Exploring the perceptions and experiences of community rehabilitation for Long COVID from the perspectives of Scottish general practitioners' and people living with Long COVID: a qualitative study

OBJECTIVES

To explore the experience of accessing Long COVID community rehabilitation from the perspectives of people with Long COVID and general practitioners (GPs).

DESIGN

Qualitative descriptive study employing one-to-one semistructured virtual interviews analysed using the framework method.

SETTING

Four National Health Service Scotland territorial health boards.

PARTICIPANTS

11 people with Long COVID (1 male, 10 female; aged 40-65 (mean 53) and 13 GPs (5 male, 8 female).

RESULTS

Four key themes were identified: (1) The lived experience of Long COVID, describing the negative impact of Long COVID on participants' health and quality of life; (2) The challenges of an emergent and complex chronic condition, including uncertainties related to diagnosis and management; (3) Systemic challenges for Long COVID service delivery, including lack of clear pathways for access and referral, siloed services, limited resource and a perceived lack of holistic care, and (4) Perceptions and experiences of Long COVID and its management, including rehabilitation. In this theme, a lack of knowledge by GPs and people with Long COVID on the potential role of community rehabilitation for Long COVID was identified. Having prior knowledge of rehabilitation or being a healthcare professional appeared to facilitate access to community rehabilitation. Finally, people with Long COVID who had received rehabilitation had generally found it beneficial.

CONCLUSIONS

There are several patient, GP and service-level barriers to accessing community rehabilitation for Long COVID. There is a need for greater understanding by the public, GPs and other potential referrers of the role of community rehabilitation professionals in the management of Long COVID. There is also a need for community rehabilitation services to be well promoted and accessible to the people with Long COVID for whom they may be appropriate. The findings of this study can be used by those (re)designing community rehabilitation services for people with Long COVID.

Investigating Scottish Long COVID community rehabilitation service models from the perspectives of people living with Long COVID and healthcare professionals: a qualitative descriptive study

OBJECTIVES

This study aimed to explore the perceptions and experiences of barriers and facilitators to accessing Long COVID community rehabilitation.

DESIGN

We used a qualitative descriptive design over two rounds of data collection with three participant groups: (1) people with experience of rehabilitation for Long COVID (PwLC); (2) National Health Service (NHS) staff delivering and/or managing community rehabilitation services (allied health professionals (AHPs)) and (3) NHS staff involved in strategic planning around Long COVID in their health board (Long COVID leads).

SETTING

Four NHS Scotland territorial health boards.

PARTICIPANTS

51 interviews: eight Long COVID leads (11 interviews); 15 AHPs (25 interviews) and 15 PwLC (15 interviews).

RESULTS

Three key themes were identified: (1) accessing care for PwLC, (2) understanding Long COVID and its management and (3) strengths and limitations of existing Long COVID rehabilitation services.

CONCLUSIONS

Organisational delivery of Long COVID community rehabilitation is complex and presents multiple challenges. In addition, access to Long COVID community rehabilitation can be challenging. When accessed, these services are valued by PwLC but require adequate planning, publicity and resource. The findings presented here can be used by those developing and delivering services for people with Long COVID.

Accuracy of heart rate measured by military-grade wearable ECG monitor compared with reference and commercial monitors

INTRODUCTION

Physiological monitoring of soldiers can indicate combat readiness and performance. Despite demonstrated use of wearable devices for HR monitoring, commercial options lack desired military features. A newly developed OMNI monitor includes desired features such as long-range secure data transmission. This study investigated the accuracy of the OMNI to measure HR via accuracy of R-R interval duration relative to research-grade ECG and commercial products.

METHODS

54 healthy individuals (male/female=37/17, age=22.2±3.6 years, height=173.0±9.1 cm, weight=70.1±11.2 kg) completed a submaximal exercise test while wearing a reference ECG (Biopac) and a randomly assigned chest-based monitor (OMNI, Polar H10, Equivital EQ-02, Zephyr Bioharness 3). All participants also wore two wrist-based photoplethysmography (PPG) devices, Garmin fēnix 6 and Empatica E4. Bland-Altman analyses of agreement, concordance correlation coefficient (CCC) and root-mean-squared error (RMSE) were used to determine accuracy of the OMNI and commercial devices relative to Biopac. Additionally, a linear mixed-effects model evaluated the effects of device and exercise intensity on agreement.

RESULTS

Chest-based devices showed superior agreement with Biopac for measuring R-R interval compared with wrist-based ones in terms of mean bias, CCC and RMSE, with OMNI demonstrating the best scores on all metrics. Linear mixed-effects model showed no significant main or interaction effects for the chest-based devices. However, significant effects were found for Garmin and Empatica devices (p<0.001) as well as the interaction effects between both Garmin and Empatica and exercise intensity (p<0.001).

CONCLUSIONS

Chest-based ECG devices are preferred to wrist-based PPG devices due to superior HR accuracy over a range of exercise intensities, with the OMNI device demonstrating equal, if not superior, performance to other commercial ECG monitors. Additionally, wrist-based PPG devices are significantly affected by exercise intensity as they underestimate HR at low intensities and overestimate HR at high intensities.

Exercise therapy for tendinopathy: a mixed-methods evidence synthesis exploring feasibility, acceptability and effectiveness

Background

Tendinopathy is a common, painful and functionally limiting condition, primarily managed conservatively using exercise therapy.

Review questions

(i) What exercise interventions have been reported in the literature for which tendinopathies? (ii) What outcomes have been reported in studies investigating exercise interventions for tendinopathy? (iii) Which exercise interventions are most effective across all tendinopathies? (iv) Does type/location of tendinopathy or other specific covariates affect which are the most effective exercise therapies? (v) How feasible and acceptable are exercise interventions for tendinopathies?

Methods

A scoping review mapped exercise interventions for tendinopathies and outcomes reported to date (questions i and ii). Thereafter, two contingent systematic review workstreams were conducted. The first investigated a large number of studies and was split into three efficacy reviews that quantified and compared efficacy across different interventions (question iii), and investigated the influence of a range of potential moderators (question iv). The second was a convergent segregated mixed-method review (question v). Searches for studies published from 1998 were conducted in library databases (n = 9), trial registries (n = 6), grey literature databases (n = 5) and Google Scholar. Scoping review searches were completed on 28 April 2020 with efficacy and mixed-method search updates conducted on 19 January 2021 and 29 March 2021.

Results

Scoping review - 555 included studies identified a range of exercise interventions and outcomes across a range of tendinopathies, most commonly Achilles, patellar, lateral elbow and rotator cuff-related shoulder pain. Strengthening exercise was most common, with flexibility exercise used primarily in the upper limb. Disability was the most common outcome measured in Achilles, patellar and rotator cuff-related shoulder pain; physical function capacity was most common in lateral elbow tendinopathy. Efficacy reviews - 204 studies provided evidence that exercise therapy is safe and beneficial, and that patients are generally satisfied with treatment outcome and perceive the improvement to be substantial. In the context of generally low and very low-quality evidence, results identified that: (1) the shoulder may benefit more from flexibility (effect sizeResistance:Flexibility = 0.18 [95% CrI 0.07 to 0.29]) and proprioception (effect sizeResistance:Proprioception = 0.16 [95% CrI -1.8 to 0.32]); (2) when performing strengthening exercise it may be most beneficial to combine concentric and eccentric modes (effect sizeEccentricOnly:Concentric+Eccentric = 0.48 [95% CrI -0.13 to 1.1]; and (3) exercise may be most beneficial when combined with another conservative modality (e.g. injection or electro-therapy increasing effect size by ≈0.1 to 0.3). Mixed-method review - 94 studies (11 qualitative) provided evidence that exercise interventions for tendinopathy can largely be considered feasible and acceptable, and that several important factors should be considered when prescribing exercise for tendinopathy, including an awareness of potential barriers to and facilitators of engaging with exercise, patients' and providers' prior experience and beliefs, and the importance of patient education, self-management and the patient-healthcare professional relationship.

Limitations

Despite a large body of literature on exercise for tendinopathy, there are methodological and reporting limitations that influenced the recommendations that could be made.

Conclusion

The findings provide some support for the use of exercise combined with another conservative modality; flexibility and proprioception exercise for the shoulder; and a combination of eccentric and concentric strengthening exercise across tendinopathies. However, the findings must be interpreted within the context of the quality of the available evidence.

Future work

There is an urgent need for high-quality efficacy, effectiveness, cost-effectiveness and qualitative research that is adequately reported, using common terminology, definitions and outcomes.

Study registration

This project is registered as DOI: 10.11124/JBIES-20-00175 (scoping review); PROSPERO CRD 42020168187 (efficacy reviews); https://osf.io/preprints/sportrxiv/y7sk6/ (efficacy review 1); https://osf.io/preprints/sportrxiv/eyxgk/ (efficacy review 2); https://osf.io/preprints/sportrxiv/mx5pv/ (efficacy review 3); PROSPERO CRD42020164641 (mixed-method review).

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) HTA programme and will be published in full in HTA Journal; Vol. 27, No. 24. See the NIHR Journals Library website for further project information.

Patient ratings in exercise therapy for the management of tendinopathy: a systematic review with meta-analysis

OBJECTIVE

To synthesise exercise therapy intervention data investigating patient rating outcomes for the management of tendinopathy.

DESIGN

A systematic review and meta-analysis of randomized controlled trials investigating exercise therapy interventions and reporting patient rating outcomes.

SETTING

Any setting in any country listed as very high on the human development index.

PARTICIPANTS

People with a diagnosis of any tendinopathy of any severity or duration.

INTERVENTIONS

Exercise therapy for the management of tendinopathy comprising five different therapy classes: 1) resistance; 2) plyometric; 3) vibration; 4) flexibility, and 5) movement pattern retraining modalities, were considered for inclusion.

MAIN OUTCOME MEASURES

Outcomes measuring patient rating of condition, including patient satisfaction and Global Rating of Change (GROC).

RESULTS

From a total of 124 exercise therapy studies, 34 (Achilles: 41%, rotator cuff: 32%, patellar: 15%, elbow: 9% and gluteal: 3%) provided sufficient information to be meta-analysed. The data were obtained across 48 treatment arms and 1246 participants. The pooled estimate for proportion of satisfaction was 0.63 [95%CrI: 0.53-0.73], and the pooled estimate for percentage of maximum GROC was 53 [95%CrI: 38-69%]. The proportion of patients reporting positive satisfaction and perception of change increased with longer follow-up periods from treatment onset.

CONCLUSION

Patient satisfaction and GROC appear similar and are ranked moderately high demonstrating that patients generally perceive exercise therapies positively. Further research including greater consistency in measurement tools is required to explore and where possible, identify patient- and exercise-related moderating factors that can be used to improve person-centred care.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO ID=CRD42020168187 CONTRIBUTION OF PAPER.

Autophagy Plays a Crucial Role in Ameloblast Differentiation

Tooth enamel is generated by ameloblasts. Any failure in amelogenesis results in defects in the enamel, a condition known as amelogenesis imperfecta. Here, we report that mice with deficient autophagy in epithelial-derived tissues (K14-Cre;Atg7^F/F and K14-Cre;Atg3^F/F conditional knockout mice) exhibit amelogenesis imperfecta. Micro-computed tomography imaging confirmed that enamel density and thickness were significantly reduced in the teeth of these mice. At the molecular level, ameloblast differentiation was compromised through ectopic accumulation and activation of NRF2, a specific substrate of autophagy. Through bioinformatic analyses, we identified Bcl11b, Dlx3, Klk4, Ltbp3, Nectin1, and Pax9 as candidate genes related to amelogenesis imperfecta and the NRF2-mediated pathway. To investigate the effects of the ectopic NRF2 pathway activation caused by the autophagy deficiency, we analyzed target gene expression and NRF2 binding to the promoter region of candidate target genes and found suppressed gene expression of Bcl11b, Dlx3, Klk4, and Nectin1 but not of Ltbp3 and Pax9. Taken together, our findings indicate that autophagy plays a crucial role in ameloblast differentiation and that its failure results in amelogenesis imperfecta through ectopic NRF2 activation.

Oral anticoagulation therapy in atrial fibrillation patients with advanced chronic kidney disease: CODE-AF Registry

Background and objectives

Advanced chronic kidney disease (CKD), including end-stage renal disease (ESRD) on dialysis, increases thromboembolic risk among patients with atrial fibrillation (AF). This study examined the comparative safety and efficacy of direct-acting oral anticoagulant (DOAC) compared to warfarin or no OAC among AF patients with advanced CKD or ESRD on dialysis.

Methods

Using data from the COmparison study of Drugs for symptom control and complication prEvention of AF (CODE-AF) registry, 260 non-valvular AF patients with advanced CKD (defined as estimated glomerular filtration rate [eGFR] &lt;3 0ml/min per 1.73 m2) or ESRD on dialysis were enrolled from June 2016 to July 2020. The study population was categorized into DOAC, warfarin, and no OAC group, and differences in major or clinically relevant non-major (CRNM) bleeding, stroke/systemic embolism (SE), myocardial infarction/critical limb ischemia (CLI), and death were assessed.

Results

During a median 24 months of follow-up, major or CRNM bleeding risk was significantly reduced in the DOAC group compared to the warfarin group (hazard ratio [HR] 0.21, 95% confidence interval [CI] 0.05 to 0.95, p=0.042). In addition, the risk of composite adverse clinical outcome (major or CRNM bleeding, stroke/SE, myocardial infarction/CLI, and death) was significantly reduced in the DOAC group compared to the no OAC group (HR 0.32, 95% CI 0.11 to 0.96, p=0.043).

Conclusion

Among AF patients with advanced CKD or ESRD on dialysis, DOAC was associated with a lower risk of major or CRNM bleeding compared to warfarin and a lower risk of composite adverse clinical outcome compared to no OAC.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Korean Healthcare Technology R&D project funded by the Ministry of Health & Welfare (HI15C1200, HC19C0130)

Resting heart rate and cardiovascular outcomes in patients with atrial fibrillation: CODE-AF registry

Funding Acknowledgements

Type of funding sources: None.

Background

The prognostic significance of resting heart rate and its therapeutic target in atrial fibrillation (AF) is uncertain.

Purpose

The aim of this study was to investigate the relationships between resting heart rate and cardiovascular outcomes in patients with AF.

Methods

A total of 8,886 patients with AF was included from the COmparison study of Drugs for symptom control and complication prEvention of AF (CODE-AF) registry. Patients were categorized according to baseline heart rate, and cardiovascular outcomes were accessed during a median follow-up of 30 months. The primary outcome was a composite of cardiovascular death, hospitalization due to heart failure, and myocardial infarction/critical limb ischemia.

Results

Compared to heart rate ≥100 beats per minute (bpm), heart rate 80-99 bpm was associated with the lowest risk of primary outcome (adjusted hazard ratio [HR] 0.56, 95% confidence interval [CI] 0.40-0.79, p=0.001). In subgroup of patients with heart failure with preserved ejection fraction (HFpEF), heart rate between 80-99 bpm was associated with reduced risk of primary outcome compared to heart rate ≥100 bpm (HR 0.40, 95% CI 0.16-0.98, p=0.045). However, in patients with heart failure with reduced ejection fraction (HFrEF), there was no association between resting heart rate and cardiovascular outcomes (P for interaction 0.001).

Conclusion

Resting heart rate was associated with cardiovascular outcomes in patients with AF, and those with a resting heart rate between 80-99 bpm had the lowest risk of adverse events. The impact of resting heart rate on adverse events persisted in patients with concomitant HFpEF but was not apparent in those with concomitant HFrEF.

Impact of mapping technology on procedural characteristics during radiofrequency or cryoballoon pulmonary vein isolation for atrial fibrillation

Funding Acknowledgements

Type of funding sources: None.

Background/Introduction: Cryoballoon ablation (CBA) is often associated with shorter procedure times along with tradeoffs such as increased fluoroscopy use compared to radiofrequency (RF) ablation of atrial fibrillation (AF), however the impact of mapping technology on these characteristics is not fully understood.

Purpose

To assess the effect of mapping technology on trends in fluoroscopy use and procedure times in AF pulmonary vein isolation (PVI) procedures with an RF or CBA catheter.

Methods

Acute procedure data from 210 de novo AF cases using a 3D mapping system was prospectively collected from 48 centers in eight countries. Choice of technology was left to physician discretion; a PVI only ablation strategy was utilized in all cases. Procedure data such as total procedure and fluoroscopy times from cases using either an RF or CBA catheter with either a grid-style mapping catheter (HD Grid) or circular mapping catheter (CMC) were compared.

Results

Of the 210 cases, RF ablation was used in 103 (49%), and CBA used in 107 (51%). In RF cases, a relatively even split between CMC and HD Grid use was observed (n=46, 45% vs. n=57, 55%), while a CMC was used in 100% of CBA cases (Figure 1). Across all cases, fluoroscopy and procedure times were significantly shorter when HD Grid was used (7.4±26.7 minutes; 108.2±46.3 minutes) compared to a CMC (20.4±17.6 minutes; 133.7±62.7) (p&lt;0.001; p=0.003). A similar trend was also observed in RF cases using HD Grid (7.4±26.7 minutes; 108.2±46.3 minutes) compared to a CMC (17.9±12.3 minutes; 175.1±50.5) (p=0.01; p&lt;0.001). Fluoroscopy times in RF cases with HD Grid (7.4±26.7 minutes) were significantly shorter compared to CBA cases with a CMC (21.5±19.4 minutes) (p&lt;0.001), while procedure times were similar (108.2±46.3 minutes; 116.0±59.2 minutes, p=0.20).

Conclusion(s)

Use of HD Grid resulted in significantly shorter procedure and fluoroscopy times compared to a CMC across all cases, including those using RF ablation. Fluoroscopy times were also significantly shorter in RF cases using HD Grid compared to CBA cases using a CMC, with similar procedure times. These observations suggest that use of HD Grid may better enable safer and more efficient PVI, specifically when employing RF ablation, in addition to safer and equally efficient RF PVI compared to CBA with a CMC. Further study in in a larger, randomized cohort may be necessary.

Global preferences in mapping technology and its impact on fluoroscopy and procedure times during catheter ablation of atrial fibrillation

Funding Acknowledgements

Type of funding sources: None.

Background/Introduction

Choice in mapping technology may play a critical role in reducing fluoroscopy and procedure times during atrial fibrillation (AF) ablation, however this relationship is not well studied.

Purpose

To assess the impact of mapping technology on trends in fluoroscopy use and procedure times in AF ablation procedures.

Methods

Acute procedure data from 525 AF cases was prospectively collected from 68 centers in nine countries. Choice of technology and ablation strategy, including PVI and substrate modification, were left to physician discretion. Procedure data such as total procedure and fluoroscopy times from cases using a grid-style mapping catheter (HD Grid) were compared to those using a circular mapping catheter (CMC).

Results

Of the 525 cases, HD Grid was used in 230 (44%), and CMC was used in 295 (56%). HD Grid was routinely used for both de novo and redo procedures while CMC was used predominantly for de novo procedures (Table 1). Similar procedure times were noted in redo PAF and redo PersAF procedures, while significantly shorter procedure times were observed for the HD Grid group in both de novo PAF and PersAF (113.9±48.8 vs. 125.9±56.3 minutes, p=0.04; and 142.8±53.2 vs. 169.8±52.2 minutes, p=0.001).

Overall fluoroscopy times were significantly shorter using HD Grid compared to a CMC (9.0±19.6 minutes vs. 19.8±16.4 minutes, p&lt;0.001), including significantly shorter fluoroscopy times in de novo PAF, de novo PersAF, and redo PAF (Table 1). There were 155 cases completed without fluoroscopy use; zero fluoroscopy cases accounted for 50% (114/230) and 14% (41/295) of total cases completed with HD Grid and a CMC, respectively (p&lt;0.001).

Conclusion(s)

Use of HD Grid was observed in a significantly higher portion of zero fluoroscopy cases and resulted in significantly shorter procedure and fluoroscopy times in both de novo PAF and de novo PersAF and significantly shorter fluoroscopy times in redo PAF. These observations suggest that use of HD Grid may better enable faster and safer procedures in these specific AF types compared to CMCs, although further analysis in a larger, randomized cohort may be warranted.

Patients follow three distinct outcome trajectories following total knee arthroplasty

AIMS

Although total knee arthroplasty (TKA) is a highly successful procedure, about 20% of patients remain dissatisfied postoperatively. This proportion is derived from dichotomous models of the assessment of surgical success or failure, which may not reflect the spectrum of outcomes. The aim of this study was to explore differing responses to surgery, and assess whether there are distinct groups of patients with differing patterns of outcome.

METHODS

This was a secondary analysis of a UK multicentre TKA longitudinal cohort study. We used a group-based trajectory modelling analysis of Oxford Knee Score (OKS) in the first year following surgery with longitudinal data involving five different timepoints and multiple predictor variables. Associations between the derived trajectory groups and categorical baseline variables were assessed, and predictors of trajectory group membership were identified using Poisson regression and multinomial logistic regression, as appropriate. The final model was adjusted for sociodemographic factors (age, sex) and baseline OKS.

RESULTS

Data from 731 patients were available for analysis. Three distinct trajectories of outcome were identified: "poor" 14.0%, "modest" 39.1%, and "good" 46.9%. The predicted probability of membership for patients assigned to each trajectory group was high (0.89 to 0.93). Preoperative mental, physical health, and psychosocial factors determined which trajectory is likely to be followed. Poor responders were characterized by a comparatively small number of factors, preoperative expectations of pain and limitations, coping strategies, and a lower baseline physical health status, while the good responders were characterized by a combination of clinical, psychosocial, mental health, and quality of life factors.

CONCLUSION

We identified three distinct response trajectories in patients undergoing TKA. Controlling for baseline score, age, and sex, psychosocial factors such as expectations of pain and limited function and poor coping strategies differentiated the trajectory groups, suggesting a role for preoperative psychosocial support in optimizing the clinical outcome. Cite this article: Bone Joint J 2021;103-B(6):1096-1102.

Pathological response post neoadjuvant therapy for locally advanced rectal cancer is an independent predictor of survival

AIM

Neoadjuvant treatment (NaT) for locally advanced rectal cancer prior to surgery has led to improved outcomes. However, the relationship between pathological response to NaT and survival is not entirely clear. The aim of this study was to assess the degree of pathological response to NaT on survival outcomes.

METHODS

Clinical and pathological data were collected from a prospectively maintained pathology database between 2005 and 2017. The primary outcome was the overall survival based on pathological response categorized as complete, good partial, partial and minimal. Univariate and multivariate analyses were conducted to identify variables predictive of survival. Cox proportional hazard ratios were used for survival.

RESULTS

A total of 596 patients had surgery following NaT for locally advanced rectal cancer. The median follow-up was 4.57 years (interquartile range 2.21-8.15 years). The overall survival for complete pathological response was 75.6% vs. 37.3% for minimal response (P < 0.001). The overall survival at the end of the study in the good partial vs. partial response groups was 58.9% vs. 39% (P < 0.001). On multivariate analysis, the degree of pathological response remains an independent variable for overall and disease-specific survival across all categories.

DISCUSSION

In addition to other pathological variables, the degree of pathological response to NaT is an independent predictor for survival outcomes. Future verification of these findings elsewhere could support NaT response being used for adjuvant therapy decision making.

Depression and risk of atrial fibrillation: a nationwide population-based study

Background

Although treatments of atrial fibrillation (AF) based on the biological mechanisms for initiation and maintenance of AF improve cardiovascular outcomes, psychosocial factors have been also implicated in the etiology and progression of cardiovascular disease.

Objective

We aimed to evaluate the association between depression and incident AF using nationwide database from the National Health Insurance Service in South Korea.

Methods

A total of 9,075,224 participants with data of national health checkup in 2009 were included, and participants who were diagnosed with AF before the examination were excluded. Exposure to depression is determined by the precedence of depression diagnosed within 2 years.

Results

Depression was diagnosed in 1.37% (124,709) of participants at baseline. Compared to the non-depression group, depression group was likely to be female and had higher comorbidities. After adjusting covariates, depression group had a higher risk of incident AF compared with non-depression group (hazard ratio, 1.30; 95% confidence interval, 1.26–1.34). Repeated exposure to depression increased a risk of incident AF (Figure 1).

Conclusion

Depression was associated with an increased risk of new-onset AF. This association was stronger for patients who had more burden of depression. Future studies should investigate whether early treatment of depression can prevent incident AF.

Figure 1

Funding Acknowledgement

Type of funding source: None

Quantifying and predicting the effect of anti-TNF therapy on axSpA-related fatigue: results from the BSRBR-AS registry and meta-analysis

OBJECTIVES

Effective management of axial spondyloarthritis (axSpA)-related fatigue is a major unmet clinical need. Anti-TNF therapy may reduce fatigue levels, although any effect has yet to be definitively quantified and predictors of any such improvements are unknown.

METHODS

The British Society of Rheumatology Register in Axial Spondyloarthritis (BSRBR-AS) prospectively recruited axSpA patients across the UK. Changes in fatigue levels (measured using the Chalder Fatigue Scale) >1 year were compared between those starting anti-TNF therapy at the time of recruitment and those not. Differences between treatment groups were adjusted using propensity score matching. Results were meta-analysed with the extant literature to calculate pooled estimates. Then, among those BSRBR-AS anti-TNF commencers with clinically relevant fatigue, baseline predictors of response were investigated.

RESULTS

Of the 998 BSRBR-AS recruits with complete fatigue data, 310 were anti-TNF commencers. At 1-year follow-up, the former group reported a mean fatigue change of -2.6 (95% CI -4.1, -1.9) points while the latter reported a mean worsening of fatigue by 0.2 points. Following propensity score adjustment, those commencing anti-TNF therapy reduced fatigue by 3.0 points compared with those not. Of those with significant fatigue and commencing anti-TNF, poor sleep quality at baseline predicted fatigue improvement. In the meta-analysis, including 1109 subjects, treatment with anti-TNF therapy resulted in a significant improvement in fatigue [Standardized mean difference (SMD) = 0.36, 95% CI 0.15, 1.56].

CONCLUSION

Anti-TNF therapy results in a significant but modest reduction in fatigue amongst axSpA patients, with those reporting poor sleep quality most likely to report improvement. Effective management will likely require additional approaches.

Introducing mobile fracture prevention services with DXA in Northern Scotland: a comparative study of three rural communities

Mobile fracture prevention services, with DXA, significantly improved access to care for those at high risk of fracture living in rural areas. Introduction of mobile services facilitated access to fracture liaison services and development of integrated of care pathways across community- and secondary-based care.

INTRODUCTION

The ageing population is growing faster in rural areas, yet most fracture prevention services are located in urban areas. As part of a wider study, evaluating the introduction of mobile fracture prevention services, we focus on whether mobile services improve access to care for those at highest risk of fracture.

METHODS

Services outcomes were assessed against the Royal Osteoporosis Society clinical standards for fracture liaison services. This included standardised, age-specific referral rates, FRAX 10-year probability of major osteoporotic and hip fracture of referrals, pre- and post-introduction of the mobile service across two island and one rural mainland sites. This was compared with referrals from a similar rural mainland region with local access to a comprehensive service.

RESULTS

Greatest impact occurred in areas with most limited service provision at baseline. Mean age of patients referred increased from 59 to 68 years (CI 6.8-10.1, p < 0.001). Referral rates increased from 2.8 to 5.4 per 1000 population between 2011 and 2018, with a 5-fold rise in those ≥ 75 years (0.4 to 2.0 per 1000). Mean FRAX 10-year risk of major osteoporotic fracture increased from 12.7 to 17.7% (CI 3.2-5.7, p < 0.001). Mean hip fracture risk probability increased from 3.0 to 5.7% (CI 2.0-3.4, p < 0.001). However, referral rates from the mobile sites remained lower than the comparator site.

CONCLUSIONS

Mobile fracture prevention services, including DXA, greatly improved uptake amongst high-risk individuals. Mobile services facilitated development of integrated of care pathways, including fracture liaison services, across community- and secondary-based care.

The prevalence of fibromyalgia in axial spondyloarthritis

Comorbid fibromyalgia, in axial spondyloarthritis (axSpA) has been shown to influence disease activity and function, and quality of life. Although several papers exist, there is no comprehensive and robust systematic review to determine the prevalence of fibromyalgia in this patient group. Thus, the aim of the current study was to provide a definitive estimate of prevalence of fibromyalgia in axSpA, and in axSpA sub-classifications. A systematic literature search was conducted in Ovid MEDLINE, EMBASE, Evidence Based Medicine (EBM), and Cochrane Library, updated to April 2020, combining keywords and relevant MeSH headings, to identify papers reporting the prevalence of fibromyalgia in axSpA, or data from which this could be computed. This was then combined in a meta-analysis with data from the Scotland Registry for Ankylosing Spondylitis (SIRAS), a national axSpA register in Scotland. Data was pooled using random or fixed effects models where heterogeneity was greater or lesser than 75%. From 3401 manuscripts initially identified, 15 papers were included in the final review, plus SIRAS, giving data from 16 separate sources. The prevalence of fibromyalgia, among a total of 5214 patients, was 16.4% (95% CI 12.3–20.5%). Prevalence varied with axSpA sub-classification: ankylosing spondylitis: 13.8% (9.1–18.6%); MRI positive non-radiographic axSpA 20.3% (6.5–34.1%); and ‘clinical’ disease: 11.1% (6.0–16.2%). Overall, around 1 in 6 patients with axSpA also meet criteria for fibromyalgia. While estimates from individual studies vary, comorbid fibromyalgia represents a considerable burden across all sub-classifications of axSpA. This emphasises that focusing management solely on inflammatory disease in this patient group is unlikely to yield optimal improvements in quality of life.

Outcomes and treatment responses, including work productivity, among people with axial spondyloarthritis living in urban and rural areas: a mixed-methods study within a national register

Objective

To examine differences in clinical and patient-reported outcomes, including work, in individuals with axial spondyloarthritis (axSpA) living in rural and urban settings.

Methods

Using a sequential, explanatory mixed-method design, data from the British Society for Rheumatology Biologics Register for Ankylosing Spondylitis were used to (1) characterise participants with axSpA living in rural and urban areas and (b) assess any differences in outcome after commencement of biologic therapy (phase 1). Semistructured interviews (phase 2) further explored the results from phase 1.

Results

Patients with axSpA living in rural areas were older and more likely to work in a physical job. Among patients prescribed biologics, there were no differences in response to biologics, but after adjustment for age, sex and local area deprivation rural dwellers reported more presenteeism and overall work impairment. Work effects could be explained by accounting for individual differences in disease activity, fatigue, physical function and job type. Interviews highlighted the complex relationship between clinical factors, contextual factors (work environment, job demands) and work disability. The ability to work and flexibility in terms of what, when and how tasks are undertaken were important. Support from employers was variable and healthcare professionals were often perceived as unsupportive.

Conclusions

Patients with axSpA living in rural areas report a greater impact of their disease on work productivity. New measures are needed to capture important contextual factors and comprehensively determine the impact of long-term conditions on work. Future European League Against Rheumatism axSpA recommendations should include support to work as a target to optimise quality of life in patients with axSpA.

Copper-doped ZrO2 nanoparticles as high-performance catalysts for efficient removal of toxic organic pollutants and stable solar water oxidation

Doping effect on the photoelectrochemical (PEC) water splitting efficiency and photocatalytic activities of ZrO₂ under visible light are reported. The XRD analysis revealed that pure, 0.1 and 0.3 mol% doped samples showed mixed crystal phases (tetragonal and monoclinic) and 0.5 mol% doped sample showed a pure tetragonal phase. Under visible light, 90% of methyl orange dye degradation was achieved with in 100 min. Moreover, the optimal doped sample showed a significant degradation rate constant over other samples. The doped photoelectrodes display a better PEC water oxidation performance over pure photoelectrode. Furthermore, the optimal doped (0.3 mol %) electrode shows 0.644 mAcm^-2 photocurrent density, corresponding to an approximate 50-fold enhancement over pure electrode (0.013 mAcm^-2). The optimized doped sample achieved 98% degradation of methyl orange within 100 min of light irradiation. The superior PEC water oxidation and photocatalytic activity of optimal doped samples under visible light are credited to suitable doping content, crystalline size, greater surface area, suitable bandgap, a lower charge carrying resistance, surface properties and the ability for decreasing the charge carrier's recombination rate.

O25 Quantifying and predicting the effect of anti-TNF therapy on axSpA-related fatigue: results from the BSRBR-AS registry and meta-analysis

Background

Fatigue represents a critical priority among patients with axial spondyloarthritis (axSpA). Its effective management is a major unmet clinical need. Existing studies indicate that anti-TNF therapy may reduce fatigue levels, although any effect has yet to be definitively quantified. Moreover, predictors of any such improvements have not been studied.

Methods

The British Society for Rheumatology Register in Axial Spondyloarthritis (BSRBR-AS) prospectively recruited axSpA patients across 83 centres in the UK. Changes in fatigue levels (measured using the Chalder Fatigue Scale (0-33)) over 1 year were compared between those starting anti-TNF therapy at the time of recruitment and those not. Differences between treatment groups were adjusted using propensity score matching. Results were combined with other studies in a meta-analysis to calculate pooled estimates. Then, among those BSRBR-AS anti-TNF commencers with clinically relevant fatigue, baseline predictors of response were investigated.

Results

Of the 998 BSRBR-AS recruits with complete fatigue outcome data, 310 were anti-TNF commencers and 688 were not. At 1 year follow-up, the former group reported a mean change in fatigue of -2.6 (95% CI -4.1, -1.9) points while the latter reported a mean worsening of fatigue by 0.2 points. Following propensity score adjustment, those commencing anti-TNF therapy reduced fatigue by 3.0 points compared to those not 95% CI (-4.1-1.9). In the meta-analysis, including 1109 subjects across 5 observational studies and trials, treatment with anti-TNF therapy resulted in a significant improvement in fatigue (SMD 0.36, 95% CI 0.15-1.56). Of those BSRBR-AS recruits commencing anti-TNF, n = 205 (66%) reported clinically significant fatigue at baseline of whom n = 139 (68%) experienced a clinically relevant improvement in their fatigue at 1 year. Poor sleep quality at baseline was predictive of fatigue improvement.

Conclusion

Anti TNF therapy results in a significant but modest reduction in fatigue amongst axSpA patients, with those reporting poor sleep quality most likely to report improvement. Effective management will likely require additional, possibly non-pharmacological, approaches.

Disclosures

J. Shim None. L. Dean None. M. Karabayas None. G. Jones None. G. Macfarlane None. N. Basu None.

Lilac flower-shaped ZnCo2O4electrocatalyst for efficient methanol oxidation and oxygen reduction reactions in an alkaline medium

A ZnCo₂O₄electrocatalyst for the efficient MOR and ORR.

P2860The effects of single nucleotide polymorphisms in Korean patients with early-onset lone atrial fibrillation after catheter ablation

Background

The status of SNPs among patients with extremely early-onset lone AF and the association with outcome of catheter ablation has not been evaluated before. This study evaluated the status of single nucleotide polymorphisms (SNPs) in Korean patients with early-onset (<40 years old) lone AF and effects on the outcome after catheter ablation.

Methods

A total of 89 consecutive patients (mean age 35.7±3.7 years, 81 males) with drug-refractory AF (paroxysmal 64.0%) who underwent catheter ablation were included. Sixteen SNPs including rs13376333, rs10465885, rs10033464, rs2200733, rs17042171, rs6843082, rs7193343, rs2106261, rs17570669, rs853445, rs11708996, rs6800541, rs251253, rs3807989, rs11047543 and rs3825214 were genotyped. Serial 48-day Holter electrocardiographic recordings were acquired to detect AF recurrences during long-term follow up.

Results

Wild type of rs7193343 [CC; 0/7 (0%) vs. CT; 22/40 (55.0%) vs. TT; 18/41 (43.9%), p=0.025] and rs11047543 [GG; 26/69 (37.7%) vs. GA; 13/18 (72.2%) vs. AA; 0/0, p=0.009] and homozygous variant of rs3825214 [AA; 16/31 (51.6%) vs. AG; 22/43 (51.2%) vs. GG; 2/13 (15.4%), p=0.05] were significantly associated with lower rate of late recurrence. When the patients were assigned to four groups according to the number of risk alleles (n=0–3), Kaplan-Meier survival analysis showed incremental prognostic value according to the number of variant alleles (p=0.002) (Figure 1).

Figure 1

Conclusions

Polymorphisms on rs7193343, rs3825214 and rs11047543 modulate the risk for AF recurrence after catheter ablation during long term follow up in Korean patients with early-onset lone AF.

Acknowledgement/Funding

Korean Society of Cardiology

P1026Risk factors for the occurrence of stroke after atrial fibrillation ablation

Background

Risk factors for the occurrence of embolic stroke (ES) after atrial fibrillation (AF) ablation have not been fully elucidated. Our aim was to assess incidence of ES during long-term follow-up following AF ablation and to identify predicting factors associated with post-ablation ES.

Methods

We enrolled patients who experienced ES after AF ablation and body mass index-matched controls from AF ablation registries. Epicardial adipose tissue (EAT) was assessed using multislice computed tomography prior to ablation.

Results

A total of 3,464 patients who underwent AF ablation were recruited. During a mean follow-up of 47.2 months, ES occurred in 47 patients (1.36%) with a mean CHA2DS2-VAS score of 2.15 and overall incidence of ES was 0.34 per 100 patients/year. Compared with control group (n=190), ES group had more higher prior thromboembolic event and AF recurrence rates, larger LA size, lower creatinine clearance rate (CCr), and greater total and periatrial EAT volumes although no differences in AF type, CHA2DS2-VASc score, ablation extent, and anti-thrombotics use were found. On multivariate regression analysis, a prior history of thromboembolism, CCr, and periatrial EAT volume were independently associated with ES occurrence after AF ablation.

Cox regression analysis Risk factor Univariate Multivariate HR (95% CI) p value HR (95% CI) p value Age 1.017 (0.984–1.051) 0.31 Prior thromboembolism 2.488 (1.134–5.460) 0.023 2.916 (1.178–7.219) 0.021 CHA2DS2-VASc score 1.139 (0.899–1.445) 0.282 CCr 0.984 (0.970–0.999) 0.038 0.982 (0.996–0.998) 0.029 LA diameter (mm) 1.070 (1.012–1.130) 0.017 1.072 (0.999–1.150) 0.054 EAT_total (ml) 1.020 (1.010–1.029) <0.001 1.008 (0.993–1.023) 0.297 EAT_periatrial (ml) 1.085 (1.045–1.126) <0.001 1.065 (1.005–1.128) 0.032 PVI + additional ablation 0.846 (0.460–1.557) 0.592 No anticoagulant use 0.651 (0.346–1.226) 0.184 Recurrence 2.011 (1.007–4.013) 0.048 1.240 (0.551–2.793) 0.603 CCr, creatinine clearance rate; EAT, epicardial adipose tissue; LA, left atrium; PVI, pulmonary vein isolation.

K-M curve for stroke-free survival

Conclusions

Incidence of ES after AF ablation was lower than expected rate based on CHA2DS2-VASc score even though anticoagulants use was limited. Periatrial EAT volume, a prior thromboembolism event, and CCr were independent factors in predicting ES irrespective of AF recurrence and CHA2DS2-VASc score in patients who underwent AF ablation.

P3762The impact of type and burden of atrial fibrillation on stroke occurrence in patients with atrial fibrillation: from a prospective cohort of atrial fibrillation patients (CODE-AF Registry)

Background and purpose

Although several studies reported that stroke risk in patients with paroxysmal atrial fibrillation (AF) is similar to those with persistent or permanent AF, there is still controversy on the relationship of AF type and stroke occurrence. We investigated the effect of AF type on AF burden and stroke risk in patients with non-valvular AF.

Methods

Within the CODE-AF prospective, outpatient registry (COmparison study of Drugs for symptom control and complication prEvention of Atrial Fibrillation), we identified 8,883 patients ≥18 years of age with non-valvular AF and eligible follow-up visits. We compared AF burden and stroke risk among patients with 3 types of AF: paroxysmal (n=5,808) or persistent (n=2,806) or permanent (n=269).

Results

The median age of the overall population was 68.0 (interquartile range, 60.0–75.0); 36.0% were female. Patients with persistent and permanent AF were older and had higher CHA2DS2-VASc scores and anticoagulation rate than those with paroxysmal AF. Compared with permanent AF (5.2±16.4%), the arrhythmic burden of AF on 24hrs Holter monitoring was significantly lower in paroxysmal AF (2.1±7.2%, p<0.001) and persistent AF (2.0±7.5%, p<0.001). During median follow-up period of 1.38 years (interquartile range: 0.96–1.67), total 82 (0.92%) patients experienced ischemic stroke with incidence rates of 0.51, 1.04 and 1.69 events per 100 person-years for paroxysmal, persistent and permanent AF, respectively. Compared with paroxysmal AF, the risk of ischemic stroke was increased in persistent AF with clinical variable adjusted hazard ratio (aHR) of 1.94 (95% confidence intervals [CI], 1.23–3.07; P=0.005) and permanent AF with aHR of 2.64 (95% CI, 1.09–6.41; P=0.03).

AF type and HR of stroke occurrence Paroxysmal (n=5,808) Persistent (n=2,806) Permanent (n=269) Stoke events 39 37 6 Person years (PYs) 7673 3544 356 /100 PYs 0.51 1.04 1.69 HR (95% CI), p-value HR (95% CI), p-value HR (95% CI), p-value Unadjusted HR 1 (Reference) 2.05 (1.27–3.31), 0.003 3.32 (1.15–7.90), 0.02 Clinical variables adjusted HR 1 (Reference) 1.94 (1.23–3.07), 0.005 2.64 (1.09–6.41), 0.03 PYs: Person years; HR: Hazard ratio.

Conclusion

Persistent and permanent AF was associated with the increased risk of stroke than paroxysmal AF, after adjustment of clinical variables including age, sex, comorbidities and anticoagulation rate. These results suggest that AF type and burden might be related with the risk of ischemic stroke and should be considered in the stroke prevention of AF.

P11.32 Combined effects of niclosamide and temozolomide against human glioblastoma tumorspheres

BACKGROUND

Glioblastoma (GBM) is the most aggressive type of brain tumor and has poor survival outcomes, even after a combination of surgery, radiotherapy, and chemotherapy. Temozolomide is the only agent that has been shown to be effective against GBM, suggesting that combination of temozolomide with other agents may be more effective. Niclosamide, an FDA approved anthelmintic agent, has shown anti-cancer effects against human colon, breast, prostate cancers as well as GBM. However, the efficacy of the combination of niclosamide with temozolomide against GBM tumorspheres (TSs) has not been determined. We hypothesized that the combined treatment could effectively suppress GBM TSs.

MATERIAL AND METHODS

Effects of niclosamide and/or temozolomide on GBM TSs were evaluated. Viability, stemness, and invasive properties of GBM TSs were examined. In vivo anticancer efficacy was tested in a mouse orthotopic xenograft model.

RESULTS

The combination of niclsoamide and temozolomide significantly inhibited the viability, sphere formation, expression of stemness-related proteins, and invasive properties of GBM TSs. This combination significantly down-regulated the expression of epithelial mesenchymal transition-related proteins. Bioluminescence imaging further showed that compared with either agent alone, combination of niclosamide and temozolomide significantly reduced the tumor burden in orthotopic xenograft models.

CONCLUSION

The combination of niclosamide and temozolomide effectively decreased the stemness and invasive properties of GBM TSs, suggesting that this regimen may be therapeutically effective in treating patients with GBM.

Comparative responsiveness of the PROMIS-10 Global Health and EQ-5D questionnaires in patients undergoing total knee arthroplasty

AIMS

Responsiveness to clinically important change is a key feature of any outcome measure. Throughout Europe, health-related quality of life following total knee arthroplasty (TKA) is routinely measured with EuroQol five-dimension (EQ-5D) questionnaires. The Patient-Reported Outcomes Measurement Information System 10-Question Short-Form (PROMIS-10 Global Health) score is a new general heath outcome tool which is thought to offer greater responsiveness. Our aim was to compare these two tools.

PATIENTS AND METHODS

We accessed data from a prospective multicentre cohort study in the United Kingdom, which evaluated outcomes following TKA. The median age of the 721 patients was 69.0 years (interquartile range, 63.3 to 74.6). There was an even division of sex, and approximately half were educated to secondary school level. The preoperative EQ-5D, PROMIS-10, and Oxford Knee Scores (OKS) were available and at three, six, and 12 months postoperatively. Internal responsiveness was assessed by standardized response mean (SRM) and effect size (Cohen's d). External responsiveness was assessed by correlating change scores of the EQ-5D and PROMIS-10, with the minimal clinically important difference (MCID) of the OKS. Receiver operating characteristic (ROC) curves were used to assess the ability of change scores to discriminate between improved and non-improved patients.

RESULTS

All measures showed significant changes between the preoperative score and the various postoperative times (p < 0.001). Most improvement occurred during the first three months, with small but significant changes between three and six months, and no further change between six and 12 months postoperatively. SRM scores for EQ-5D, PROMIS-10, and OKS were large (> 0.8). ROC curves showed that both EQ-5D and PROMIS-10 were able to discriminate between patients who achieved the OKS MCID and those who did not (area under the curve (AUC) of 0.7 to 0.82).

CONCLUSION

The PROMIS-10 physical health tool showed greater responsiveness to change than the EQ-5D, most probably due to the additional questions on physical health parameters that are more susceptible to modification following TKA. The EQ-5D was, however, shown to be sensitive to clinically meaningful change following TKA, and provides the additional ability to calculate health economic utility scores. It is likely, therefore, that EQ-5D will continue to be the global health metric of choice in the United Kingdom. Cite this article: Bone Joint J 2019;101-B:832-837.

Systematic review and meta-analysis on outcomes of salvage therapy in patients with tumour recurrence during 'watch and wait' in rectal cancer

INTRODUCTION

The 'watch and wait' approach has recently emerged as an alternative approach for managing patients with complete clinical response in rectal cancer. However, less is understood whether the intervention is associated with a favourable outcome among patients who require salvage therapy following local recurrence.

MATERIALS AND METHODS

A comprehensive systematic search was performed using EMBASE, PubMed, MEDLINE, Journals@Ovid as well as hand searches; published between 2004 and 2018, to identify studies where outcomes of patients undergoing watch and wait were compared with conventional surgery. Study quality was assessed using the Newcastle-Ottawa assessment scale. The main outcome was relative risks for overall and disease specific mortality in salvage therapy.

RESULTS

Nine eligible studies were included in the meta-analysis. Of 248 patients who followed the watch and wait strategy, 10.5% had salvage therapy for recurrent disease. No statistical heterogeneity was found in the results. The relative risk of overall mortality in the salvage therapy group was 2.42 (95% confidence interval 0.96-6.13) compared with the group who had conventional surgery, but this was not statistically significant (P > 0.05). The relative risk of disease specific mortality in salvage therapy was 2.63 (95% confidence interval 0.81-8.53).

CONCLUSION

Our findings demonstrated that there was no significant difference in overall and disease specific mortality in patients who had salvage treatment following recurrence of disease in the watch and wait group compared with the standard treatment group. However, future research into the oncological safety of salvage treatment is needed.

Impact of biological therapy on work outcomes in patients with axial spondyloarthritis: results from the British Society for Rheumatology Biologics Register (BSRBR-AS) and meta-analysis

OBJECTIVES

To quantify, among patients with axial spondyloarthritis (axSpA), the benefit on work outcomes associated with commencing biologic therapy.

METHODS

The British Society for Rheumatology Biologics Register in Axial Spondyloarthritis (BSRBRAS) recruited patients meeting Assessment of SpondyloArthritis International Society criteria for axSpA naïve to biological therapy across 83 centres in Great Britain. Work outcomes (measured using the Work Productivity and Activity Impairment Index) were compared between those starting biological therapy at the time of recruitment and those not. Differences between treatment groups were adjusted using propensity score matching. Results from BSRBR-AS were combined with other studies in a meta-analysis to calculate pooled estimates.

RESULTS

Of the 577 participants in this analysis who were in employment, 27.9% were starting biological therapy at the time of recruitment. After propensity score adjustment, patients undergoing biological therapy, at 12-month follow-up, experienced significantly greater improvements (relative to non-biological therapy) in presenteeism (-9.4%, 95% CI -15.3% to -3.5%), overall work impairment (-13.9%, 95% CI -21.1% to -6.7%) and overall activity impairment (-19.2%, 95% CI -26.3% to -12.2%). There was no difference in absenteeism (-1.5%, 95% CI -8.0 to 4.9). Despite these improvements, impact on work was still greater in the biological treated cohort at follow-up. In the meta-analysis including 1109 subjects across observational studies and trials, treatment with biological therapy was associated with significantly greater improvements in presenteeism, work impairment and activity impairment, but there was no difference in absenteeism.

CONCLUSIONS

There is consistent evidence that treatment with biological therapy significantly improves work productivity and activity impairment in people with axSpA. However, there remain substantial unmet needs in relation to work.

Identifying Persons with Axial Spondyloarthritis At Risk of Poor Work Outcome: Results from the British Society for Rheumatology Biologics Register

OBJECTIVE

First, to test the hypothesis that, among working patients with axial spondyloarthritis (axSpA), those who report issues with reduced productivity at work (presenteeism) are at higher risk of work absence (absenteeism), and patients who report absenteeism are at higher risk of subsequently leaving the workforce. Second, to identify characteristics of workers at high risk of poor work outcome.

METHODS

The British Society for Rheumatology Biologics Register in Ankylosing Spondylitis has recruited patients meeting Assessment of Spondyloarthritis international Society criteria for axSpA from 83 centers. Data collection involved clinical and patient-reported measures at recruitment and annually thereafter, including the Work Productivity and Activity Impairment scale. Generalized estimating equations were used to identify factors associated with poor work outcomes.

RESULTS

Of the 1188 participants in this analysis who were working at recruitment, 79% reported some presenteeism and 19% some absenteeism in the past week owing to their axSpA. Leaving employment was most strongly associated with previous absenteeism (RR 1.02 per % increase in absenteeism, 95% CI 1.01-1.03), which itself was most strongly associated with previous presenteeism, a labor-intensive job, and peripheral joint involvement. High disease activity, fatigue, a labor-intensive job, and poorer physical function were all independently associated with future presenteeism.

CONCLUSION

Clinical and patient-reported factors along with aspects of work are associated with an increased risk of axSpA patients having a poor outcome in relation to work. This study has identified modifiable factors as targets, facilitating patients with axSpA to remain productive at work.

Development of a clinical risk score for pain and function following total knee arthroplasty: results from the TRIO study

Objectives

The aim was to develop and validate a simple clinical prediction model, based on easily collected preoperative information, to identify patients at high risk of pain and functional disability 6 months after total knee arthroplasty (TKA).

Methods

This was a multicentre cohort study of patients from nine centres across the UK, who were undergoing a primary TKA for OA. Information on sociodemographic, psychosocial, clinical and quality-of-life measures were collected at recruitment. The primary outcome measure for this analysis was the Oxford knee score (OKS), measured 6 months postoperatively by postal questionnaire. Multivariable logistic regression was used to develop the model. Model performance (discrimination and calibration) and internal validity were assessed, and a simple clinical risk score was developed.

Results

Seven hundred and twenty-one participants (mean age 68.3 years; 53% female) provided data for the present analysis, and 14% had a poor outcome at 6 months. Key predictors were poor clinical status, widespread body pain, high expectation of postoperative pain and lack of active coping. The developed model based on these variables demonstrated good discrimination. At the optimal cut-off, the final model had a sensitivity of 83%, specificity of 61% and positive likelihood ratio of 2.11. Excellent agreement was found between observed and predicted outcomes, and there was no evidence of overfitting in the model.

Conclusion

We have developed and validated a clinical prediction model that can be used to identify patients at high risk of a poor outcome after TKA. This clinical risk score may be an aid to shared decision-making between patient and clinician.

Support Vector Machine Quantile Regression for Detecting Differentially Expressed Genes in Microarray Analysis

Objectives: One of the main objectives of microarray analysis is to identify genes differentially expressed under two distinct experimental conditions. This task is complicated by the noisiness of data and the large number of genes that are examined. Fold change (FC) based gene selection often misleads because error variability for each gene is heterogeneous in different intensity ranges. Several statistical methods have been suggested, but some of them result in high false positive rates because they make very strong parametric assumptions.

Methods: We present support vector quantile regression (SVMQR) using iterative reweighted least squares (IRWLS) procedure based on the Newton method instead of usual quadratic programming algorithms. This procedure makes it possible to derive the generalized approximate cross validation (GACV) method for choosing the parameters which affect the performance of SVMAR. We propose SVMQR based on a novel method for identifying differentially expressed genes with a small number of replicated microarrays.

Results: We applied SVMQR to both three biological dataset and simulated dataset and showed that it performed more reliably and consistently than FC-based gene selection, Newton’s method based on the posterior odds of change, or the nonparametric t-test variant implemented in significance analysis of microarrays (SAM).

Conclusions: The SVMQR method was an exploratory method for cDNA microarray experiments to identify genes with different expression levels between two types of samples (e.g., tumor versus normal tissue). The SVMQR method performed well in the situation where error variability for each gene was heterogeneous in intensity ranges.

Measuring Sarcopenia Severity in Older Adults and the Value of Effective Interventions

OBJECTIVES

Little is known about the severity and long-term health and economic consequences of sarcopenia. We developed a sarcopenia index to measure severity in older Americans and estimated the long-term societal benefits generated by effective interventions to mitigate severity.

DESIGN

Using a micro-simulation model, we quantified the potential societal value generated in the US in 2010-2040 by reductions in sarcopenia severity in older adults. All analyses were performed in Stata and SAS.

SETTING AND PARTICIPANTS

Secondary data from the National Health and Nutrition Examination Survey (NHANES) (N = 1634) and Health and Retirement Study (HRS) (N = 952) were used to develop a sarcopenia severity index in older adults.

MEASUREMENTS

Multi-trait multi-method and factor analyses were used to validate and calibrate the sarcopenia severity index, which was modeled as a function of gait speed, walking without an assistive device, and moderate physical activity.

RESULTS

In representative elderly populations, reducing sarcopenia severity by improving gait speed by 0.1 m/s in those with gait speed under 0.8 m/s generated a cumulative benefit of $65B by 2040 (2015 dollars). Improving walking ability in those with walking difficulty generated cumulative social benefit of $787B by 2040.

CONCLUSIONS

Reducing sarcopenia severity would generate significant health and economic benefits to society-almost $800B in the most optimistic scenarios.

Interleukin33 deficiency causes tau abnormality and neurodegeneration with Alzheimer-like symptoms in aged mice

This corrects the article DOI: 10.1038/tp.2017.142.