Epidemiology and clinical characteristics of interstitial lung disease in patients with rheumatoid arthritis from the JointMan database

Interstitial lung disease (ILD) is a progressive fibrotic disease associated with rheumatoid arthritis (RA); real-world data for evaluating RA-associated ILD (RA-ILD) are limited. We evaluated prevalence, time to onset, clinical characteristics and prognostic factors in patients diagnosed with RA (n = 8963) in the Discus Analytics JointMan database (2009-2019) with and without ILD. ILD prevalence was 4.1% (95% confidence interval 3.7-4.5); > 90% had an ILD diagnosis after RA diagnosis (mean time to onset 3.3 years). At baseline, a higher proportion of patients with RA-ILD were older (> 65 years), male, with history of chronic obstructive pulmonary disease (COPD) compared with patients in the RA cohort. Patients in the RA-ILD cohort were likely to have more severe RA characteristics and joint evaluation compared with patients without ILD, at baseline and before/after ILD diagnosis. In this large, real-world database patients with (vs without) ILD had a higher burden of RA characteristics. Previously established risk factors for RA-ILD were confirmed (age, baseline COPD, anti-cyclic citrullinated peptide positivity, C-reactive protein, Clinical Disease Activity Index score); thus, recognition of these factors and tracking routine disease activity metrics may help identify patients at higher risk of RA complications and lead to improved diagnosis and earlier treatment.

Mental health disorders in English newspapers of India: A retrospective study

BACKGROUND

In recent years there has been significant coverage of mental health in Indian newspapers; the media can play a significant role in perpetuating as well as reducing stigma towards people with mental illness. This paper analyses the content, context and type of newspaper coverage of various mental health disorders in English language newspapers in India between 2016 and 2021.

METHODS

A detailed analysis was performed on a sample of articles about mental illness in a range of English language Indian newspapers.

RESULTS

Depression was the most prevalent topic amongst the articles followed by anxiety, schizophrenia and bipolar disorder. Our study describes a wide range of use of mental health disorders in various newspapers. All diagnoses were generally described in a criminal context like homicide, sexual assault and other crimes. Over time newspaper coverage of mental illness has become less stigmatising. Further exploration of non-English medium newspapers is required to fully understand the extent of the role of print media in perpetuating unhelpful stereotypes of people with mental illness in India.

PsychStart: a novel mentoring scheme for supporting and valuing medical students interested in psychiatry

We describe the establishment and evaluation of a career-based mentoring scheme (PsychStart) for medical students interested in psychiatry. Medical students reported multiple benefits of mentoring, including enhanced personal and professional development, increased career and clinical knowledge, and broadened exposure to psychiatry. The mentoring scheme was also found to promote and sustain interest in the specialty. Further evaluation is required to determine the long-term effects of mentoring and how this may compare with other undergraduate enrichment activities. We conclude that mentoring in psychiatry could offer innovative solutions for improving recruitment and retention, and for supporting and valuing medical students who demonstrate an early interest in the specialty.

Trends in training progression: response to the study by Silkens et al

Recruitment and retention are of major concern to all in medicine. Improvement in recruitment to UK speciality training programmes does not directly translate into senior workforce capacity, which remains dependent on trainee progression. In 2021, Silkens et al undertook a mixed-methods study to investigate this and described a trainee-driven shift away from conventional training pathways and expectations. These findings suggest a need for a broad change in approach to careers, underpinned by commitment to reducing differential attainment, acknowledgment that trainees may have a range of unique needs, and development of a culture of equality, diversity and inclusion.

Effectiveness and safety of non-vitamin K antagonist oral anticoagulants versus warfarin among nonvalvular atrial fibrillation patients with prior bleeding events

Background

Patients with non-valvular atrial fibrillation (NVAF) use oral anticoagulants such as warfarin or non-vitamin K antagonist oral anticoagulants (NOACs) for the prevention of stroke. However, the effectiveness and safety of warfarin and NOACs can be influenced by pre-existing patient comorbidities, such as a history of bleeding, and limited evidence are available to inform the choice of the most appropriate anticoagulant treatment for NVAF patients with bleeding history.

Purpose

This study used five United States insurance claims databases to evaluate the risk of stroke/systemic embolism (S/SE) and major bleeding (MB) among NVAF patients with prior bleeding events who were prescribed NOACs versus warfarin.

Methods

This retrospective observational study used data from 5 databases (CMS Medicare and four commercial databases, covering >180 million beneficiaries) to select adult NVAF patients who were treated with apixaban, dabigatran, rivaroxaban, or warfarin (01JAN2013–30JUN2019). Patients were required to have a prior bleeding event, defined as a hospitalization with a diagnosis for intracranial hemorrhage (ICH), gastrointestinal (GI) bleeding or bleeding at other key sites prior to or during the index treatment episode. In each database, three 1:1 NOAC-warfarin propensity-score-matched (PSM) cohorts were created before pooling the results. Outcome measures were time to first stroke/SE, (ischemic stroke, hemorrhagic stroke, and SE), and time to first MB (gastrointestinal bleeding, intracranial hemorrhage, and MB at other key sites), and were measured from the index treatment episode to treatment discontinuation or switch, death, health plan disenrollment, or end of study period. Hazard ratios of S/SE and MB were calculated using Cox proportional hazards models.

Results

Among the eligible NVAF population, 8.2% of patients had a prior bleeding event (ICH: 12.3%; GI: 60.7%; Other: 27.0%). After PSM, a total of 43,092 apixaban-warfarin, 11,295 dabigatran-warfarin, and 32,723 rivaroxaban-warfarin patient pairs with prior bleeding were selected with a mean follow-up of 8–9 months. Apixaban and rivaroxaban were associated with a lower risk of S/SE, and dabigatran was associated with a similar risk of S/SE when compared to warfarin. Apixaban and dabigatran were associated with a lower risk of MB, and rivaroxaban was associated with a similar risk of MB, compared to warfarin (Figure).

Conclusion

Among NVAF patients with prior bleeding events, NOACs were associated with varying risks of S/SE and MB compared to warfarin. These results can help inform healthcare providers concerning the impact of OAC treatment in NVAF patients with history of bleeding.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Bristol-Myers Squibb Company and Pfizer, Inc.

Time at home among nonvalvular atrial fibrillation patients treated with non-vitamin K antagonist oral anticoagulants: an ARISTOPHANES analysis

Background

Patient-centered outcomes, such as home time, are becoming increasingly important quality-of-life measures. There are limited data on the impact of oral anticoagulants (OACs) on home time among patients with non-valvular atrial fibrillation.

Purpose

This analysis, based on the previously published ARISTOPHANES study, used five US insurance claims databases (CMS Medicare and four commercial databases) to compare home time among NVAF patients who were prescribed non-vitamin K antagonist OACs (NOACs).

Methods

Adult NVAF patients who were newly prescribed apixaban, dabigatran, or rivaroxaban (01JAN2013–30SEP2015) were selected. Time at home was calculated as the number of days from the index date (NOAC prescription) without any of the following: an inpatient, skilled nursing facility (SNF) or nursing facility, hospice, or inpatient rehabilitation facility admission. Time at home and without external AF-related care was defined as days from index date without any events from the home time endpoint or any days with a claim for bleeding, stroke/systemic embolism (S/SE), AF, or an INR test. Time at home and without external AF-related care were measured during the 180 days of follow-up; patients were required to have been alive and have 180 days of follow-up post index. In each database, three 1:1 NOAC-NOAC propensity-score-matched (PSM) cohorts were created before combining the databases. For each NOAC-NOAC matched cohort, Poisson regression was conducted to compare time at home and time at home without external AF-related care.

Results

After PSM, 37,314 apixaban-dabigatran, 107,236 apixaban-rivaroxaban, and 37,693 rivaroxaban-dabigatran patient pairs were created of which 37–44% had 180 days of follow-up available. Across the NOAC cohorts, approximately 21–25% of patients had an admission to a hospital, SNF, nursing facility, rehabilitation center, or hospice during the 180-day follow-up. The time at home was generally consistent between the NOAC cohorts (177 days); however, apixaban patients had 0.5 more days at home compared to rivaroxaban patients. Across all NOAC cohorts, 7–8% had a claim for a S/SE, 11–15% had a claim for bleeding, and 15–22% had an INR test, while 87–89% of all patients had an AF-claim during the 180-day follow-up. Patients prescribed apixaban had 1 more day at home without external AF-related care compared to dabigatran, and 1.5 more days at home without external AF-related care compared to rivaroxaban. Dabigatran had <1 more day at home without external AF-related care compared to rivaroxaban.

Conclusion

Among NVAF patients treated with NOACs, there were small differences in the time at home and time at home without external AF-related care during the first 6 months of NOAC treatment. As NVAF is a chronic condition, it is important to understand the impact of NOAC treatment on these patient-centered outcomes.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Bristol-Myers Squibb Company and Pfizer Inc.

Time at home among nonvalvular atrial fibrillation patients treated with non-vitamin K antagonist oral anticoagulants versus warfarin

Background

Clinical trials and real-world database studies have shown the benefits of non-vitamin K antagonist oral anticoagulants (NOACs) compared to warfarin; however, measures of functional outcomes are critical in evaluating a patient's quality of life. Previous measures of time spent out of hospital in a home setting and time spent receiving disease-related care among non-valvular atrial fibrillation (NVAF) patients are lacking in the current literature.

Purpose

This analysis was based on the previously published ARISTOPHANES study, and used multiple data sources to evaluate the amount of time spent at a patient's home among NVAF patients who were prescribed NOACs versus warfarin.

Methods

This retrospective observational study used US data from CMS Medicare and four commercial databases to select adult NVAF patients who initiated apixaban, dabigatran, rivaroxaban, or warfarin (01JAN2013–30SEP2015). Time at home and time at home without external AF-related care were measured during the 180 days after the index date (OAC prescription). Time at home was defined as days from index date without any of the following: an inpatient, skilled nursing facility or nursing facility, hospice, or inpatient rehabilitation facility admission. Time at home and without external AF-related care was defined as days away from home and days with a claim for bleeding, stroke/systemic embolism, AF, or an INR test. Each day a claim was observed was counted as one day. In each database, three 1:1 NOAC-warfarin propensity-score-matched (PSM) cohorts were created before pooling the results. After PSM, a subgroup of patients who were alive and had ≥180 days of follow-up was created. Poisson regression was conducted in each NOAC-warfarin matched cohort to compare time at home and time at home without external AF-related care.

Results

After matching, a total of 100,977 apixaban-warfarin, 36,990 dabigatran-warfarin, and 125,068 rivaroxaban-warfarin patient pairs were selected. Of those patients, 38–46% had 180 days of follow-up available. Across treatment cohorts, approximately 75% of patients were at home for the 180-day follow-up. Apixaban, dabigatran, and rivaroxaban patients had 1.3, 0.9, and 0.8 more days at home, respectively, compared to warfarin patients. Patients treated with apixaban had 13.4 more days at home without AF-related care compared to warfarin, while dabigatran and rivaroxaban had 11.6 and 11.7 more days at home without AF-related care compared to warfarin. A greater proportion of warfarin patients than NOAC patients had an INR test (81–82% vs 14–21%), and days with INR testing were the main driver for external AF-related care for warfarin patients.

Conclusion

Among NVAF patients treated with OACs, NOACs were associated with a longer time at home and time at home without external AF-related care compared to warfarin. These results can help inform healthcare providers and patients regarding the impact of NOAC treatment in NVAF patients.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Bristol-Myers Squibb Company and Pfizer Inc.

Effectiveness and safety of non-vitamin K antagonist oral anticoagulants among nonvalvular atrial fibrillation patients with prior bleeding events

Background

Among non-valvular atrial fibrillation (NVAF) patients with a history of bleeding, there is a reluctance to use oral anticoagulants (OACs) due to concerns about the risk of bleeding associated with OACs. However, lack of OAC treatments for NVAF patients is associated with a higher risk of stroke and mortality. Non-vitamin K antagonist OAC (NOACs) have been approved for the prevention of stroke in NVAF patients. There are limited data comparing the risk of stroke/systemic embolism (S/SE) and major bleeding (MB) between patients prescribed NOACs and with a history of bleeding.

Purpose

This study used multiple United States data sources to evaluate the risk of S/SE and MB among NVAF patients with prior bleeding events who were prescribed NOACs.

Methods

This retrospective observational study used data from CMS Medicare and four commercial databases–covering >180 million beneficiaries. The study selected adult NVAF patients who were prescribed apixaban, dabigatran, or rivaroxaban (01JAN2013–30JUN2019) and had a prior bleeding event which was defined as a hospitalization with a bleeding diagnosis (intracranial hemorrhage [ICH], gastrointestinal [GI] bleeding, or other bleeding sites) prior to or during the index treatment episode. After 1:1 propensity-score-matched (PSM) in each database between NOACs (apixaban-dabigatran, apixaban-rivaroxaban, and dabigatran-rivaroxaban), the resulting patient records were pooled. S/SE and MB (identified by inpatient claims) were captured during the follow-up period, which was defined as the time between the day after the index treatment date and treatment discontinuation or switch, death, end of study period, or end of medical and pharmacy enrollment. Hazard ratios of S/SE and MB were calculated using Cox proportional hazards models.

Results

Of the overall NVAF population treated with NOACs, 6.2% had a prior bleeding event (ICH: 13.5%; GI: 61.8%; Other: 24.6%). After PSM, a total of 11,106 apixaban-dabigatran, 30,665 apixaban-rivaroxaban, and 11,148 dabigatran-rivaroxaban pairs were matched. Apixaban was associated with a lower risk of S/SE compared to dabigatran and rivaroxaban, and dabigatran was associated with a similar risk of S/SE compared to rivaroxaban. Apixaban was associated with a lower risk of MB compared to dabigatran and rivaroxaban, and dabigatran was associated with a lower risk of MB compared to rivaroxaban (Figure).

Conclusions

In this subgroup of NVAF patients with a history of bleeding, apixaban was associated with a lower risk of S/SE and MB compared to dabigatran and rivaroxaban. Dabigatran was associated with a lower risk of MB compared to rivaroxaban. These results are informative for understanding the impact of NOAC treatment in NVAF patients with prior bleeding events.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Bristol-Myers Squibb Company and Pfizer, Inc.

Unleashing talent in mental health sciences: gender equality at the top

Society is undergoing a shift in gender politics. Science and medicine are part of this conversation, not least as women's representation and pay continue to drop as one progresses through more senior academic and clinical levels. Naming and redressing these inequalities needs to be a priority for us all.Declaration of interestNone.

Immediate post-release survival of eastern barred bandicoots Perameles gunnii at Woodlands Historic Park, Victoria, with reference to fox activity

On mainland Australia, eastern barred bandicoots (Perameles gunnii) are now restricted to a single wild population at Hamilton in western Victoria, and recovery efforts are focussed on establishing new populations at reintroduction sites. The success in founding these populations has been variable, and post-release survival has not been accurately quantified. It is believed that predation by the red fox (Vulpes vulpes) is largely responsible for post-release loss of P. gunnii, despite the implementation of predator control programs at release sites. An intensive fox control program was established to protect 10 released P. gunnii at Woodlands Historic Park, near Melbourne. Monitoring of fox activity was undertaken prior to and after the release in an attempt to better understand the effectiveness of control operations. Seven bandicoots were known to be alive at the conclusion of the study five weeks after their release (and an additional animal was trapped four months later), with weight loss appearing to be an important factor in determining post-release survival. Despite constant levels of bait-take by V. vulpes, fox activity measured from sand-pads remained high. We hypothesise that the presence of suitable refugia is allowing the persistence of a low-density bandicoot population at Woodlands despite constant, high levels of fox activity.

Disruption of prior uterine incision following misoprostol for labor induction in women with previous cesarean delivery

BACKGROUND

Although induction of labor in women with prior cesareans is controversial, we compared misoprostol to oxytocin in such women in a randomized trial. The investigation was terminated prematurely because of safety concerns.

CASES

Disruption of the prior uterine incision was found in two of 17 misoprostol-treated women. The first woman underwent repeat cesarean delivery at 42 weeks because of fetal tachycardia and repetitive late decelerations. A 10-cm vertical rent in the anterior myometrium was discovered. The second woman underwent induction for fetal growth restriction. Loss of fetal heart tones and abnormal abdominal contour prompted emergent cesarean for suspected uterine rupture. An 8-cm longitudinal uterine defect was found.

CONCLUSION

When misoprostol is used in women with previous cesareans, there is a high frequency of disruption of prior uterine incisions.

MR imaging characteristics of noncancerous lesions of the prostate

Radical prostatectomy specimens from 53 men with clinical stage A or B prostate cancer were retrospectively reviewed and compared with correlative axial T2-weighted magnetic resonance (MR) images obtained just before surgery. Non-cancerous lesions were evaluated for signal intensity and location. Focal high-signal-intensity areas (n = 72) were present in 81% of patients. The 26% of lesions seen in the central gland all correlated with cystic atrophy. Of the 53 lesions seen in the peripheral prostate, 47 (89%) were cystic atrophy without associated cancer, four (7.5%) cystic atrophy with cancer, and two (3.8%) focal inflammation. Focal low-signal-intensity areas (n = 42) were present in 60% of patients. Of the 31% of lesions in the central prostate, one-fifth correlated with benign prostatic hyperplasia (BPH) and four-fifths with fibrous tissue. Of the 69% of peripheral lesions, 83% corresponded to fibrous tissue, 10% to BPH, and 7% to normal tissue. Mixed lesions (n = 42) were present in 64% of patients; 86% of these were located centrally and 14% peripherally. All mixed central lesions were BPH; the peripheral lesions were areas of combined cystic atrophy and fibrosis. BPH of low or mixed signal intensity can extend into the peripheral prostate and mimic cancer. High-intensity cystic atrophy associated with cancer can mimic normal tissue.

Localization of cyclic nucleotide phosphodiesterase activity within the bovine photoreceptor cell

Cyclic nucleotide phosphodiesterase was measured in the outer layers of the bovine retina by quantitative histochemical methods. The outer segment region contained the highest specific enzyme activity. Phosphodiesterase activity with different kinetic properties was also observed in the outer plexiform layer.