Utilization of the validated Psoriasis Epidemiology Screening Tool to identify signs and symptoms of psoriatic arthritis among those with psoriasis: a cross-sectional analysis from the US-based Corrona Psoriasis Registry

Background

Despite increasing awareness of the disease, rates of undiagnosed psoriatic arthritis (PsA) are high in patients with psoriasis (PsO). The validated Psoriasis Epidemiology Screening Tool (PEST) is a five‐item questionnaire developed to help identify PsA at an early stage.

Objectives

To assess the risk of possible undiagnosed PsA among patients with PsO and characterize patients based on PEST scores.

Methods

This study included all patients enrolled in the Corrona PsO Registry with data on all five PEST questions. Demographics, clinical characteristics and patient‐reported outcomes were compared in Corrona PsO Registry patients with PEST scores ≥3 and <3 using t‐tests for continuous variables and chi‐squared tests for categorical variables; scores ≥3 may indicate PsA.

Results

Of 1516 patients with PsO, 904 did not have dermatologist‐reported PsA; 112 of these 904 patients (12.4%) scored ≥3 and were significantly older, female, less likely to be working, and had higher BMI than patients with scores <3. They also had significantly longer PsO duration, were more likely to have nail PsO and had worse health status, pain, fatigue, Dermatology Life Quality Index and activity impairment.

Conclusions

Improved PsA screening is needed in patients with PsO because the validated PEST identified over one‐tenth of registry patients who were not noted to have PsA as having scores ≥3, who could have had undiagnosed PsA. Appropriate, earlier care is important because these patients were more likely to have nail PsO, worse health‐related quality of life and worse activity impairment.

Higher Incidence Rates of Comorbidities in Patients with Psoriatic Arthritis Compared with the General Population Using U.S. Administrative Claims Data

BACKGROUND

Psoriatic arthritis (PsA) is associated with multiple comorbid conditions, including cardiovascular (CV) comorbidities that impose a considerable burden on patients. Effective management of PsA requires an understanding of comorbidity profiles.

OBJECTIVE

To compare the frequency and incidence rates of comorbidities and hospitalizations among newly diagnosed PsA patients and a matched general population without PsA, using large national claims databases in the United States.

METHODS

This retrospective observational study used MarketScan databases from January 1, 2008, to September 30, 2015, to identify adult patients with newly diagnosed PsA (i.e., no PsA diagnosis during the 1 year before the first observed PsA diagnosis). The earliest date of PsA diagnosis was defined as the index date. Patients with no PsA diagnosis any time during the study period (controls) were directly matched to PsA patients with demographic characteristics. All patients had ≥ 2 years of medical and pharmacy coverage before the index date and ≥ 1 year of follow-up. Incident rates per 100 person-years for comorbidities of interest were evaluated. The hazard ratios of having various comorbid conditions for PsA patients were estimated by Cox proportional hazards models. All-cause and CV-related hospitalizations during the follow-up period were evaluated.

RESULTS

A total of 14,898 PsA patients and 35,037 matched controls met the study criteria. Compared with controls, PsA patients had a higher risk of CV disorders (incidence rate = 6.5 vs. 5.8; HR = 1.46; 95% CI = 1.37-1.56) and a higher risk of the majority of the specific CV disorders (hypertension, hyperlipidemia, coronary artery disease, cerebrovascular disease, peripheral vascular disease). PsA patients also had a higher risk for any autoimmune disease (incidence rate = 8.4 vs. 1.6; HR = 18.26; 95% CI = 17.18-19.40) and most autoimmune categories (psoriasis, ankylosing spondylitis, rheumatoid arthritis, multiple sclerosis, and other autoimmune disorders). Rates of other PsA-related comorbidities (diabetes, anxiety, fatigue, smoking, alcohol use, obesity or overweight, depression, osteoporosis, uveitis, eczema, and gout) were also significantly higher for PsA patients. The all-cause hospitalization rate was higher among PsA patients than controls (24.9% vs. 16.2%; P < 0.001). The CV-related hospitalization rate varied depending on whether the CV condition was the primary discharge diagnosis only or was any diagnosis on the inpatient claims. The rates of coronary artery disease hospitalizations were significantly higher in PsA patients than in controls with both methods of analysis (primary diagnosis: 0.8% vs. 0.5%; P < 0.001; nonprimary diagnosis: 3.2% vs. 2.2%; P < 0.001).

CONCLUSIONS

This retrospective U.S.-based claims study found that PsA patients had a high comorbidity burden. Compared with the non-PsA population, PsA patients were associated with a higher incidence of CV comorbidities, autoimmune diseases, and other PsA-related comorbidities and a higher rate of all-cause and CV-related hospitalizations. Understanding these comorbidity profiles may provide insight on the effect of comorbid conditions on disease management and health care utilization associated with PsA.

DISCLOSURES

This study was funded by Novartis. Kaine is a paid consultant for Novatis. Hur and Palmer are Novartis employees and stockowners. Song and Kim work for Truven Health Analytics, which received funding from Novartis to conduct this study.

Treatment Patterns Among Patients with Psoriatic Arthritis Treated with a Biologic in the United States: Descriptive Analyses from an Administrative Claims Database

BACKGROUND

In patients with psoriatic arthritis (PsA), limited data exist regarding patterns of biologic therapy use.

OBJECTIVE

To examine treatment patterns and therapy modifications in U.S. patients with PsA receiving a tumor necrosis factor inhibitor (TNFi) or an anti-interleukin (IL)-12/23 inhibitor.

METHODS

Adults with PsA who newly initiated a biologic therapy (index biologic) between January 1, 2013, and January 31, 2015, were included from the Optum Research Database. Biologic therapies comprised those that were approved by the FDA for the treatment of PsA at the time of the study initiation (adalimumab, certolizumab pegol, etanercept, golimumab, infliximab, or ustekinumab). Outcomes included adherence, persistence, and discontinuation of the index biologic; initiation of adjunctive medications (nonbiologics, including those commonly used for pain and/or inflammation); and dose escalation of the index biologic during the 12-month follow-up period.

RESULTS

Of the 1,235 patients included, 52.5% were female, and mean (SD) age was 50.3 (12.1) years. The mean (SD) duration of persistence with a newly initiated index biologic (etanercept [48.1%], adalimumab [24.0%], infliximab [10.4%], golimumab [8.3%], ustekinumab [7.2%], or certolizumab pegol [2.0%]) was 246 (128) days; 44.5% of patients persisted with the index biologic for ≥ 12 months. During the 12-month follow-up period, 22.9% of patients switched to a different biologic, 26.8% discontinued without switching or restarting, and 5.8% discontinued and restarted the index biologic. Of the 1,010 patients who persisted with the index biologic for > 90 days, 45.6% received ≥ 1 adjunctive medication during the period from 90 days after the index date to the end of persistence or 12 months. The most commonly initiated adjunctive medications were corticosteroids (22.0%), opioids (17.1%), and nonsteroidal anti-inflammatory drugs (12.9%). Overall, 9.6% of patients had a dose escalation of the index biologic in the immediate 12-month post-index period.

CONCLUSIONS

This real-world study of treatment patterns for PsA, which used a large U.S. claims database, demonstrated that the majority of patients with PsA discontinued their index biologic (TNFi or anti-IL-12/23 inhibitor) before 12 months. Nearly half of patients initiated an adjunctive medication, many of which were pain and conventional anti-inflammatory medications.

DISCLOSURES

This study was sponsored by Novartis Pharmaceuticals. Optum was commissioned by Novartis to conduct this study, but employment was not contingent on results of the study. Walsh is a paid consultant for Novartis. Adejoro was an employee of Optum at the time of the study and writing of the manuscript. Chastek is an employee of Optum. Palmer and Hur are employees of Novartis. Results of this study were presented as an abstract and poster at the Academy of Managed Care Pharmacy Nexus 2017; October 16-19, 2017; Dallas, TX; and the EULAR 2017 Annual European Congress of Rheumatology; June 14-17, 2017; Madrid, Spain.

Characterization of Patients With Ankylosing Spondylitis and Nonradiographic Axial Spondyloarthritis in the US-Based Corrona Registry

Objective

To describe the characteristics of patients with ankylosing spondylitis (AS) and patients with nonradiographic axial spondyloarthritis (SpA) in the US.

Methods

Demographics, clinical characteristics, patient‐reported outcomes, and treatment characteristics of patients with AS and those with nonradiographic axial SpA were assessed at the time of enrollment in the Corrona Psoriatic Arthritis/Spondyloarthritis Registry. Patients with AS were defined as those who fulfilled the 1984 modified New York criteria for AS; patients with nonradiographic axial SpA were defined as all other patients with axial SpA who did not fulfill the radiology criterion.

Results

Of the 407 patients with a diagnosis of axial SpA who were included in this study, 310 had AS, and 97 had nonradiographic axial SpA. Although patients with nonradiographic axial SpA were younger and showed a trend toward a shorter symptom duration, the nonradiographic axial SpA and AS groups shared a similar disease burden, as reflected by comparisons of disease activity and function, quality of life, pain, fatigue, job absenteeism, and loss of work productivity (all P > 0.05). The proportions of patients with nonradiographic axial SpA and patients with AS who received prior biologic disease‐modifying drugs (DMARDs) (74.2% and 64.8%, respectively) or were currently receiving biologic DMARDs (63.9% and 61.3%, respectively) were also similar (P > 0.05).

Conclusion

This was the first nationwide study to characterize patients with AS and nonradiographic axial SpA in the US. Consistent with studies published outside of the US, this study showed that patients with nonradiographic axial SpA and patients with AS shared a comparable degree of disease burden and had similar treatment patterns in clinical practice.

Direct healthcare costs and comorbidity burden among patients with psoriatic arthritis in the USA

This study assessed the comorbidity burden and direct healthcare costs associated with psoriatic arthritis (PsA). Adults (18-64 years) with ≥ 2 claims for a PsA diagnosis ≥ 30 days apart in the Truven Health MarketScan database (July 2009-June 2014) were selected as the case group. The index date was randomly selected after the first claim for PsA. Controls free of PsA and psoriasis (PsO) in their entire claims history were assigned the same index date and were matched with the cases on age, gender, and geographic region. All patients had ≥ 12 months of continuous eligibility before and after (study period) the index date. PsA-associated comorbidities, medication use, and medical service utilization were compared between matched groups using Wilcoxon signed rank and McNemar's tests. Costs were compared using multivariable generalized linear models. The 35,061 matched pairs had a mean age of 49.11 ± 10.20 years and 52.73% were female. During the study period, PsA patients had more PsA-associated comorbidities and significantly higher medication use than controls (all-cause medications 96.64 vs. 78.95%, p < 0.0001). PsA patients had significantly greater medical service use (inpatient admissions, hospitalization days, emergency room visits, outpatient services; all p < 0.0001) and higher annual direct healthcare costs per patient than controls (adjusted cost difference [ACD] = $18,482, including higher medical costs [ACD = $6440] and all-cause pharmacy costs [ACD = $11,737]; all p < 0.0001). Overall, PsA patients had a significantly higher PsA-related comorbidity burden, healthcare utilization, and direct healthcare costs than people free of PsA and PsO, underscoring the need for more effective treatments and improved care delivery systems.

Influence of Axial Involvement on Clinical Characteristics of Psoriatic Arthritis: Analysis from the Corrona Psoriatic Arthritis/Spondyloarthritis Registry

Objective.

We analyzed the characteristics of patients with psoriatic arthritis (PsA) with and without axial involvement in the US-based Corrona Psoriatic Arthritis/Spondyloarthritis Registry.

Methods.

All patients were included who had PsA and data on axial involvement, defined as physician-reported presence of spinal involvement at enrollment, and/or radiograph or magnetic resonance imaging showing sacroiliitis. Demographics, clinical measures, patient-reported outcomes, and treatment characteristics were assessed at enrollment.

Results.

Of 1530 patients with PsA, 192 (12.5%) had axial involvement and 1338 (87.5%) did not. Subgroups were similar in sex, race, body mass index, disease duration, presence of dactylitis, and prevalence of most comorbidities. However, patients with axial involvement were younger and more likely to have enthesitis, a history of depression, and more frequently used biologics at enrollment. They were also more likely to have moderate/severe psoriasis (body surface area ≥ 3%, 42.5% vs 31.5%) and significantly worse disease as measured by a lower prevalence of minimal disease activity (30.1% vs 46.2%) and higher nail psoriasis scores [visual analog scale (VAS) 11.4 vs 6.5], enthesitis counts (5.1 vs 3.4), Bath Ankylosing Spondylitis Disease Activity Index (4.7 vs 3.5) scores, Bath Ankylosing Spondylitis Functional Index (3.8 vs 2.5) scores, C-reactive protein levels (4.1 vs 2.4 mg/l), and scores for physical function (Health Assessment Questionnaire, 0.9 vs 0.6), pain (VAS, 47.7 vs 36.2), and fatigue (VAS, 50.2 vs 38.6).

Conclusion.

Presence of axial involvement was associated with a higher likelihood of moderate/severe psoriasis, with higher disease activity and greater effect on quality of life. These findings highlight the importance of monitoring patients with PsA for signs of axial symptoms or spinal involvement.

Baseline patient characteristics associated with response to biologic therapy in patients with psoriatic arthritis enrolled in the Corrona Psoriatic Arthritis/Spondyloarthritis Registry

Objectives

To compare baseline characteristics between patients with psoriatic arthritis (PsA) who achieved and did not achieve minimal disease activity (MDA) with biologic therapy in the US-based Corrona Psoriatic Arthritis/Spondyloarthritis Registry.

Methods

Patients with PsA aged ≥18 years enrolled between March 2013 and March 2016 who were receiving biologics at enrolment (baseline), not in MDA and had ≥2 follow-up visits were included. Patients were classified as those who remained on their index biologic and achieved MDA at the second follow-up visit (MDA achievers (MDA-A)) and those who did not (MDA non-achievers (MDA-NA)). Demographics, clinical characteristics, patient-reported outcomes and medication history were compared between groups.

Results

Of 148 patients with PsA who met the inclusion criteria, 34 (23.0%) and 114 (77.0%) were classified as MDA-A and MDA-NA, respectively. At baseline, most patients (96.6%) were receiving tumour necrosis factor inhibitors, and both groups were similar in age, sex, race, medication history, enthesitis and dactylitis counts, disease duration and comorbidities. Compared with MDA-A, MDA-NA had significantly worse mean tender joint count (7.2 vs 3.4), patient-reported pain (51.2 vs 35.7), patient-reported fatigue (54.1 vs 42.4), physical function (Health Assessment Questionnaire, 1.0 vs 0.6), Bath Ankylosing Disease Activity Index (5.0 vs 3.4) and Bath Ankylosing Spondylitis Functional Index (4.0 vs 2.0) scores (all p<0.05).

Conclusions

Approximately one in four patients achieved MDA with their index biologic at the time of the second follow-up visit. Both groups were similar in several baseline demographic and clinical features; however, patients who did not achieve MDA generally had worse tender joint counts and patient-reported outcomes.

Treatment Patterns Among Patients with Psoriatic Arthritis Treated with a Biologic in the United States: Descriptive Analyses from an Administrative Claims Database

BACKGROUND

In patients with psoriatic arthritis (PsA), limited data exist regarding patterns of biologic therapy use.

OBJECTIVE

To examine treatment patterns and therapy modifications in U.S. patients with PsA receiving a tumor necrosis factor inhibitor (TNFi) or an anti-interleukin (IL)-12/23 inhibitor.

METHODS

Adults with PsA who newly initiated a biologic therapy (index biologic) between January 1, 2013, and January 31, 2015, were included from the Optum Research Database. Biologic therapies comprised those that were approved by the FDA for the treatment of PsA at the time of the study initiation (adalimumab, certolizumab pegol, etanercept, golimumab, infliximab, or ustekinumab). Outcomes included adherence, persistence, and discontinuation of the index biologic; initiation of adjunctive medications (nonbiologics, including those commonly used for pain and/or inflammation); and dose escalation of the index biologic during the 12-month follow-up period.

RESULTS

Of the 1,235 patients included, 52.5% were female, and mean (SD) age was 50.3 (12.1) years. The mean (SD) duration of persistence with a newly initiated index biologic (etanercept [48.1%], adalimumab [24.0%], infliximab [10.4%], golimumab [8.3%], ustekinumab [7.2%], or certolizumab pegol [2.0%]) was 246 (128) days; 44.5% of patients persisted with the index biologic for ≥ 12 months. During the 12-month follow-up period, 22.9% of patients switched to a different biologic, 26.8% discontinued without switching or restarting, and 5.8% discontinued and restarted the index biologic. Of the 1,010 patients who persisted with the index biologic for > 90 days, 45.6% received ≥ 1 adjunctive medication during the period from 90 days after the index date to the end of persistence or 12 months. The most commonly initiated adjunctive medications were corticosteroids (22.0%), opioids (17.1%), and nonsteroidal anti-inflammatory drugs (12.9%). Overall, 9.6% of patients had a dose escalation of the index biologic in the immediate 12-month post-index period.

CONCLUSIONS

This real-world study of treatment patterns for PsA, which used a large U.S. claims database, demonstrated that the majority of patients with PsA discontinued their index biologic (TNFi or anti-IL-12/23 inhibitor) before 12 months. Nearly half of patients initiated an adjunctive medication, many of which were pain and conventional anti-inflammatory medications. DISCLOSURES This study was sponsored by Novartis Pharmaceuticals. Optum was commissioned by Novartis to conduct this study, but employment was not contingent on results of the study. Walsh is a paid consultant for Novartis. Adejoro was an employee of Optum at the time of the study and writing of the manuscript. Chastek is an employee of Optum. Palmer and Hur are employees of Novartis. Study concept and design were contributed by Walsh, Chastek, Adejoro, Palmer, and Hur. Adejoro, Chastek, Walsh, Palmer, and Hur collected the data. Data interpretation was performed by Walsh, Palmer, Adejoro, Chastek, and Hur. The manuscript was written and revised by Walsh and Hur, along with the other authors. Results of this study were presented as an abstract and poster at the Academy of Managed Care Pharmacy Nexus 2017; October 16-19, 2017; Dallas, Texas; and the EULAR 2017 Annual European Congress of Rheumatology; June 14-17, 2017; Madrid, Spain.

Evaluation of Self-reported Patient Experiences: Insights from Digital Patient Communities in Psoriatic Arthritis

Objective.

To evaluate the types of experiences and treatment access challenges of patients with psoriatic arthritis (PsA) using self-reported online narratives.

Methods.

English-language patient narratives reported between January 2010 and May 2016 were collected from 31 online sources (general health social networking sites, disease-focused patient forums, treatment reviews, general health forums, mainstream social media sites) for analysis of functional impairment and 40 online sources for assessment of barriers to treatment. Using natural language processing and manual curation, patient-reported experiences were categorized into 6 high-level concepts of functional impairment [social, physical, emotional, cognitive, role activity (SPEC-R), and general] and 6 categories to determine barriers to treatment access (coverage ineligibility, out-of-pocket cost, issues with assistance programs, clinical ineligibility, formulary placement/sequence, doctor guidance). The SPEC-R categorization was also applied to 3 validated PsA patient-reported outcome (PRO) instruments to evaluate their capacity to collect lower-level subconcepts extracted from patient narratives.

Results.

Of 15,390 narratives collected from 3139 patients with PsA for exploratory analysis, physical concepts were the most common (81.5%), followed by emotional (50.7%), cognitive (20.0%), role activity (8.1%), and social (5.6%) concepts. Cognitive impairments and disease burden on family and parenting were not recorded by PsA PRO instruments. The most commonly cited barriers to treatment were coverage ineligibility (51.6%) and high out-of-pocket expenses (31.7%).

Conclusion.

Patients often discussed physical and emotional implications of PsA in online platforms; some commonly used PRO instruments in PsA may not identify cognitive issues or parenting/family burden. Nearly one-third of patients with PsA reported access barriers to treatment.

Clinical Characteristics, Disease Activity, and Patient-Reported Outcomes in Psoriatic Arthritis Patients With Dactylitis or Enthesitis: Results From the Corrona Psoriatic Arthritis/Spondyloarthritis Registry

OBJECTIVE

To characterize psoriatic arthritis (PsA) patients with dactylitis or enthesitis and evaluate the associations of these manifestations with disease activity and patient-reported outcomes.

METHODS

Using the Corrona PsA/Spondyloarthritis Registry, patient characteristics, disease activity, and patient-reported outcomes at registry enrollment were assessed for PsA patients ages ≥18 years with or without dactylitis or enthesitis. Regression models were used to evaluate associations of dactylitis and enthesitis with outcomes, including minimal disease activity, Health Assessment Questionnaire scores, patient-reported pain and fatigue, and work productivity (Work Productivity and Activity Impairment questionnaire). Adjustments were made for age, sex, race, body mass index, disease duration, and history of biologic agent, disease-modifying antirheumatic drug, and prednisone use.

RESULTS

This analysis included 1,567 PsA patients (420 with enthesitis; 228 with dactylitis). Patients with versus without dactylitis or enthesitis had greater disease activity and were less likely to be in minimal disease activity (P < 0.05). Patients with versus without enthesitis had poorer functional status as assessed by the Health Assessment Questionnaire (adjusted P = 4.15 x 10^-5 ), greater patient-reported pain and fatigue (adjusted P < 0.0001), and greater likelihood of any impairment while working (adjusted odds ratio [OR] 1.57, P = 0.027), overall work impairment (OR 1.85, P = 0.006), and activity impairment (OR 1.77, P = 0.008). Dactylitis was associated with similar numerical trends, but differences versus patients without dactylitis did not reach statistical significance.

CONCLUSION

Enthesitis and dactylitis are associated with greater overall disease burden of PsA, underscoring the importance of identifying, assessing, and effectively managing these periarticular manifestations.

The effect of bolus volume on laryngeal closure and UES opening in swallowing: Kinematic analysis using 320-row area detector CT study

This study investigated the effects of three different volumes of honey-thick liquid on the temporal characteristics of swallowing. Twenty-six healthy subjects (15 males, 11 females) underwent 320-row area detector CT scan while swallowing 3, 10 and 20 mL of honey-thick liquid barium. Three-dimensional images were created at 10 images/s. Kinematic events involving six structures (velopharynx, hyoid bone, epiglottis, laryngeal vestibule (LV), true vocal cords (TVC), upper esophageal sphincter (UES)) and timing of bolus movement were timed using frame by frame analysis. The overall sequence of events did not differ across three volumes; however, increasing bolus volume significantly changed the onset and termination of events. The bolus head reached to pharynx and esophagus earlier and the duration of bolus passing through UES was significantly longer in 10 and 20 mL compared to 3 mL (P < .05). Consequently, the onset of UES opening was significantly earlier with increased volume (P < .05). LV and TVC closure occurred later in 20 mL compared to 3 mL (P < .05). These changes in motion of pharynx and larynx appeared to promote swallow safety by preventing aspiration, suggesting that anatomical structure movements adapt in response to bolus volume. Our findings also suggest that the pharyngeal swallow behaviours may be modified by afferents in the oral cavity. The three-dimensional visualization and quantitative measurements provided by 320-ADCT provide essential benchmarks for understanding swallowing, both normal and abnormal.

Treatment modifying factors of biologics for psoriatic arthritis: a systematic review and Bayesian meta-regression

OBJECTIVES

The aim of this study was to explore factors that modify treatment effects of non-conventional biologics versus placebo in patients with psoriatic arthritis.

METHODS

A systematic literature review and meta-regression was conducted. The biologics included etanercept, infliximab, adalimumab, golimumab, certolizumab, ustekinumab, tocilizumab, anakinra, abatacept, rituximab, and secukinumab. Outcomes included American College of Rheumatology (ACR) 20 and 50, Psoriasis Area Severity Index (PASI) 75, and 36-Item Short Form Health Survey (SF-36) Physical and Mental Component Summaries (PCS and MCS).

RESULTS

Twelve RCTs were eligible for meta-regression. Treatment effects for ACR-20 at 12 weeks were higher in trials with longer disease durations (OR=2.94), and lower in trials enrolling older patients (OR=0.48), and those recently published (OR=0.49). Treatment effects for ACR-50 at 12 weeks were higher in trials with more males (OR=2.27), but lower in trials with high prior anti-TNF use (OR=0.28) and recently published trials (OR=0.37). For PASI-75, trials with more male patients (24 weeks: OR=2.56), and with higher swollen and tender joint counts (12 weeks: OR=8.33; 24 weeks: OR=14.44) showed higher treatment effects, and trials with high prior anti-TNF use had lower effects (OR=0.41). Treatment effects for SF-36 PCS at 24 weeks were higher in trials with longer psoriasis disease durations (OR=2.95) and PsA disease durations (OR=4.76), and those published earlier (OR=4.19).

CONCLUSIONS

Our analyses show that differences in baseline characteristics may explain some of the differences in response to biologics versus placebo across different trials. Accounting for these factors in future studies will likely be important.

Clinical and Patient-reported Outcomes in Patients with Psoriatic Arthritis (PsA) by Body Surface Area Affected by Psoriasis: Results from the Corrona PsA/Spondyloarthritis Registry

OBJECTIVE

Psoriatic arthritis (PsA) is commonly comorbid with psoriasis; the extent of skin lesions is a major contributor to psoriatic disease severity/burden. We evaluated whether extent of skin involvement with psoriasis [body surface area (BSA) > 3% vs ≤ 3%] affects overall clinical and patient-reported outcomes (PRO) in patients with PsA.

METHODS

Using the Corrona PsA/Spondyloarthritis Registry, patient characteristics, disease activity, and PRO at registry enrollment were assessed for patients with PsA aged ≥ 18 years with BSA > 3% versus ≤ 3%. Regression models were used to evaluate associations of BSA level with outcome [modified minimal disease activity (MDA), Health Assessment Questionnaire (HAQ) score, patient-reported pain and fatigue, and the Work Productivity and Activity Impairment questionnaire score]. Adjustments were made for age, sex, race, body mass index, disease duration, and history of biologics, disease-modifying antirheumatic drug, and prednisone use.

RESULTS

This analysis included 1240 patients with PsA with known BSA level (n = 451, BSA > 3%; n = 789, BSA ≤ 3%). After adjusting for potential confounding variables, patients with BSA > 3% versus ≤ 3% had greater patient-reported pain and fatigue and higher HAQ scores (p = 2.33 × 10^-8, p = 0.002, and p = 1.21 × 10^-7, respectively), were 1.7× more likely not to be in modified MDA (95% CI 1.21-2.41, p = 0.002), and were 2.1× more likely to have overall work impairment (1.37-3.21, p = 0.0001).

CONCLUSION

These Corrona Registry data show that substantial skin involvement (BSA > 3%) is associated with greater PsA disease burden, underscoring the importance of assessing and effectively managing psoriasis in patients with PsA because this may be a contributing factor in PsA severity.

Economic impact of biologic utilization patterns in patients with psoriatic arthritis

The aim of the study is to examine the frequency and costs associated with above-label dosing of biologics in patients with psoriatic arthritis (PsA). MarketScan identified adults with ≥1 International Classification of Diseases, Clinical Modification diagnosis for PsA and ≥1 pharmacy claim for biologics of interest between January 1, 2011 and December 31, 2013. The first biologic claim was the index date with a 1-year follow-up period and three additional months to confirm continuous biologic use. Exclusion criteria included switching to a different biologic or diagnosis with another autoimmune disease. During the follow-up period, duration was stratified into three groups: <30, 30–179, and ≥180 days of above-label dosing (>10% of the labeled dose). One-tailed t test was conducted to examine the impact of above-label duration on healthcare costs. We identified 4245 PsA patients receiving etanercept (n = 2342), adalimumab (n = 1788), and golimumab (n = 115). Above-label dosing of <30 days (85% adalimumab, 90.4% etanercept, and 95.7% golimumab) and ≥180 days (9.6% adalimumab, 4.1% etanercept, and 2.6% golimumab) was observed. All-cause total healthcare costs for <30 days of above-label use (etanercept $30,625, adalimumab $31,620, and golimumab $37,224), 30–179 days (etanercept $35,602, adalimumab $38,915, and golimumab $64,349), and ≥180 days (etanercept $55,349, adalimumab $54,176, and golimumab $47,993) were reported. Longer above-label duration (30–179 versus <30 days, ≥180 versus 30–179 and ≥180 days) with etanercept or adalimumab was significantly associated with higher mean increased total all-cause healthcare, PsA-specific healthcare, and biologic costs (p < 0.05). Above-label use of anti-TNF biologics does occur and is associated with significantly increased healthcare costs.

Misalignment between physicians and patient satisfaction with psoriatic arthritis disease control

The main objective of the present study is to evaluate the misalignment between psoriatic arthritis (PsA) patient- and physician-reported satisfaction with PsA control. Data came from the Adelphi Rheumatology Disease Specific Programme, a retrospective, cross-sectional survey of US-based rheumatologists and patients. Physicians provided satisfaction and clinical characteristics on tender joint count, swollen joint count, and percent body surface area (BSA) affected by psoriasis. Patients provided data on satisfaction, the Work Productivity Activity Impairment and Health Assessment Questionnaire-Disability Index (HAQ-DI) questionnaires. Based on their satisfaction response, patient-physician pairs were classified into aligned (both satisfied or dissatisfied) or misaligned (rated satisfaction differently) groups. Multivariate analysis evaluated association of characteristics with misalignment. Among 305 paired patient-physician records analyzed, 23.6% were misaligned and 76.4% were aligned. The misaligned group had shorter disease duration (mean years, 5.2 vs. 6.4), used fewer biologic disease-modifying antirheumatic drugs (49.3 vs. 62.9%), had more swollen (mean, 3.7 vs. 1.9, P = 0.0002) and tender joints (mean, 5.6 vs. 2.9, P < 0.0001), greater proportion of patients with comorbidities (72.2 vs. 63.1%), and >3% BSA affected by psoriatic skin lesions (64.2 vs. 55.1%). Misaligned patients reported greater work impairment (mean, 38.7 vs. 21.4, P = 0.0004), daily activities (mean, 38.7 vs. 22.3, P < 0.0001), and higher disease burden (mean HAQ-DI; 0.56 vs. 0.37, P = 0.0001). Multivariate analysis found the number of swollen joints (P = 0.02) and HAQ-DI score (P = 0.03) was significantly associated with misalignment among all patients; however, not in the subgroup of employed patients. Patient-physician misalignment is associated with increased disease activity and disability among patients with PsA.

Treatment patterns and costs for anti-TNFα biologic therapy in patients with psoriatic arthritis

Background

Real-world data regarding anti-tumor necrosis factor alpha (anti-TNFα) biologic therapy use in psoriatic arthritis (PsA) are limited; therefore, we described treatment patterns and costs of anti-TNFα therapy in PsA patients in the United States.

Methods

PsA patients (N = 990) aged ≥18 years who initiated anti-TNFα therapy were selected from MarketScan claims databases (10/1/2009 to 9/30/2010). Number of patients on first- (n = 881), second- (n = 72), or third- or greater (n = 37) line of anti-TNFα therapy, persistence, time-to-switch or modification, pharmacy and medical costs (measured per patient per month [PPPM]) for each line of therapy were observed during the 3-year follow-up.

Results

PsA patients receiving only one line of anti-TNFα therapy remained on first-line for ~17 months while those who switched to second- or third- or greater persisted on first-line for ~11 to 12 months, respectively. Time to first-line modification was longer for patients who switched to third- or greater line therapy (7 months) than those who did not switch or switched to second-line (range, ~2 to 4 months). Time-to-switch and time to first-line modification was progressively shorter with each line of therapy for patients who received third- or greater line. PPPM medical costs were higher for patients who did not switch ($322) than those who switched to second- ($167) or third- or greater ($217) line. PPPM pharmacy costs were greater for patients with third- or greater line therapy ($2539) than those who did not switch ($1985) or switched to second-line ($2045).

Conclusion

While the majority of patients received only one line of anti-TNFα therapy, a subset of patients switched to multiple lines of therapy during the 3-year follow-up period. Persistence and therapy modifications differed between these patients and those receiving only one line. Overall medical costs were highest for patients who did not switch, and pharmacy costs increased as patients switched to each new line of therapy.

Treatment satisfaction in cystic fibrosis: early patient experience with tobramycin inhalation powder

BACKGROUND

This study assessed treatment satisfaction of cystic fibrosis (CF) patients in a routine clinical setting for tobramycin inhalation powder (TIP), the first dry powder-inhaled antibiotic for Pseudomonas aeruginosa infection.

METHODS

CF patients aged 6 years or older treated with at least one cycle of TIP completed a web survey on experience with TIP, including the Treatment Satisfaction Questionnaire for Medication (TSQM). Regression analysis determined the factors associated with TSQM global satisfaction.

RESULTS

Eighty patients (mean age ± standard deviation: 24.4±9.4 years; 57.5% female; mean forced expiratory volume in 1 second ± standard deviation: 67.1%±27.3% predicted) completed the survey. The majority expressed satisfaction with TIP's administration time (100%), time to clean (97.1%), portability (97.1%), and ease of use (94.3%). Effectiveness was significantly associated with TSQM global satisfaction (regression R-squared: 0.54).

CONCLUSION

Patient preferences for TIP were based on administration time and ease of use. Global satisfaction was related to greater patient-perceived effectiveness.

Healthcare Resource Use and Direct Costs in Patients with Ankylosing Spondylitis and Psoriatic Arthritis in a Large US Cohort

Objective.

Direct costs of ankylosing spondylitis (AS) and psoriatic arthritis (PsA) have not been well characterized in the United States. This study assessed healthcare resource use and direct cost of AS and PsA, and identified predictors of all-cause medical and pharmacy costs.

Methods.

Adults aged ≥ 18 with a diagnosis of AS and PsA were identified in the MarketScan databases between October 1, 2011, and September 30, 2012. Patients were continuously enrolled with medical and pharmacy benefits for 12 months before and after the index date (first diagnosis). Baseline demographics and comorbidities were identified. Direct costs included hospitalizations, emergency room and office visits, and pharmacy costs. Multivariable regression was used to determine whether baseline covariates were associated with direct costs.

Results.

Patients with AS were younger and mostly men compared with patients with PsA. Hypertension and hyperlipidemia were the most common comorbidities in both cohorts. A higher percentage of patients with PsA used biologics and nonbiologic disease-modifying drugs (61.1% and 52.4%, respectively) compared with patients with AS (52.5% and 21.8%, respectively). Office visits were the most commonly used resource by patients with AS and PsA (∼11 visits). Annual direct medical costs [all US dollars, mean (SD)] for patients with AS and PsA were $6514 ($32,982) and $5108 ($22,258), respectively. Prescription drug costs were higher for patients with PsA [$14,174 ($15,821)] compared with patients with AS [$11,214 ($14,249)]. Multivariable regression analysis showed higher all-cause direct costs were associated with biologic use, age, and increased comorbidities in patients with AS or PsA (all p < 0.05).

Conclusion.

Biologic use, age, and comorbidities were major determinants of all-cause direct costs in patients with AS and PsA.

Association of persistent and transient worsening renal function with mortality risk, readmissions risk, length of stay, and costs in patients hospitalized with acute heart failure

BACKGROUND

Data comparing effects of transient worsening renal function (WRFt) and persistent WRF (WRFp) on outcomes in patients hospitalized with acute heart failure (AHF) are lacking. We determined the characteristics of hospitalized AHF patients who experienced no worsening renal function (non-WRF), WRFt, or WRFp, and the relationship between cohorts and AHF-related outcomes.

METHODS AND RESULTS

A patient's first AHF hospitalization (index) was identified in the Cerner Health Facts(®) database (January 2008-March 2011). Patients had WRF if serum creatinine (SCr) was ≥0.3 mg/dL and increased ≥25% from baseline, and they were designated as WRFp if present at discharge or WRFt if not present at discharge. A total of 55,436 patients were selected (non-WRF =77%, WRFp =10%, WRFt =13%). WRFp had greater comorbidity burden than WRFt. At index hospitalization, WRFp patients had the highest mortality, whereas WRFt patients had the longest length of stay (LOS) and highest costs. These trends were observed at 30, 180, and 365 days postdischarge and confirmed by multivariable analyses. WRF patients had more AHF-related readmissions than non-WRF patients. In sensitivity analyses of the patient subset with live index hospitalization discharges, postdischarge LOS and costs were highest in WRFt patients, whereas mortality associated with a HF hospitalization was significantly higher for WRF patients vs non-WRF patients, with no difference between WRFp and WRFt.

CONCLUSION

In patients hospitalized for AHF, WRFp was associated with the highest mortality, whereas WRFt was associated with the highest LOS and costs. WRF patients had higher readmissions than non-WRF patients. Transient increases in SCr appear to be associated with detrimental outcomes, especially longer LOS and higher costs.

Abstract 284: Association of Worsening Renal Function With Mortality and Heart Failure Readmissions in Patients Hospitalized With Acute Heart Failure

Background: The impact of worsening renal function (WRF) on heart failure (HF)-related readmissions (HFR) and HF-related mortality among hospitalized acute HF patients was examined.

Methods: A patient’s first acute HF hospitalization event (index) was identified in Cerner Health Facts® database (Jan 2008–March 2011). Patients were categorized as WRF (serum creatinine ≥0.3 mg/dL and ≥25% increase from baseline) persisting at discharge (WRFp), not persisting at discharge (WRFt), or non WRF. Outcomes were compared for the index hospitalization and cumulatively at 30, 180, and 365 days post discharge. Generalized linear model (HFR count) and logistic regression models (mortality) were constructed.

Results: The acute HF patients (77% [42,507 of 55,436] non WRF, 10% [5,563 of 55,436] WRFp, and 13% [7,366 of 55,436] WRFt) were 53% [29,442 of 55,436] female with a mean age of 72.4 (±14.3) years. WRFp had higher index mortality rates (23.6% [1,312 of 5,563] vs 5.7% [418 of 7,366] vs 3.9% [1,673 of 42,507], P<0.0001) than WRFt and non WRF patients, respectively. For mortality, 70% [3,403 of 4,883] of deaths occurred at the index hospitalization. WRFp and WRFt patients combined had higher 30-day HFR counts than non WRF patients (0.12 vs 0.09, P<0.0001), but there was no difference between WRFp and WRFt. These observations were consistent across all cumulative time points and confirmed by multivariable analyses.

Conclusion: Acute HF patients with WRF were more likely to die or be readmitted than non WRF patients. WRFp patients experienced higher HF-related mortality rates than WRFt patients but there were no differences in HFR between WRFt and WRFp.

Use of drugs with anticholinergic properties among nursing home residents with dementia: a national analysis of Medicare beneficiaries from 2007 to 2008

BACKGROUND

Older adults with dementia are vulnerable to the central deteriorating effects of drugs with anticholinergic properties (DAPs). These effects include falls and confusion and may exacerbate dementia-related symptoms. Many individuals with dementia also receive acetylcholinesterase inhibitors (AChEIs), indicated for mild to moderate Alzheimer's disease. AChEIs have opposing effects to DAPs and, consequently, concomitant use of DAPs and AChEIs may further impair cognition among patients with dementia.

OBJECTIVES

Our objectives were to (1) evaluate the anticholinergic burden among nursing home (NH) residents with dementia; (2) characterize trends in use of DAPs and concomitant use of DAPs and AChEIs among NH residents with dementia; and (3) identify factors associated with the use of DAPs and concomitant use of DAPs and AChEIs.

METHODS

We conducted a retrospective analysis of Medicare data from 2007 to 2008 linked to the Minimum Data Set.

RESULTS

During the study period, 53,805 (77%) NH residents with dementia used at least one DAP each month. Sixty-seven percent of residents with dementia used Anticholinergic Cognitive Burden Scale (ACBS) level 1 DAPs, 3% used level 2 DAPs, and 31% used level 3 DAPs. Thirteen percent of NH residents with dementia concomitantly used ACBS levels 2 or 3 DAPs and AChEIs.

CONCLUSIONS

This study sheds new light on the prevalence of DAP use and concomitant use of DAPs and AChEIs among NH residents with dementia. Clinicians should consider alternatives with lower anticholinergic effects, particularly in patients already taking DAPs.

ORION laser target diagnostics

The ORION laser facility is one of the UK's premier laser facilities which became operational at AWE in 2010. Its primary mission is one of stockpile stewardship, ORION will extend the UK's experimental plasma physics capability to the high temperature, high density regime relevant to Atomic Weapons Establishment's (AWE) program. The ORION laser combines ten laser beams operating in the ns regime with two sub ps short pulse chirped pulse amplification beams. This gives the UK a unique combined long pulse/short pulse laser capability which is not only available to AWE personnel but also gives access to our international partners and visiting UK academia. The ORION laser facility is equipped with a comprehensive suite of some 45 diagnostics covering optical, particle, and x-ray diagnostics all able to image the laser target interaction point. This paper focuses on a small selection of these diagnostics.

Effects of respiration on soft palate movement in feeding

Cyclic soft palate elevation is temporally associated with masticatory jaw movement. However, the soft palate is normally lowered during nasal breathing to maintain retropalatal airway patency. We tested the hypothesis that the frequency and amplitude of soft palate elevation associated with mastication would be reduced during inspiration. Movements of radiopaque soft palate markers were recorded by videofluorography while 11 healthy volunteers ate solid foods. Breathing was monitored with plethysmography. Masticatory sequences were divided into processing and stage II transport cycles (food transport to the oropharynx before swallowing). In food processing, palatal elevation was less frequent and its displacement was smaller during inspiration than expiration. In stage II transport, the soft palate was elevated less frequently during inspiration than expiration. These findings suggest that masticatory soft palate movement is diminished during inspiration. The control of breathing appears to have a significant effect on soft palate elevation in mastication.

Cyclic motion of the soft palate in feeding

The soft palate moves rhythmically during feeding, but the timing and frequency of this motion are not known. We tested the hypothesis that cyclic soft palate motion is temporally linked to cyclic jaw movement. Nine healthy, asymptomatic human subjects with normal dentition ate solid food coated with barium. Videofluorographic recordings showed that rhythmic motions of the soft palate during mastication were linked temporally to jaw motion. Soft palate motion occurred in every recording but not in every jaw cycle. The soft palate moved upward as the jaw opened, but the nasopharynx was not sealed. During swallowing, however, the soft palate invariably elevated during the intercuspal phase of jaw motion, sealing the nasopharynx. The frequency of soft palate cycles was lowest early in a feeding sequence and gradually increased as the sequence progressed from ingestion to swallowing. We conclude that cyclic movement of the soft palate in feeding is temporally linked to jaw motion.

Comparison of adult and fetal cytokine secretion during mixed lymphocyte reactions

Umbilical cord blood transplants are associated with a lower incidence of graft-versus-host disease (GVHD) than adult marrow or peripheral blood stem cell transplants, and this could be related to a difference in cytokine production between fetal and adult mononuclear cells after allogeneic stimulation. Mixed lymphocyte reactions (MLRs) involving adult cells were associated with greater interferon-gamma (IFNgamma) secretion than MLRs between cord blood cells, although IL-2 secretion was similar. Experiments in which T cells were separated from accessory cells then recombined in artificial combinations indicated that differences in T cells were primarily responsible for the greater [IFNgamma]:[IL-2] ratios generally found after MLRs involving adult cells compared to fetal cells, but accessory cells also influenced this ratio. The cellular basis for the observed difference was not established, but mononuclear cell preparations from cord blood contained significantly higher proportions of CD16(+)56(-) NK-type cells and a CD19(+)1c(+) B cell subset, as well as more CD45 RA-expressing nai;ve T cells.

Effect of liquid bolus consistency and delivery method on aspiration and pharyngeal retention in dysphagia patients

There is no empirically derived consensus as to what food consistency types and method of food delivery (spoon, cup, straw) should be included in the videofluoroscopic swallowing (VFSS) studies. In the present study, we examine the rates of aspiration and pharyngeal retention in 190 dysphagic patients given thin (apple juice) and thick (apricot nectar) liquids delivered by teaspoon and cup and ultrathick (pudding-like) liquid delivered by teaspoon. Each patient was tested with each of the bolus/delivery method combinations. The fractions of patients exhibiting aspiration for each bolus/method of delivery combination were (1) thick liquids (cup), 13.2%; (2) thick liquids (spoon), 8.9%; (3) thin liquids (cup), 23.7%; (4) thin liquids (spoon), 15.8%, (5) ultrathick liquids (spoon), 5.8%. In each comparison [thick liquid (cup) vs. thick liquid (spoon), thin liquid (cup) vs. thin liquid (spoon), thick liquid (cup) vs. thin liquid (cup), thick liquid (spoon) vs. thin liquid (spoon), and thick liquid (spoon) vs. ultrathick liquid (spoon)], the p value for chi 2 was < 0.001. These results suggest that utilizing thin, thick, and ultrathick liquids and delivery by cup and spoon during a VFSS of a patient with mild or moderate dysphagia can increase the chances of identifying a consistency that the patient can swallow without aspirating and without pharyngeal retention after swallowing.

Ontogeny of postnatal hyoid and larynx descent in humans

Postnatal descent of the hyoid and larynx relative to the palate and mandible, which occurs uniquely in humans, is an anatomical prerequisite for quantal speech. This study tested the hypothesis that spatial constraints related to deglutition impose greater restrictions on the rate and degree of hyo-laryngeal descent than do adaptations for vocalization. Ontogenetic data on changes in the size and shape of the pharynx, the vocal tract, and the spatial positions of the larynx, hyoid, mandible and hard palate relative to each other and to the oral cavity were obtained for 15 males and 13 females from a longitudinal series of lateral radiographs (the Denver Growth Study) taken between the ages of 1 month and 14 years. To establish growth patterns, nine linear dimensions of the pharynx and 15 different pharyngeal and vocal-tract proportions were regressed against percentage growth. The results demonstrate that certain aspects of vocal-tract shape change markedly during ontogeny, especially in the first postnatal year and during the adolescent growth spurt. The ratio of pharynx height to oral cavity length (which is important for speech) decreases significantly (P<0.001) from 1.5 to 1.0 between birth and 6-8 years, after which it remains stable. In contrast, regression analyses indicated that superoinferior spatial relations between the positions of the vocal folds, the hyoid body, the mandible and the hard palate do not change significantly throughout the entire postnatal growth period (P<0.05). Sexual dimorphism in pharyngeal shape and size before the age of 14 years is very limited. The results suggest that the descent of the hyoid and larynx relative to the mandible is constrained by muscle function related to deglutition, highlighting the different functional roles of the hyoid during speech and oral transport.

Motions of the posterior pharyngeal wall in human swallowing: a quantitative videofluorographic study

OBJECTIVE

To quantify segmental motions of the posterior pharyngeal wall during swallowing.

DESIGN

Prospective study.

SETTING

Hospital radiology suite.

PARTICIPANTS

Six healthy adult volunteers.

INTERVENTIONS

Videofluorography of the pharynx in posteroanterior and lateral projections during water swallows by 6 able-bodied adults. Radiopaque suction markers, inserted through the nose, were attached by suction to the midline of the posterior pharyngeal wall of the upper and lower oropharynx, pharyngoesophageal segment (PES), or cervical esophagus.

MAIN OUTCOME MEASURES

Displacement of the larynx, hyoid bone, and markers.

RESULTS

Marker pathways were ovoid in the oropharynx but linear in the PES and esophagus. Marker displacement was greatest in the vertical dimension, intermediate in posteroanterior dimension, and smallest in mediolateral dimension. Vertical displacement was greater for the PES marker than for larynx, hyoid bone, or oropharynx markers (p < .001), so that the pharynx shortened significantly during each swallow. Marker displacement was unaffected by bolus volume.

CONCLUSIONS

The pharyngeal wall shortened during swallowing. The mechanism for PES elevation may differ from that of laryngeal elevation. Shortening of the pharynx may be produced by contraction of the pharyngeal suspensory muscles and traction on the larynx by suprahyoid muscles.

Evaluation and treatment of swallowing impairments

Swallowing disorders are common, especially in the elderly, and may cause dehydration, weight loss, aspiration pneumonia and airway obstruction. These disorders may affect the oral preparatory, oral propulsive, pharyngeal and/or esophageal phases of swallowing. Impaired swallowing, or dysphagia, may occur because of a wide variety of structural or functional conditions, including stroke, cancer, neurologic disease and gastroesophageal reflux disease. A thorough history and a careful physical examination are important in the diagnosis and treatment of swallowing disorders. The physical examination should include the neck, mouth, oropharynx and larynx, and a neurologic examination should also be performed. Supplemental studies are usually required. A videofluorographic swallowing study is particularly useful for identifying the pathophysiology of a swallowing disorder and for empirically testing therapeutic and compensatory techniques. Manometry and endoscopy may also be necessary. Disorders of oral and pharyngeal swallowing are usually amenable to rehabilitative measures, which may include dietary modification and training in specific swallowing techniques. Surgery is rarely indicated. In patients with severe disorders, it may be necessary to bypass the oral cavity and pharynx entirely and provide enteral or parenteral nutrition.

Helicobacter pylori infection rates in duodenal ulcer patients in the United States may be lower than previously estimated

OBJECTIVE

Published studies have estimated the rate of Helicobacter pylori (H. pylori) infection in patients with duodenal ulcer disease to be as high as 95%; the majority of remaining duodenal ulcers have been attributed to the use of ulcerogenic drugs such as nonsteroidal antiinflammatory drugs (NSAIDs). We aimed to assess the H. pylori prevalence rates of U.S. duodenal ulcer patients in large, well-controlled studies.

METHODS

More than 2900 patients with endoscopically diagnosed non-NSAID duodenal ulcers were enrolled in a series of six placebo-controlled, double-blind studies conducted in the United States that assessed H. pylori using a combination of tests. Patients were considered infected with H. pylori only if culture growth was observed, or both histological and CLOtest results were positive. Patients were considered uninfected if the results of at least two tests were negative. Patients with missing test results, results of only a single test, or conflicting test results were not evaluable for H. pylori assessment.

RESULTS

Of the 2394 endoscopically diagnosed evaluable duodenal ulcer patients, 73% (1737) were confirmed infected with H. pylori at study entry.

CONCLUSIONS

The results of six carefully designed and controlled studies suggest that an assumed H. pylori infection rate of approximately 95% may overestimate the actual rate of H. pylori infection in duodenal ulcer patients in the United States. Although H. pylori infection is an important factor in the etiology of noniatrogenic duodenal ulcer disease, other factors may predominate in some patients and should not be overlooked in determining an appropriate course of treatment. The empiric use of antibiotic therapy for ulcer patients without confirmation of the presence of H. pylori cannot be recommended.

Food transport and bolus formation during complete feeding sequences on foods of different initial consistency

Food movements during complete feeding sequences on soft and hard foods (8 g of chicken spread, banana, and hard cookie) were investigated in 10 normal subjects; 6 of these subjects also ate 8 g peanuts. Foods were coated with barium sulfate. Lateral projection videofluorographic tapes were analyzed, and jaw and hyoid movements were established after digitization of records for 6 subjects. Sequences were divided into phases, each involving different food management behaviors. After ingestion, the bite was moved to the postcanines by a pull-back tongue movement (Stage I transport) and processed for different times depending on initial consistency. Stage II transport of chewed food through the fauces to the oropharyngeal surface of the tongue occurred intermittently during jaw motion cycles. This movement, squeeze-back, depended on tongue-palate contact. The bolus accumulated on the oropharyngeal surface of the tongue distal to the fauces, below the soft palate, but was cycled upward and forward on the tongue surface, returning through the fauces into the oral cavity. The accumulating bolus spread into the valleculae. The total oropharyngeal accumulation time differed with initial food consistency but could be as long as 8-10 sec for the hard foods. There was no predictable tongue-palate contact at any time in the sequence. A new model for bolus formation and deglutition is proposed.

Intra- and interrater variation in the evaluation of videofluorographic swallowing studies

The objective of this study was to determine the inter- and intrarater reliability in evaluating videofluoroscopic swallowing studies (VFSS). Participants included 4 physicians (3 physiatrists and 1 internist) and 5 speech-language pathologists with at least 5 years experience in evaluating VFSS. The main outcomes of the study were reliability ratios of positive and negative tests in inter- and intrarater evaluations. Raters independently rated each of 20 VFSS on two separate occasions. Traits evaluated included oral stage impairment, aspiration, pharyngeal retention, and several functional components: timing of swallow onset, adequacy of velopharyngeal apposition, laryngeal elevation, epiglottic tilt, pharyngeal contraction, and pharyngoesophageal (PE) segment opening. Reliability varied widely depending on food type and the trait under evaluation. Inter- and intrarater reliability ratios did not differ widely. Reliability ratios values typically were highest (greater than 90%) for aspiration, especially with solid food, and lowest for the functional components. It was concluded that inter- and intrarater reliability in VFSS are adequate for evaluating oral stage, laryngeal penetration, and aspiration and pharyngeal retention, but questionable for functional components.

Developmental variation in stem-cell markers from human fetal liver and umbilical cord blood leukocytes

Fetal tissues containing haematopoietic stem cells (HSC) are of potential value for allogeneic transplantation and gene therapy. Flow cytometry was used to investigate CD34+ cells from human fetal livers and umbilical cord (placental) blood (UCB). CD34+ cells, expressed as a proportion of CD45-positive leukocytes, were much more abundant in fetal livers (mean 38%) than in UCB (mean 0.3%), but fetal liver cells had lower proportions of CD34+HLA-DR+ and CD34+ CD38+ subsets. In fetal liver, there was a strong and highly significant inverse correlation between CD34+ cells (as a proportion of total leukocytes) and gestational age; no such relationship was found for subsets of CD34+ cells coexpressing CD38 or CDw90 (Thy-1), but CD34+HLA-DR+ cells were less abundant in first-compared to second-trimester livers. In UCB, a trend towards decreasing CD34+ cells (as a proportion of total leukocytes) with increasing gestational age in late pregnancy was also observed. The composition of fetal leukocytes changes during development, and therefore the timing of fetal HSC harvesting could be of relevance to transplantation outcome.

Bolus aggregation in the oropharynx does not depend on gravity

OBJECTIVE

To determine whether bolus aggregation in the oropharynx (before swallowing) depends on gravity.

DESIGN

Before-during trial, with subjects serving as their own controls.

SETTING

Hospital radiology suite.

PARTICIPANTS

Five asymptomatic adult volunteers.

INTERVENTIONS

Videofluorography was performed while subjects ate soft and hard foods containing barium, first seated upright and then kneeling face down (quadruped position).

MAIN OUTCOME MEASURES

Duration of food processing in the oral cavity, bolus aggregation in the valleculae, and pharyngeal swallow.

RESULTS

Transport of chewed solid food from the oral cavity to the oropharynx (stage II transport) typically started several seconds before onset of swallow, regardless of head position or initial food consistency. Bolus aggregation in the valleculae (between the epiglottis and the tongue) began an average of 1.7 +/- 2.5sec before the onset of the pharyngeal swallow (p < .001). Stage II transport was driven by tongue-palate contact.

CONCLUSIONS

Transport of chewed solid food from the oral cavity to the pharynx is driven actively by tongue-palate contact and does not depend on gravity. A bolus may accumulate in the valleculae for several seconds before the swallow.

Tongue-jaw linkages in human feeding: a preliminary videofluorographic study

Motions of the tongue and jaw are closely coupled during feeding in mammals, but this relation has not been studied in humans. A videofluorographic method for measuring tongue movement relative to jaw motion using small radiopaque markers affixed to the tongue with dental adhesive was developed and tested in five individuals. Sagittal movements of the anterior tongue marker (ATM) and the lower jaw were measured for complete feeding sequences with a computerized image-analysis system. The ATM and jaw moved in loosely linked, semirhythmic cycles. Vertical and horizontal maxima of ATM motion were determined for each motion cycle in relation to maximum and minimum gape (greatest jaw opening and closing, respectively). The amplitude of tongue movements and their timing differed between hard and soft foods (p < 0.001). For both food types, motions varied as the feeding sequence progressed from ingestion to terminal swallow (p < 0.001). A basic temporal sequence was found in 70% of the 224 cycles analysed. On average, the ATM reached its most inferior position just after maximum gape, its most posterior during jaw closing, its most superior just after minimum gape, and its most anterior during jaw opening (p < 0.001). This study confirms that tongue and jaw movements are linked during human feeding, as they are in other mammals.

The efficacy and tolerability of inhaled salmeterol and individually dose-titrated, sustained-release theophylline in patients with reversible airways disease

In a double-blind, double-dummy, cross-over, multicentre study, 141 patients with moderate reversible airways disease were randomized to receive either 50 micrograms salmeterol via a metered dose inhaler or individually dose-titrated oral theophylline, both twice daily for a 2-week period. Just over half (n = 77) the patients had received theophylline before, but 64 patients were new to theophylline therapy. Efficacy was based on lung function data and symptom scores. Salmeterol produced significantly higher increase in mean morning peak expiratory flow (PEF) of 161 min-1 (P < 0.001; 95% Confidence Interval (CI); 8-241 min-1) and mean evening PEF of 151 min-1 (p < 0.001; 95% CI; 7-221 min-1) compared with theophylline therapy. Further analysis of the data revealed that the increase in PEF with salmeterol compared with theophylline was highest in a sub-group of patients new to theophylline therapy. Patients on salmeterol had significantly less night-time awakenings than those on theophylline (P = 0.011) and significantly less daytime symptoms (P = 0.017). There was also a significant increase in the number of nights (P = 0.013) and days (P < 0.001) on salmeterol when no additional salbutamol was required compared with theophylline. Theophylline produced a higher incidence of adverse events compared with salmeterol. The results of this study show that inhaled salmeterol is more effective and better tolerated than individually dose-titrated oral theophylline over a 2-week study period in patients with moderate asthma.

Multidrug resistance gene (MDR 1) expression in neuro-axial tumours of children and young adults

Drug resistance in many cancers outside the CNS has been associated with over-expression of the multidrug resistance gene (MDR1), which codes for the transmembrane efflux pump P-glycoprotein (Pgp). To determine whether tumours of the neuroaxis over-express MDR1 and to identify the site of Pgp expression we examined 50 tumour specimens from 46 children and young adults using immunocytochemistry. Pgp was not expressed by any neoplastic cells, but was detected in the endothelium of tumour blood vessels in 35 of the 50 samples (70%). 11/35 (31%) were Pgp positive in the majority of vessels, 11/35 (31%) in a proportion, but < 50% of vessels, and 13/35 (37%) in one or two vessels. Pgp was also detected in surrounding normal brain capillaries. MDR1 may play a role in the chemoresistance of neuro-axial tumours either by its expression in the normal blood-brain barrier or by forming a blood-tumour barrier. The proportion of vessels expressing Pgp may determine the degree of resistance.

Salmeterol provides prolonged protection against exercise-induced bronchoconstriction in a majority of subjects with mild, stable asthma

In patients with asthma, exercise-induced symptoms are well recognized and frequently limiting. Currently available beta 2-receptor agonists have a short duration of action and breakthrough symptoms may occur. We studied the efficacy of the recently developed long acting inhaled beta 2-agonist salmeterol with respect to protection against exercise-induced bronchoconstriction. Twelve patients with mild to moderate, stable asthma were recruited (age range 21-33 years). They each underwent treadmill exercise tests, with target heart rate of approximately 90% of predicted maximum, 1, 6 and 12 h after a single dose of salmeterol 50 micrograms, salbutamol 200 micrograms and placebo. Patients breathed through a two-way valve, inspiring dry air from a compressed air cylinder via a Douglas bag to maintain constant humidity. The primary efficacy variable analysed was the maximum percentage fall in FEV1 and FVC from pre-exercise readings within the first 30 min post-exercise. At 1 h post-dose there was significant protection in terms of fall in mean +/- SEM FEV1 in response to exercise challenge after either salmeterol (0.83 +/- 6.2%) or salbutamol (3.8 +/- 5.5%) as compared with placebo (27.1 +/- 7.3%). At 6 h post-dose, fall in FEV1 on salmeterol was 11.3 +/- 3.8% as compared with salbutamol, 28.0 +/- 5.7% and placebo, 32.0 +/- 7.0%. At 12 h post-dosing there was still significant protection in terms of fall in FEV1 in the salmeterol treated group, 12.8 +/- 4.9%, as compared with salbutamol, 28.7 +/- 4.9% and placebo, 25.4 +/- 7.3%.(ABSTRACT TRUNCATED AT 250 WORDS)

A protocol for the videofluorographic swallowing study

This paper presents a detailed protocol for performing the videofluorographic swallowing study (VFSS), and describes how it evolved from its antecedents. The objectives of the VFSS are both diagnostic and therapeutic. Preparing for the VFSS is described, including the equipment, food preparation, and a brief discussion of the clinical evaluation. The detailed description of the VFSS procedure covers the position of the patient, the foods presented, the views obtained, modifications of feeding and swallowing that are commonly employed, the standardized set of observations, and reporting the results. Criteria for deviating from the protocol or aborting the study are presented. The VFSS does not necessarily end when a patient aspirates. Indeed, the complete evaluation of aspiration, and the effects of maneuvers designed to reduce it, is a major purpose of the VFSS. Modifications of feeding and swallowing are tested empirically during the study. The modifications include therapeutic and compensatory techniques that may improve the safety and efficiency of swallowing. A rationale for deciding which modifications to test in a given patient is discussed. The protocol has been used successfully in more than 350 patients. It has improved the efficiency and quality of our videofluorographic examinations.

Twelve month comparison of salmeterol and salbutamol as dry powder formulations in asthmatic patients. European Study Group

BACKGROUND

Salmeterol is a potent selective beta 2 agonist that has been shown to have a duration of action in excess of 12 hours. In this study salmeterol and salbutamol were compared over a three month period with a further extension of nine months.

METHODS

Three hundred and eighty eight patients with mild to moderate reversible airways obstruction (forced expiratory volume in one second (FEV1) > 50% predicted) were randomised to receive salmeterol (50 micrograms) twice daily or salbutamol (400 micrograms) four times daily, both by dry powder, in a double blind parallel group study. During the first three months detailed assessment of efficacy was made with recording of morning and evening peak expiratory flow rates (PEF), asthma symptoms, and bronchodilator use when necessary for the relief of symptoms. Patients continued in the study for a further nine months with the salbutamol dose reduced to 400 micrograms twice daily. Lung function was measured at the clinic and safety data were collected during this period.

RESULTS

Salmeterol produced a significantly higher mean morning PEF (mean difference compared with salbutamol 21 (95% CI 12-31) l/min), and a significant reduction in mean diurnal variation in PEF (from 30 l/min at baseline to 11 34 l/min at baseline to 32 l/min during salbutamol treatment). Salmeterol also reduced day and night symptoms and use of rescue bronchodilator. FEV1 increased with both salmeterol and salbutamol treatment over the 12 month treatment period. For both treatments the number of patients reporting exacerbations of asthma and the frequency of these exacerbations remained constant during the study. Thirty six patients in the salmeterol and 49 in the salbutamol group withdrew during the 12 months of the study.

CONCLUSIONS

In this study salmeterol (50 micrograms twice daily) was more effective than salbutamol (400 micrograms four times daily) in the control of asthma over three months, and more effective than salbutamol (400 micrograms twice daily) over a further nine months. Neither salmeterol nor salbutamol was associated with any worsening of control of asthma.