference standard. Diagnostic indexes were calculated for US and CR alone and combined. Poisson models with robust estimation were used to estimate the best sequence of these diagnostic methods for a more accurate diagnosis of CPPD.

Results

51 pts were enrolled (63% F, mean age 74y ± 8). Diagnostic indexes of US and CR alone and combined are indicated in Table 1. Compared to histology, US demonstrated to be a sensitive tool for identification of CPPD at the knee, with a good sensitivity in all sites and in the overall evaluation. Instead, CR was less sensitive, but it was a highly specific exam for CPPD identification. Combining US and CR led to a higher sensitivity compared with CR alone, but a lower specificity compared to both CR and US alone, and it offered no additional increase in diagnostic accuracy. The Figure 1 shows the results of the appropriate sequence of use of US and CR in patients with suspected CPPD: in case of a positive CR at any of the 3 sites (menisci and HC) no additional exam is necessary, and the same in case of a positive US in at least two sites; however in case of a negative CR, US could help in a statistically significant way to identify CPPD patients, and further in case of a positive US in a single site CR can offer additional information.

Table 1.

diagnostic indexes of US, CR and US + CR in the identification of CPPD. MM: medial meniscus, LM: lateral meniscus, HC: hyaline cartilage, SN: sensitivity, SP: specificity, PPV: positive predictive value, NPV: negative predictive value, ACC: accuracy.

USSNSPPPVNPVACCMM0.880.810.820.880.84LM0.880.730.760.860.80HC0.780.860.820.830.82Overall0.920.640.730.890.78CRMM0.32110.610.67LM0.400.960.910.630.69HC0.480.930.850.680.73Overall0.540.920.880.660.73US + CRMM0.880.810.820.880.84LM0.920.690.740.900.80HC0.870.820.800.890.84Overall0.920.560.670.880.75Figure 1.

evaluation of sequence of US and CR

Conclusion

US confirmed a high diagnostic accuracy in identifying patients affected by CPPD at knee level, while CR demonstrated a high specificity but a low sensitivity. Performing both diagnostic tests could make sense in case of a negative CR or in case of an inconclusive US (only one positive site). To our knowledge, this is the first study that investigates the role of the combination of the two exams in CPPD. Further studies in a large number of patients and in different joints would be helpful to address this point.

References

[1]Filippou G. et al, Ann Rheum Dis, 2020

Disclosure of Interests

None declared

OP0164 A POPULATION-BASED, PROSPECTIVE METABOLOMICS STUDY IN THE UK BIOBANK IDENTIFIES GLYCOPROTEIN ACETYLS AS A NOVEL BIOMARKER OF INCIDENT GOUT

Background

Serum urate (SU) level is the strongest known causal predictor of clinical gout, but only ~20% with prolonged hyperuricemia develop gout, motivating the need for additional biomarkers for risk prediction and stratification. The metabolome represents a compelling intermediate trait between genome and phenome to elucidate disease mechanisms. Multiple cross-sectional studies of prevalent gout from men in Asia have been conducted, but no prospective data for incident gout (prediagnostic metabolome) are available.

Objectives

Our objectives were to (1) conduct a discovery-based metabolome-wide study to identify novel biomarkers of incident gout; and (2) replicate novel metabolomic biomarkers of gout in independent samples.

Methods

We conducted a prospective cohort analysis of 105,703 UK Biobank (UKB) participants (46% males, mean age 57.2 years) with targeted NMR metabolomic profiling (N=168 metabolites, including routine lipids and amino acids) available from baseline samples (2006-10), and no prior diagnosis of gout or urate lowering therapy use. Incident cases of gout were documented from linked medical records until gout diagnosis, death, or end of study period (Dec 31/19). We used Cox proportional hazard models to obtain hazard ratios (HR) and 95% confidence intervals (CIs) per standard deviation (SD) increase in each of the 168 metabolites to determine associations with incident gout.

To replicate our findings, we assessed association of metabolome-wide significant metabolites in a replication set, restricted to 4,804 non-overlapping participants who provided blood in the repeat assessment visit (2012-13).

Results

During a median 10.4 years follow-up, we documented 1,367 cases of incident gout in the discovery set. After correction for multiple comparisons, glycoprotein acetyls (GlycA) were positively associated with risk of incident gout (multivariable HR per 1SD increase = 1.34 (1.27 to 1.41), P = 9.04x 10-28) after adjusting for age, sex, and lifestyle and clinical covariates (Table 1). This association persisted even after SU adjustment (HR 1.07, P = 0.0091). In the replication set, among 4,804 participants followed for a median of 6.8 years, we documented 22 cases. In this dataset, we replicated GlycA association with incident gout (multivariable HR per 1SD increase =1.56 (1.08 to 2.25), P = 0.017).

Table 1.

Association of glycoprotein acetyls (GlycA) with risk of incident gout in the UK Biobank

ModelUnivariable HR, (95% CI)PMultivariable HR, (95% CI)PDiscovery (N= 105,703)Per Standard deviation:GlycA, per SD1.48 (1.41 to 1.60)3.7x10-591.34 (1.27 to 1.41)9.04x 10-28Categorized as quintiles:GlycA, Q11.0 Ref1.0 RefGlycA, Q21.43 (1.13 – 1.80)0.0021.30 (1.03 – 1.64)0.0252GlycA, Q32.06 (1.66 – 2.56)4.88 x 10-111.73 (139 – 2.15)7.64 x 10-07GlycA, Q42.53 (2.05 – 3.12)4.15 x 10-181.98 (1.60 – 2.45)3.96 x 10-10GlycA, Q53.70 (3.02 – 4.52)3.21 x 10-372.63 (2.12 – 3.23)2.01 x 10-19Replication (N= 4804)Per Standard deviation:GlycA, per SD1.65 (1.19 to 2.29)0.00271.56 (1.08 to 2.25)0.0172

1 Hazard ratios (HR) and 95% confidence intervals (CIs) obtained after adjusting for the first 4 genomic principal components (controlling for population stratification), age, sex, fasting (<4 hrs, 4-8 hrs and ≥8 hrs), smoking (never, former, current), freq of alcohol, BMI, diabetes (yes/no) and hypertension at baseline (yes/ no).

Conclusion

In this large-scale, prospective metabolomics study, we identified and independently replicated our findings that plasma levels of GlycA are associated with incident gout in UKB participants. GlycA is novel for gout, though this pro-inflammatory biomarker has predicted risk of other cardiometabolic-inflammatory phenotypes, independent of CRP.1 These findings may provide insight into the metabolic-inflammatory pathogenesis of gout, with implications for risk prediction, even beyond SU, but call for further investigation with more extensive metabolome profiling and external replication.

References

[1]Kettunen; PMID 30571186

Disclosure of Interests

Amit Joshi: None declared, Natalie McCormick: None declared, Chio Yokose: None declared, Na Lu: None declared, Hyon Choi Consultant of: Ironwood, Selecta, Horizon, Takeda, Kowa, Vaxart, Grant/research support from: Ironwood, Horizon

POS1171 TRIPLE THE RATE OF EMERGENCY ROOM VISITS AND HOSPITALIZATIONS FOR GOUT AMONG US BLACKS VS WHITES – 2019 NATIONWIDE ANALYSIS

Background

Gout is a highly prevalent inflammatory arthritis with increasing global disease burden in recent years.1,2 Gout prevalence has been reported to be higher among Blacks compared to Whites,3 and that they are less likely to receive allopurinol in outpatient care.4 The potential nationwide impact of these racial disparities on emergency department (ED) visits and hospitalizations is unknown.

Objectives

To examine the contemporary racial disparities in ED visits and hospitalizations with a primary discharge diagnosis of gout in the US (2019).

Methods

We compared ED visits and hospitalizations between Blacks and Whites in the latest data (2019) from the US National Emergency Department Sample (NEDS) and National Inpatient Sample (NIS). We focused on encounters for which the primary diagnosis was gout based on ICD codes (M1A.xx, M10.xx). We calculated annual population rates of ED visits and hospitalizations for gout (per 100,000 US adults) using the 2019 US census adult population (>18 years) according to race.

Results

There were a total of 160,759 ED visits and 9,560 hospitalizations among White and Blacks with a gout diagnosis in the US in 2019. The mean age (58.2 years vs. 56.5 years) and male proportion (78.0% vs. 74.8%) tended to be higher among Whites, while more Blacks tended to live in the South (40.7% vs. 66.5%) and reported a median household income of < $50,000 (30.7% vs. 57.1%). Compared to Whites, Blacks had 2.7- and 3.2-fold higher rates of gout ED visits and hospitalizations, respectively, after adjusting for age, sex, payer, region, and household income (Table 1 & Figure 1). Black women, in particular, had 3.4- and 4.0-fold higher rates of ED visits and hospitalizations compared to White women, while the corresponding rate ratios for men were 2.5 and 2.8, respectively. The mean costs per gout ED visit were similar for Blacks compared to Whites (adjusted difference, -$7.6 [95% CI, -25.4 to 1.0]), while hospitalizations were more costly (adjusted difference, $1,055.3 [95% CI, 553.1 to 1557.5]). The duration of ED visits and hospitalizations was also higher among Blacks than Whites (adjusted difference of 0.41 days [95% CI, 0.19 to 0.63] and 0.59 days [95% CI, 0.25 to 0.94], respectively).

Table 1.

Racial Disparities in Emergency Department Visits and Hospitalizations with Primary Diagnosis of Gout in 2019

Emergency Department VisitsHospitalizationsRaceWhiteBlackWhiteBlackAll6801196524521330198510434519150Visits, N888107194962003360Rate per 100,000130.6293.431.274.4Rate Ratio (95% CI)*1.0 (ref)2.81 (2.63, 3.00)1.0 (ref)3.08 (2.79, 3.40)Rate Ratio (95% CI)**1.0 (ref)2.66 (2.50, 2.82)1.0 (ref)3.17 (2.86, 3.50)Women3785136914363031110390932647105Visits, N195671816317701145Rate per 100,00051.7126.516.043.3Rate Ratio (95% CI)*1.0 (ref)3.68 (3.39, 3.99)1.0 (ref)4.01 (3.40, 4.73)Rate Ratio (95% CI)**1.0 (ref)3.36 (3.11, 3.62)1.0 (ref)4.02 (3.39, 4.78)Men301561011015657388098151871620Visits, N692285378344302215Rate per 100,000229.6529.550.3118.3Rate Ratio (95% CI)*1.0 (ref)2.59 (2.42, 2.78)1.0 (ref)2.66 (2.36, 3.00)Rate Ratio (95% CI)**1.0 (ref)2.47 (2.32, 2.64)1.0 (ref)2.77 (2.45, 3.14)

*Adjusted for age and sex for all, adjusted for age for sex-specific rate ratios

**Adjusted for age, sex, payment, region, and household income

Conclusion

These latest national data indicate that ED visits and hospitalization due to gout are both 3 times higher among Blacks than Whites; this disparity was particularly prominent among women with gout. Higher risk of developing gout3 and suboptimal care4 both translate to these avoidable costly healthcare utilizations, calling for improved primary prevention and gout care.

References

[1]Safiri et al., PMID 32755051

[2]Xia et al., PMID 31624843

[3]Chen-Xu et al., PMID 30618180

[4]Krishnan et al., PMID 18260174

Disclosure of Interests

Chio Yokose: None declared, Natalie McCormick: None declared, Na Lu: None declared, Amit Joshi: None declared, Lesley Jackson: None declared, Minna Kohler Speakers bureau: Lilly, Consultant of: Mymee, Novartis, Grant/research support from: Setpoint Medical, Janeth Yinh: None declared, Yuqing Zhang: None declared, Kenneth Saag Consultant of: Arthrosi, Atom Bioscience, Horizon Therapeutics, LG Pharma, Mallinkrodt, SOBI, Takeda, Grant/research support from: Horizon Therapeutics, SOBI, Shanton, Hyon Choi Consultant of: Ironwood, Selecta, Horizon, Takeda, Kowa, and Vaxart, Grant/research support from: Ironwood and Horizon

AB0624 Patients with vasculitis have a high prevalence of coronary microvascular dysfunction

Background

Vasculitides are a heterogenous group of diseases characterized by intense vessel wall inflammation, endothelial injury, and systemic inflammation. Several vasculitides are associated with high risk of cardiovascular (CV) disease, an important source of morbidity and mortality in this population. This excess CV risk is attributed both to a high burden of traditional risk factors and to inflammation, but this remains poorly studied. Indeed, inflammation is a known risk factor for CV disease and implicated in coronary microvascular dysfunction (CMD) which may precede obstructive coronary artery disease (CAD).

Objectives

We sought to assess whether vasculitis is associated with CMD in the absence of obstructive CAD.

Methods

We retrospectively identified subjects with systemic vasculitis who underwent symptom prompted rest/stress myocardial perfusion PET. Patients with an abnormal myocardial perfusion study (summed stress score ≥3) or LVEF<40% were excluded. Controls were identified from the same population and matched on age, gender and cardiovascular risk factors (CAD, hypertension, dyslipidemia, diabetes mellitus, and obesity). Coronary flow reserve (CFR), was calculated as the ratio of myocardial blood flow (ml/min/g) at peak stress compared to rest. CMD was defined as CFR <2.

Results

We studied 26 vasculitis cases and 66 matched controls. The most common vasculitides were giant cell arteritis (38%), ANCA-associated vasculitis (31%), and Takayasu’s arteritis (12%). Median (IQR) time between diagnosis and PET was 6.5 (2.9, 14.2) years. Seven (27%) cases had active vascultis at the time of PET. Cases and controls were well-matched on age, sex, and CV risk factors (Table 1). Despite a similar prevalence of CV risk factors, coronary flow reserve (reflected by CMD) was abnormal in 38% of vasculitis cases compared to 15% of controls (p=0.004). The mean [SD] CFR was 19% lower in vasculitis cases vs controls (2.11 [0.5] versus 2.6 [0.7], p=0.003).

Table 1.

The presence of coronary microvasculature dysfunction in patients with systemic vasculitis without obstructive coronary artery disease

Cohort characteristicsVasculitis (n=26)Control (n=66)P-valueAge at PET, years62 (18)61 (17)0.24Time from Vasculitis Diagnosis to PET, years (median, IQR)6.5 (2.9, 14.2)n/aFemale, n (%)18 (72%)43 (65%)0.99Vasculitis CharacteristicsLarge Vessel (e.g., giant cell arteritis, Takayasu’s), n(%)13 (50%)n/an/aMedium Vessel (e.g., polyarteritis nodosa, Kawasaki’s arteritis), n(%)2 (8%)n/an/aSmall Vessel (e.g., ANCA-associated vasculitis, Henoch-Schonlein Purpura), n(%)11 (42%)n/an/aCardiovascular Risk FactorsAt DiagnosisAt PETAt PETHypertension, n (%)12 (46%)20 (71%)47 (80%)0.47Obesity, n (%)3 (12%)2 (32%)2 (32%)0.84Diabetes, n (%)3 (12%)5 (20%)13 (20%)0.99Dyslipidemia, n (%)4 (15%)15 (58%)40 (61%)0.99Known CAD, n (%)0 (0%)1 (4%)1 (2%)0.48Imaging FindingsRest myocardial blood flow, ml/min/g1.0 (0.3)1.0 (0.3)0.8Stress myocardial blood flow, ml/min/g2.1 (0.6)2.6 (1.0)0.008Coronary Flow Reserve, ml/min/g*2.1 (0.5)2.6 (0.7)0.003Coronary Microvasculature Dysfunction** (CMD), n (%)10 (38%)11 (15%)0.004

Conclusion

Patients with systemic vasculitis, even in the absence of obstructive CAD, have a high prevalence of CMD compared with non-vasculitis patients. These differences were observed despite matching cases and controls on traditional CV risk factors, highlighting the importance of other factors, such as inflammation and vasculitis treatments on CMD and CV disease in this population. CMD is a known independent risk factor for CV mortality. Future prospective studies are needed to understand the relationship between vasculitis, systemic inflammation, and CMD.

Disclosure of Interests

None declared

POS0370 COMPARATIVE RETINOPATHY RISK OF HIGH- VS LOW-DOSE HYDROXYCHLOROQUINE AMONG 4,677 INCIDENT LONG-TERM USERS: EMULATED TARGET TRIAL ANALYSES

Background

Hydroxychloroquine (HCQ) is a key treatment for patients with lupus, but the major long-term toxicity is HCQ retinopathy. A large cross-sectional study found a prevalence of HCQ retinopathy of 7.5% overall and 5 times higher odds associated with HCQ dose >5 mg/kg/day, which led to ophthalmology guidelines recommending the avoidance of HCQ dosing >5 mg/kg.1 However, whether this dosing recommendation is applicable to the future risk of HCQ retinopathy is unknown, as is the incidence of severe bullseye retinopathy vs. the mild, pre-symptomatic stage. Furthermore, recent studies have indicated that the use of lower doses of HCQ may increase the risk of lupus flares and hospitalizations.2

Objectives

To determine the incidence of HCQ retinopathy associated with long-term HCQ use and compare them according to HCQ dose.

Methods

We emulated a hypothetical target trial using observational data3 from the US integrated health network Kaiser Permanente Northern California to compare two HCQ weight-based dosing strategies, >5 vs ≤5 mg/kg/day, based on dispensed tablets per year. A secondary analysis evaluated >80% of prescription days covered by dispensed tablets per year with HCQ dose >5 vs ≤5 mg/kg. We included 4,677 patients who initiated and continued HCQ for at least 5 years between 1997-2020. We emulated randomization of treatment strategy by cloning each subject and assigning a replicate to each treatment group.3 We censored replicates if and when they deviated from the assigned treatment group, assessed as the average dose in the first 5 years and annually thereafter. We used inverse probability weighting to account for censoring. The primary outcome was HCQ retinopathy, assessed by expert adjudication of spectral domain-optical coherence tomography (SD-OCT) and graded by severity. All SD-OCTs were prospectively reviewed by an expert ophthalmologist (RM), and a second expert ophthalmologist (MM) reviewed all abnormal scans and a random subset of normal scans. We assessed intra-rater reliability of SD-OCT findings. We used pooled logistic regression to estimate the cumulative incidence of HCQ retinopathy for each HCQ dose strategy from initiation. The odds ratios approximated hazard ratios (HRs) because the outcome at each one-year time block is <5%.

Results

Among 4,677 patients, the mean age at HCQ initiation was 52 years; 83% were female. The racial/ethnic composition included 51% non-Hispanic White, 19% Hispanic, 14% Asian, and 11% Black patients. 756 (16.2%) and 3,921 (83.8%) patients initiated HCQ with the primary definition of the treatment strategies >5 and ≤5 mg/kg/day, respectively. The weighted kappa was 0.80 for SD-OCT reliability. 164 patients developed HCQ retinopathy (100 mild, 38 moderate, and 26 severe cases). The cumulative incidence of retinopathy over 18 years was 37.6% for >5 and 5.7% for ≤5mg/kg of HCQ in our primary analysis. The corresponding risk was 26.5% for >5 and 3.2% for ≤5 mg/kg in our secondary analysis using >80% of prescription days. Compared with ≤5 mg/kg of HCQ, the HRs of retinopathy were 9.65 (95% CI 5.73-16.65) and 10.79 (95% CI 6.40-20.07) for >5 mg/kg using the primary and secondary definitions of HCQ dose categories, respectively (Figure 1).

Conclusion

The risk of HCQ retinopathy associated with long-term adherence to >5 mg/kg dosing was high, approximately 10 times that of ≤5 mg/kg dosing. However, most cases identified during the study were mild and pre-symptomatic, supporting the value of regular screening. These data should be incorporated into individualized decisions about long-term use of HCQ.

References

[1]Melles RB, Marmor MF. The risk of toxic retinopathy in patients on long-term hydroxychloroquine therapy. JAMA Ophthalmol 2014;132(12):1453-60

[2]Almeida-Brasil CC et al. Flares after hydroxychloroquine reduction or discontinuation: results from the SLICC inception cohort. Ann Rheum Dis 2021 Dec 15, epub ahead of print

[3]Hernán MA, Robins JM. Using Big Data to Emulate a Target Trial When a Randomized Trial Is Not Available. Am J Epidemiol 2016;183(8):758-64

Disclosure of Interests

April Jorge: None declared, Ronald Melles: None declared, Michael Marmor: None declared, Carol Conell: None declared, Baijun Zhou: None declared, Jingbo Niu: None declared, Yuqing Zhang: None declared, Hyon Choi Consultant of: Ironwood, Selecta, Horizon, Takeda, Kowa, and Vaxart., Grant/research support from: Ironwood and Horizon

Patient characteristics and antiseizure medication pathways in newly diagnosed epilepsy: Feasibility and pilot results using the common data model in a single-center electronic medical record database

INTRODUCTION

Efforts to characterize variability in epilepsy treatment pathways are limited by the large number of possible antiseizure medication (ASM) regimens and sequences, heterogeneity of patients, and challenges of measuring confounding variables and outcomes across institutions. The Observational Health Data Science and Informatics (OHDSI) collaborative is an international data network representing over 1 billion patient records using common data standards. However, few studies have applied OHDSI's Common Data Model (CDM) to the population with epilepsy and none have validated relevant concepts. The goals of this study were to demonstrate the feasibility of characterizing adult patients with epilepsy and ASM treatment pathways using the CDM in an electronic health record (EHR)-derived database.

METHODS

We validated a phenotype algorithm for epilepsy in adults using the CDM in an EHR-derived database (2001-2020) against source records and a prospectively maintained database of patients with confirmed epilepsy. We obtained the frequency of all antecedent conditions and procedures for patients meeting the epilepsy phenotype criteria and characterized ASM exposure sequences over time and by age and sex.

RESULTS

The phenotype algorithm identified epilepsy with 73.0-85.0% positive predictive value and 86.3% sensitivity. Many patients had neurologic conditions and diagnoses antecedent to meeting epilepsy criteria. Levetiracetam incrementally replaced phenytoin as the most common first-line agent, but significant heterogeneity remained, particularly in second-line and subsequent agents. Drug sequences included up to 8 unique ingredients and a total of 1,235 unique pathways were observed.

CONCLUSIONS

Despite the availability of additional ASMs in the last 2 decades and accumulated guidelines and evidence, ASM use varies significantly in practice, particularly for second-line and subsequent agents. Multi-center OHDSI studies have the potential to better characterize the full extent of variability and support observational comparative effectiveness research, but additional work is needed to validate covariates and outcomes.

Antiseizure medication treatment pathways in US Medicare beneficiaries with newly treated epilepsy

Objective

This study was undertaken to characterize antiseizure medication (ASM) treatment pathways in Medicare beneficiaries with newly treated epilepsy.

Methods

This was a retrospective cohort study using Medicare claims. Medicare is the United States' federal health insurance program for people aged 65 years and older plus younger people with disabilities or end‐stage renal disease. We included beneficiaries with newly treated epilepsy (International Classification of Diseases codes for epilepsy/convulsions 2014–2017, no ASM in the previous 2 years). We displayed the sequence of ASM fills using sunburst plots overall, then stratified by mood disorder, age, and neurologist prescriber. We tabulated drug costs for each pathway.

Results

We included 21 458 beneficiaries. Levetiracetam comprised the greatest number of pill days (56%), followed by gabapentin (11%) and valproate (8%). There were 22 288 unique treatment pathways. The most common pathways were levetiracetam monotherapy (43%), gabapentin monotherapy (10%), and valproate monotherapy (5%). Gabapentin was the most common second‐ and third‐line ASM. Whereas only 2% of pathways involved first‐line lacosamide, those pathways accounted for 19% of cost. Gabapentin and valproate use was increased and levetiracetam use was decreased in beneficiaries with mood disorders compared to beneficiaries without mood disorders. Levetiracetam use was increased and gabapentin, valproate, lamotrigine, and topiramate use was decreased in beneficiaries aged >65 years compared with those aged 65 years or less. Lamotrigine, levetiracetam, and lacosamide use was increased and gabapentin use was decreased in beneficiaries whose initial prescriber was a neurologist compared to those whose prescriber was not a neurologist.

Significance

Levetiracetam monotherapy was the most common pathway, although substantial heterogeneity existed. Lacosamide accounted for a small percentage of ASMs but a disproportionately large share of cost. Neurologists were more likely to prescribe lamotrigine compared with nonneurologists, and lamotrigine was prescribed far less frequently than may be endorsed by guidelines. Future work may explore patient‐ and physician‐driven factors underlying ASM choices.

Clinical and EEG factors associated with antiseizure medication resistance in idiopathic generalized epilepsy

OBJECTIVE

We sought to determine which combination of clinical and electroencephalography (EEG) characteristics differentiate between an antiseizure medication (ASM)-resistant vs ASM-responsive outcome for patients with idiopathic generalized epilepsy (IGE).

METHODS

This was a case-control study of ASM-resistant cases and ASM-responsive controls with IGE treated at five epilepsy centers in the United States and Australia between 2002 and 2018. We recorded clinical characteristics and findings from the first available EEG study for each patient. We then compared characteristics of cases vs controls using multivariable logistic regression to develop a predictive model of ASM-resistant IGE.

RESULTS

We identified 118 ASM-resistant cases and 114 ASM-responsive controls with IGE. First, we confirmed our recent finding that catamenial epilepsy is associated with ASM-resistant IGE (odds ratio [OR] 3.53, 95% confidence interval [CI] 1.32-10.41, for all study subjects) after covariate adjustment. Other independent factors seen with ASM resistance include certain seizure-type combinations (absence, myoclonic, and generalized tonic-clonic seizures [OR 7.06, 95% CI 2.55-20.96]; absence and generalized tonic-clonic seizures [OR 4.45, 95% CI 1.84-11.34]), as well as EEG markers of increased generalized spike-wave discharges (GSWs) in sleep (OR 3.43, 95% CI 1.12-11.36 for frequent and OR 7.21, 95% CI 1.50-54.07 for abundant discharges in sleep) and the presence of generalized polyspike trains (GPTs; OR 5.49, 95% CI 1.27-38.69). The discriminative ability of our final multivariable model, as measured by area under the receiver-operating characteristic curve, was 0.80.

SIGNIFICANCE

Multiple clinical and EEG characteristics independently predict ASM resistance in IGE. To improve understanding of a patient's prognosis, clinicians could consider asking about specific seizure-type combinations and track whether they experience catamenial epilepsy. Obtaining prolonged EEG studies to record the burden of GSWs in sleep and assessing for the presence of GPTs may provide additional predictive value.

Impact of COVID-19 on TB epidemiology in South Korea

SETTING: Five referral hospitals, South Korea.OBJECTIVE: To assess epidemiological changes in TB before and during the COVID-19 pandemic.DESIGN: This was a multicentre cohort study of 3,969 patients diagnosed with TB.RESULTS: We analysed 3,453 patients diagnosed with TB prior to the COVID-19 pandemic (January 2016-February 2020) and 516 during the pandemic (March-November 2020). During the pandemic, the number of patients visits declined by 15% from the previous 4-year average, and the number of patients diagnosed with TB decreased by 17%. Patients diagnosed during the pandemic were older than those diagnosed before the pandemic (mean age, 60.2 vs. 56.6 years, P < 0.001). The proportion of patients to have primary TB at a younger age (births after 1980) among those diagnosed with TB was significantly lower during the pandemic than before (17.8% in 2020 vs. 23.5% in 2016, 24.0% in 2017, 22.5% in 2018, 23.5% in 2019; P = 0.005).CONCLUSIONS: The COVID-19 pandemic resulted in a reduction in the number of visits to respiratory departments, leading to fewer patients being diagnosed with TB. However, our results suggest that universal personal preventive measures help to suppress TB transmission in regions with intermediate TB burden.

Inverse Laplace transformation analysis of stretched exponential relaxation

We investigate the effectiveness of the Inverse Laplace Transform (ILT) analysis method to extract the distribution of relaxation rates from nuclear magnetic resonance data with stretched exponential relaxation. Stretched-relaxation is a hallmark of a distribution of relaxation rates, and an analytical expression exists for this distribution for the case of a spin-1/2 nucleus. We compare this theoretical distribution with those extracted via the ILT method for several values of the stretching exponent and at different levels of experimental noise. The ILT accurately captures the distributions for β≲0.7, and for signal to noise ratios greater than ∼40; however the ILT distributions tend to introduce artificial oscillatory components. We further use the ILT approach to analyze stretched relaxation for spin I>1/2 and find that the distributions are accurately captured by the theoretical expression for I=1/2. Our results provide a solid foundation to interpret distributions of relaxation rates for general spin I in terms of stretched exponential fits.

Genomic analysis of "microphenotypes" in epilepsy

Large international consortia examining the genomic architecture of the epilepsies focus on large diagnostic subgroupings such as "all focal epilepsy" and "all genetic generalized epilepsy". In addition, phenotypic data are generally entered into these large discovery databases in a unidirectional manner at one point in time only. However, there are many smaller phenotypic subgroupings in epilepsy, many of which may have unique genomic risk factors. Such a subgrouping or "microphenotype" may be defined as an uncommon or rare phenotype that is well recognized by epileptologists and the epilepsy community, and which may or may not be formally recognized within the International League Against Epilepsy classification system. Here we examine the genetic structure of a number of such microphenotypes and report in particular on two interesting clinical phenotypes, Jeavons syndrome and pediatric status epilepticus. Although no single gene reached exome-wide statistical significance to be associated with any of the diagnostic categories, we observe enrichment of rare damaging variants in established epilepsy genes among Landau-Kleffner patients (GRIN2A) and pediatric status epilepticus patients (MECP2, SCN1A, SCN2A, SCN8A).

The mucin protein MUCL1 regulates melanogenesis and melanoma genes in a manner dependent on threonine content

Background

The regulation of melanogenesis has been investigated as a long‐held aim for pharmaceutical manipulations with denotations for malignancy of melanoma. Mucins have a protective function in epithelial organs; however, in the most outer organ, the skin, the role of mucins has not been studied enough.

Objectives

Our initial hypothesis developed from the identification of correlations between pigmentation and expressions of skin mucins, particularly those existing in skin tissue. We aimed to investigate the action of mucins in human melanocytic cells.

Materials and methods

The expression of mucin proteins in human skin was investigated using microarray data from the Human Protein Atlas consortium (HPA) and the Genotype‐Tissue Expression consortium (GTEx) database. Mucin expression was measured at RNA and protein levels in melanoma cells. The findings were further validated and confirmed by analysis of independent experiments.

Results

We found that the several mucin proteins showed expression in human skin cells and among these, mucin‐like protein 1 (MUCL1) showed the highest expression and also clear negative correlation with melanogenesis in epidermal melanocytes. We confirmed the correlations between melanogenesis and MUCL1 by revealing negative correlations in melanocytes with different melanin production, resulting from increased composition of threonine, mucin‐conforming amino acid, and increased autophagy‐related forkhead‐box O signalling. Furthermore, threonine itself affects melanogenesis and metastatic activity in melanoma cells.

Conclusions

We identified a significant association between MUCL1 and threonine with melanogenesis and metastasis‐related genes in melanoma cells. Our results define a novel mechanism of mucin regulation, suggesting diagnostic and preventive roles of MUCL1 in cutaneous melanoma.

Whatis already known about this topic?

Despite considerable advances in radioactive therapeutics or chemotherapeutic approaches for the treatment of abnormal melanogenesis, there are still many caveats to delivery, effectiveness and safety, thus leaving a necessity for more immediate pharmaceutical targets.

Mucins have protective and chemical barrier functions in epithelial organs; however, in the skin, mucin has scarce expression and is known only as a diagnostic aid in skin disorders such as mucinosis.

Whatdoes this study add?

We provide detailed analysis demonstrating the potential of mucin‐like protein 1 (MUCL1), which showed negative correlations in melanocytes with different melanin production, resulting from increased composition of threonine and increased autophagy‐related forkhead‐box O signalling in epidermal melanocytes and melanoma cells.

We established that through an alternative pathway for MUCL1 biosynthesis, threonine supplementation recovers MUCL1 levels in melanoma. Changes, brought on by the essential amino acid threonine, resulted in substantial modulations in melanogenesis and reduced metastasis‐related genes.

Whatis the translational message?

This study demonstrates for the first time that the mucin protein of skin cells is compounded by distorted mucin homeostasis, with major effects on melanogenesis and metastasis‐related genes in melanoma.

We anticipate that these novel findings will be of keen interest to the community of scientists and medical practitioners examining skin dysfunction.

Linked Comment: C. Casalou and D.J. Tobin. Br J Dermatol 2022; 186:388–389.

Plain language summary available online

Rising rates of hospital-onset Klebsiella spp. and Pseudomonas aeruginosa bacteraemia in NHS acute trusts in England: a review of national surveillance data, August 2020-February 2021

Increases in hospital-onset Klebsiella spp. and Pseudomonas aeruginosa bacteraemia rates in England were observed between August 2020 and February 2021 to the highest levels recorded since the start of mandatory surveillance in April 2017. Cases were extracted from England's mandatory surveillance database for key Gram-negative bloodstream infections. Incidence rates for hospital-onset bacteraemia cases increased from 8.9 (N=255) to 14.9 (N=394) per 100,000 bed-days for Klebsiella spp. [incidence rate ratio (IRR) 1.7, P<0.001], and from 4.9 (N=139) to 6.2 (N=164) per 100,000 bed-days for P. aeruginosa (IRR 1.3, P<0.001) (August 2020-February 2021). These incidence rates were higher than the average rates observed during the same period in the previous 3 years. These trends coincided with an increase in the percentage of hospital-onset bacteraemia cases that were also positive for severe acute respiratory syndrome coronavirus-2.