Comorbidity clusters in patients with rheumatoid arthritis identify a patient phenotype with a favourable prognosis

OBJECTIVES

We aimed to cluster patients with rheumatoid arthritis (RA) based on comorbidities and then examine the association between these clusters and RA disease activity and mortality.

METHODS

In this population-based study, residents of an eight-county region with prevalent RA on 1 January 2015 were identified. Patients were followed for vital status until death, last contact or 31 December 2021. Diagnostic codes for 5 years before the prevalence date were used to define 55 comorbidities. Latent class analysis was used to cluster patients based on comorbidity patterns. Standardised mortality ratios were used to assess mortality.

RESULTS

A total of 1643 patients with prevalent RA (72% female; 94% white; median age 64 years, median RA duration 7 years) were studied. Four clusters were identified. Cluster 1 (n=686) included patients with few comorbidities, and cluster 4 (n=134) included older patients with 10 or more comorbidities. Cluster 2 (n=200) included patients with five or more comorbidities and high prevalences of depression and obesity, while cluster 3 (n=623) included the remainder. RA disease activity and survival differed across the clusters, with cluster 1 demonstrating more remission and mortality comparable to the general population.

CONCLUSIONS

More than 40% of patients with prevalent RA did not experience worse mortality than their peers without RA. The cluster with the worst prognosis (<10% of patients with prevalent RA) was older, had more comorbidities and had less disease-modifying antirheumatic drug and biological use compared with the other clusters. Comorbidity patterns may hold the key to moving beyond a one-size-fits-all perspective of RA prognosis.

Association between sinusitis and incident rheumatic diseases: a population-based study

OBJECTIVES

To determine whether antecedent sinusitis is associated with incident rheumatic disease.

METHODS

This population-based case-control study included all individuals meeting classification criteria for rheumatic diseases between 1995 and 2014. We matched three controls to each case on age, sex and length of prior electronic health record history. The primary exposure was presence of sinusitis, ascertained by diagnosis codes (positive predictive value 96%). We fit logistic regression models to estimate ORs for incident rheumatic diseases and disease groups, adjusted for confounders.

RESULTS

We identified 1729 incident rheumatic disease cases and 5187 matched controls (mean age 63, 67% women, median 14 years electronic health record history). After adjustment, preceding sinusitis was associated with increased risk of several rheumatic diseases, including antiphospholipid syndrome (OR 7.0, 95% CI 1.8 to 27), Sjögren's disease (OR 2.4, 95% CI 1.1 to 5.3), vasculitis (OR 1.4, 95% CI 1.1 to 1.9) and polymyalgia rheumatica (OR 1.4, 95% CI 1.0 to 2.0). Acute sinusitis was also associated with increased risk of seronegative rheumatoid arthritis (OR 1.8, 95% CI 1.1 to 3.1). Sinusitis was most associated with any rheumatic disease in the 5-10 years before disease onset (OR 1.7, 95% CI 1.3 to 2.3). Individuals with seven or more codes for sinusitis had the highest risk for rheumatic disease (OR 1.7, 95% CI 1.3 to 2.4). In addition, the association between sinusitis and incident rheumatic diseases showed the highest point estimates for never smokers (OR 1.7, 95% CI 1.3 to 2.2).

CONCLUSIONS

Preceding sinusitis is associated with increased incidence of rheumatic diseases, suggesting a possible role for sinus inflammation in their pathogenesis.

Multimorbidity in Psoriasis as a Risk Factor for Psoriatic Arthritis: A Population-Based Study

OBJECTIVES

To examine multimorbidity in psoriasis and its association with the development of PsA.

METHODS

A retrospective cohort study was performed using the Rochester Epidemiology Project. Population-based incidence (2000-2009) and prevalence (Jan 1, 2010) cohorts of psoriasis were identified by manual chart review. A cohort of individuals without psoriasis (comparators) were identified (1:1 matched on age, sex, and county). Morbidities were defined using ≥2 Clinical Classification Software codes ≥30 days apart within prior five years. PsA was defined using ClASsification of Psoriatic ARthritis (CASPAR) criteria. χ2 and rank-sum tests were used to compare morbidities, and age-, sex-, and race-adjusted Cox models to examine the association of baseline morbidities in psoriasis with development of PsA.

RESULTS

Among 817 incident psoriasis patients, the mean age was 45.2 years with 52.0% females, and 82.0% moderate/severe psoriasis. No multimorbidity differences were found between incident psoriasis patients and comparators. However, in the 1,088 prevalent psoriasis patients, multimorbidity was significantly more common compared with 1,086 comparators (OR : 1.35 and OR : 1.48 for ≥2 and ≥5 morbidities, respectively). Over a median 13.3-year follow-up, 23 patients (cumulative incidence: 2.9% by 15 years) developed PsA. Multimorbidity (≥2 morbidities) was associated with a 3-fold higher risk of developing PsA.

CONCLUSION

Multimorbidity was more common in the prevalent but not incident cohort of psoriasis compared with the general population, suggesting patients with psoriasis may experience accelerated development of multimorbidity. Moreover, multimorbidity at psoriasis onset significantly increased the risk of developing PsA, highlighting the importance of monitoring multimorbid psoriasis patients for the development of PsA.

Eggerthella lenta augments preclinical autoantibody production and metabolic shift mimicking senescence in arthritis

Although the etiology of rheumatoid arthritis (RA) is unknown, a strong genetic predisposition and the presence of preclinical antibodies before the onset of symptoms is documented. An expansion of Eggerthella lenta is associated with severe disease in RA. Here, using a humanized mouse model of collagen-induced arthritis, we determined the impact of E. lenta abundance on RA severity. Naïve mice gavaged with E. lenta produce preclinical rheumatoid factor and, when induced for arthritis, develop severe disease. The augmented antibody response was much higher in female mice, and among patients with RA, women had higher average load of E. lenta. Expansion of E. lenta increased CXCL5 and CD4 T cells, and both interleukin-17- and interferon-γ-producing B cells. Further, E. lenta gavage caused gut dysbiosis and decline in amino acids and nicotinamide adenine dinucleotide with an increase in microbe-dependent bile acids and succinyl carnitine causing systemic senescent-like inflammation.

The effect on the T-14 paediatric throat disorders outcome score of delaying adenotonsillectomy surgery due to COVID-19

INTRODUCTION

Adenotonsillectomy is commonly performed for recurrent tonsillitis and obstructive sleep apnoea. These conditions may improve with age. The COVID-19 pandemic led to all UK elective surgery being suspended. This study aimed to determine whether delaying surgery had any effect on a patient's symptoms using the validated T-14 paediatric throat disorders outcome test.

METHODS

Patients completed a T-14 questionnaire when the child was listed for surgery; this was repeated on the revised surgery date and a paired t test was used to compare the responses.

RESULTS

Questionnaires were completed by 29 patients a mean of 6.4 months apart. There was a significant improvement in scores (p<0.02) for five domains: eating habits, visits to a doctor/A&E, antibiotics for less than 2 weeks, chronic infections and school missed due to sore throats.

CONCLUSIONS

This study demonstrates that following delays resulting from the COVID-19 pandemic, paediatric patients experienced an improvement in some aspects of their quality of life while awaiting tonsillectomy and/or adenoidectomy. This was most apparent in quality-of-life measures relating to recurrent tonsillitis, namely visits to a doctor/A&E, antibiotics for less than 2 weeks, chronic infections and school missed due to sore throats. Patients may experience an improvement in some of their individual symptoms, in particular their infective symptoms, during an observation period.

Trends in incidence of chronic heart failure (HF) in patients with rheumatoid arthritis: a population-based study validating different HF definitions

OBJECTIVE

To assess trends in incidence of heart failure (HF) in patients with incident rheumatoid arthritis (RA) in 1980-2009 and to compare different HF definitions in RA.

METHODS

The study population comprised Olmsted County, Minnesota residents with incident RA (age ≥ 18 years, 1987 ACR criteria met in 1980-2009). All subjects were followed until death, migration, or 04/30/2019. Incident HF events were defined as: 1) Framingham criteria for HF; 2) Diagnosis of HF (outpatient or inpatient) by a physician; 3) ICD-9/10 codes for HF. Patients with HF prior to RA incidence/index date were excluded. Cox proportional hazards models were used to compare incident HF events by decade, adjusting for age, sex and cardiovascular risk factors. HF definitions 2 and 3 were compared to the Framingham criteria.

RESULTS

The study included 905 patients with RA (mean age 55.9 years; 68.6% female; median follow-up 13.4 years). The 10-year cumulative incidence of HF event by any chartreviewed method in RA cohort in the 1980s was 11.66% (95%CI 7.86-17.29%), 1990s was 12.64% (95%CI 9.31-17.17%), and 2000s was 7.67% (95%CI 5.36-10.97%). Incidence of HF did not change across the decades of RA incidence using any of the HF definitions. Physician diagnosis of HF and ICD-9/10 code-based definitions of HF performed well compared to Framingham criteria, showing moderate-to-high sensitivity and specificity.

CONCLUSION

Incidence of HF in patients with incident RA in 2000s versus 1980s was not statistically significantly different. Physician diagnosis of HF and ICD-9/10 codes for HF performed well against Framingham criteria.

Nutritional Management of Children with Food Allergies

Purpose of the Review

The purpose of the review is to review the evidence for the nutritional management of paediatric food allergy and provide a practical approach for healthcare professionals working in this area.

Recent Findings

Dietary elimination remains the mainstay for management of food allergies in children. However, the elimination of food allergens increases the risk for growth faltering, micronutrient deficiencies and feeding difficulties. Breastmilk remains the ideal source of nutrition for infants, but when not available, the vast majority will tolerate an extensively hydrolysed formula, and rice hydrolysate has also been suggested as a suitable alternative. Only in severe cases, including anaphylaxis, eosinophilic oesophagitis and growth faltering, is an amino acid formula indicated. The early introduction of peanut and egg and avoiding the delay in the introduction of other allergens, when not already allergic, has been highlighted by recent studies.

Summary

Whilst the elimination of allergens increases the risk of developing poor growth, micronutrient deficiencies and feeding difficulties, optimal, early dietary input, including advice on active introduction of allergens and alternative feeds, ideally from a registered dietitian/nutritionist, may be prevent and improve outcomes.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

"You can't just eat 16 teaspoons of sugar so why would you drink 16 teaspoons' worth of sugar?": a qualitative study of young adults' reactions to sugary drink warning labels

Background

Several jurisdictions have introduced nutrient warning front of pack (FoP) labels in an effort to curb consumption of ultra-processed foods and beverages high in free sugars (sugars added to foods and beverages, and sugars naturally present in honey, syrups, fruit juices and fruit juice concentrates). This study aimed to explore consumer understanding and perceptions of FoP warning labels that convey different nutritional and health information messages regarding the consumption of sugary drinks.

Methods

Sixteen focus groups were held with 4–8 young adults per group (aged 18–24; n = 105 participants in total) stratified by education level, location (rural centres, large cities) and gender (males, females) to ensure diversity. Labels shown to participants during group discussions included text warning labels of health effects, exercise equivalents, calorie/kilojoule information and sugar content as a “high in” label and as teaspoons (text and pictograms). Thematic analysis was undertaken.

Results

Four themes were identified related to participants’ perceived effectiveness of labels: the extent to which labels were perceived to be useful, relevant and credible; the extent to which a label elicited shock or disgust (perceived aversiveness); the extent to which the label message was resistant to self-exemption; and participants’ perceived potential of the label to reduce purchasing and consumption behaviour. Across all four themes, labels communicating the number of teaspoons of sugar in a sugary drink (whether by text or pictogram) were perceived as the most impactful, resistant to self-exemption and to have the greatest potential to reduce consumption, with enhanced reactions to the pictogram label. Labels depicting health effects, exercise equivalents, calorie/kilojoule information or a general ‘high in sugar’ warning were perceived by consumers to be less effective in one or more themes.

Conclusions

Labels conveying the amount of sugar in a beverage in teaspoons were perceived as highly factual, relatable and interpretable, and as having the greatest potential to impact consumption attitudes and intentions. Further quantitative studies are required to compare the potential effectiveness of the teaspoons of sugar labels in reducing purchasing and consumption behaviour than other alternative warning labels, such as health effects or “high in” sugar labels.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13648-1.

AB1397 WORK SMARTER NOT HARDER

Background

In 2014 we were a small team with only 1 WTE (Whole Time Equivalent) CNS (Clinical Nurse Specialist) and 2 WTE consultants for a population of 220,000. Most CNS clinic appointments were taken up for drug counselling. Waiting times were approx. 6 weeks for drug counselling. Consultants would often counsel for DMARDs.

That year at a national meeting a virtual group MDT (multidisciplinary) was presented by the team at Manchester Royal infirmary (MRI). They used a good quality presentation for patients starting bDMARDs as a tool for drug counselling.

After having to put on an extra clinic to counsel 5 patients, all for rituximab, frustratingly I asked why can’t I get them all in the same room to save time? We needed to work smarter, not harder, utilise time & space to ensure best practice but also ensure gold standard, patient centered care continued. We modified the format used at MRI to a face to face group education and counselling of patients to improve waiting times and patient flow.

Objectives

Reduce the amount of clinic appointments used to counsel patients for sDMARDs (synthetic disease modifying anti-rheumatic drugs) and bDMARDs (biologic).

Free up clinic appointments for follow up/ review and flares.

Standardise information given out to ensure they are all given the same gold standard information and education.

Methods

We visited the team at MRI to view the format of their virtual clinic. It didn’t meet the needs of our service so we modified and adapted the presentation.

Set up a group education session to discuss the most common sDMARDs and bDMARDs used for Inflammatory Arthritis.

I developed a power point presentation and booklet that can be used by CNS- ensuring the same information is given to every patient, both attending the group session and those not suitable for group session (ie Language barriers) who would be seen individually. We use a screening proforma to ensure safety of commencement for the individual prior to attending clinics which has a tick list for screening requirements.

The session is undertaken in our education centre. Pre Covid the session could accommodate up to 10 patients per session per week, uptake on average 8-10 patients for sDMARDs and 5-6 for bDMARDs. We alternated biologic and sDMARD sessions, if demand required, we changed a session to accommodate. The room is booked for 1½ hours every week, the sDMARD presentation lasts approximately ½ an hour & bDMARD session 50 minutes, time is allowed for group & individual questions if required at the end. This contrasts with 25 minute appointment for sDMARD & 50 minute for bDMARD counselling 1:1.

The booklet, along with information pack, is given at the group session to all patients. This includes all the information the patient requires (advice line information, blood forms). Prior to the group clinic admin team prepare the patient packs for the CNS to give to patients.

Results

We received 102 anonymous responses back from 136 patients asked. (75% response)

Following these sessions we found less calls to the advice line regarding medication queries, able to add in further cDMARDs or switch to alternate due to S/Es over the telephone

Feedback from patients.-120 comments received.

Clear simple information about a number of possible drugs used to treat my condition not just the 1 I am prescribed. If my medication needs changing I already know about it.

The lecture aspect of the types/contra-indications of meds was very useful & removed the ‘fear’ attached to these specialist drugs.

The session with other patients present stopped me from feeling alone in this position. The booklet is brilliant as it includes everything that was in the session. Also it took away the ‘fear’ of the side effects.

Conclusion

7 years on we feel that Group Counselling has been a huge success, we noticed how successful this was once we had to deal with the pandemic and cancel the group sessions. Patients feedback proves that they like the session and find them valuable. Whilst being beneficial and impoving work productivity and streamling the service.

Acknowledgements

The Rheumatology Team at The Kellgren Centre Manchester Royal Infirmary

Disclosure of Interests

Kelly Tempest Speakers bureau: Abbvie

Sanofi

Galapogos, Hanu Reddy: None declared, Samantha Johns: None declared, Kathryn Wright: None declared, Shabina Sultan Speakers bureau: Amgen, Grant/research support from: lilly

Time to transition from psoriasis to psoriatic arthritis: A population-based study

OBJECTIVE

To identify demographic and clinical characteristics associated with time between psoriasis and psoriatic arthritis (PsA).

METHODS

A retrospective, population-based cohort of incident PsA patients ≥18 years (2000-17) from Olmsted County, MN was identified. PsA patients were divided into two groups: patients with concurrent psoriasis and PsA (within 1 year), and patients with psoriasis before PsA (>1 year). Patients with PsA prior to psoriasis were excluded. Age- and sex-adjusted logistic regression models were used to examine factors associated with the time between psoriasis and PsA diagnosis.

RESULTS

Among 164 patients with incident PsA, 158 had a current or personal history of psoriasis. The mean (SD) age at PsA diagnosis was 46.3 (12.0) years, and 46% were females. The median (interquartile range) time from psoriasis to PsA was 35.5 (0.8-153.4) months. 64 patients (41%) patients had concurrent psoriasis and PsA while 94 (59%) had onset of psoriasis before PsA. The estimated age at onset of psoriasis symptom (OR per 10-year decrease = 1.63, 95% CI: 1.26-2.11) and psoriasis severity (OR = 3.65, 95% CI: 1.18-11.32 for severe vs. mild) were associated with having a psoriasis diagnosis more than one year prior to incident PsA.

CONCLUSION

In this population-based study, approximately 60% of the patients had psoriasis before PsA, and the rest had concurrent psoriasis and PsA. Patients with lower age at psoriasis onset or severe psoriasis were more likely to have a longer time to transition from psoriasis to PsA.

A multi-centre, randomized, double-blind, placebo-controlled clinical trial of the efficacy and safety of chloroquine phosphate, hydroxychloroquine sulphate and lopinavir/ritonavir for the treatment of COVID-19 in Lagos State: study protocol for a randomized controlled trial

Background

The coronavirus disease 2019 (COVID-19) is caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) that was first identified in Wuhan, Hubei, China, in December 2019. It was recognized as a pandemic by the World Health Organization on 11 March 2020. Outbreak forecasting and mathematical modelling suggest that these numbers will continue to rise. Early identification of effective remedies that can shorten the duration and severity of illness is critical for Lagos State, which is the epi-centre of the disease in Nigeria.

Methods

This is a multi-centre, randomized, double-blind placebo-controlled superiority trial. The study investigates the efficacy of chloroquine phosphate, hydroxychloroquine sulphate and lopinavir/ritonavir added on to standard of care compared to standard of care only in patients with COVID-19 disease. The primary outcome is the clinical status of patients measured using a 7-point ordinal scale at day 15. Research participants and clinicians will be blinded to the allocated intervention. Outcome measures will be directly assessed by clinicians. Statistical analysis will be done by a team blinded to the identity and allocation of research participants. Data analysis will follow intention-to-treat methods, using R software.

Discussion

The current study is of strategic importance for Lagos State in potentially curbing the health, social and economic burden of COVID-19 disease. Should the current study demonstrate that either of the three intervention drugs is more efficacious than standard therapy alone, the State Ministry of Health will develop an evidence-based guideline for the management of COVID-19 in Lagos State. The findings will also be shared nationally and with other states which may lead to a standardized national guideline for the treatment of COVID-19 in Nigeria.

Trial registration

Pan African Clinical Trials Register PACTR202004801273802. Registered prospectively on April 2, 2020

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-021-05675-x.

Exposure to Anti-Tobacco Messaging and Quit Attempts among Adolescent and Young Adult in Lagos, Nigeria: A Population-based Study

BACKGROUND

Health behavior theories suggest that knowledge about the health risks of the behavior precedes behavior change. Tobacco control messages aim to promote knowledge of health risks associated with tobacco use and encourage smoking cessation behaviors such as quit attempts and intention to quit. This study assessed the relationship between exposure to Anti-Tobacco Messaging (ATM) and quit attempts among adolescents and young adults in Lagos, Nigeria.

METHODS

This was an online cross-sectional survey of 947 participants aged between 15-35 years. The survey obtained sociodemographic information, smoking status, exposure to ATM, intention to quit and quit attempts in the past 12-months. Logistic regression analysis was used to identify the relationship between exposure to ATM and quit attempts; pvalues <0.05 were considered significant. Statistical analysis was done using STATA-15.0 software.

RESULTS

The mean age of respondents was 23.4 years (SD:4.0). Less than one-third of the respondents were smokers (23.4%). The most common source of ATM were digital sources (online and social media - 29.6%). Based on the multivariable logistic regression model, younger age (p:0.03) and an intention to quit (p: <0.001) were significantly associated with a quit attempt. Exposure to ATM in the past 12 months was also significantly associated with higher odds of a quit attempt (OR:5.33; 95% CI: 1.26,22.60; p: 0.02).

CONCLUSION

Our findings suggest an association between exposure to ATM and quit attempts among adolescent and young adult smokers in Lagos State, Nigeria. Policymakers should consider measures aimed at promoting tobacco control education and improving access to smoking cessation services.

A scoping review of systematic reviews on reducing lifestyle risk behaviours in disadvantaged groups

Background

Lifestyle risk behaviours are key risk factors for non-communicable diseases. Some disadvantaged groups face particularly poor health outcomes, which may be exacerbated by high prevalence of risk behaviours. The aim of this scoping review was to identify and bring together evidence from systematic reviews on reducing risk behaviours in these groups and highlight where there is insufficient evidence to inform policy.

Methods

MEDLINE and Embase were searched up to October 2020 for English language reviews, with supplementary searching in Epistemonikos and Health Systems Evidence. Systematic reviews reporting behavioural outcomes of interventions targeting smoking, alcohol use, diet or physical inactivity in nine disadvantaged groups were eligible. Reviews of population-level policies reporting differential effects for these groups and qualitative reviews of barriers or facilitators to change were included. Literature was mapped based on the group and behaviour targeted.

Results

Ninety-two systematic reviews were included. The majority (n = 68) focused on low income or socio-economic status. Fewer reviews were identified that included prisoners (n = 14), deprived areas (n = 12), homeless people (n = 10), people with learning disabilities (n = 9), unemployed people (n = 3) and refugees or asylum seekers (n = 2). We identified no reviews on care leavers or Gypsies, Travellers or Roma. In total only 11 reviews targeted alcohol use. There were some gaps for specific group and behaviour combinations and no intervention reviews on refugees.

Conclusions

A number of gaps were identified, highlighting where new syntheses or primary studies could add value. For example, reviews on interventions in refugees, Gypsies, Travellers and Roma, and care leavers could be useful for policy-making. Other useful contributions might include an overview of the perceptions of disadvantaged groups allowing common barriers to behaviour change to be identified as well as factors unique to specific groups.

Key messages

Nearly 100 systematic reviews focused on reducing risk behaviours in disadvantaged groups; they addressed different combinations of behaviours and groups. Gaps in the literature were identified where new syntheses could make a useful contribution to developing programmes and policies.

OP0102 DECLINE IN EXCESS RISK OF HEART FAILURE IN PATIENTS WITH RHEUMATOID ARTHRITIS IN RECENT YEARS

Background:

Heart failure (HF) is one of the most common cardiovascular conditions in patients with rheumatoid arthritis (RA). Previous studies showed a 2-fold excess risk of HF in RA versus the general population (1). Whether this has changed over time is not known. Longitudinal studies on trends in occurrence of HF in RA patients over time, and studies comparing trends in HF in RA versus the general population are lacking.

Objectives:

1) To assess trends in incidence of HF in patients with incident RA in 1980-2009; and 2) To compare incidence of HF in RA patients and population-based comparators without RA with RA incidence/ index date in 1980-2009.

Methods:

The study population comprised Olmsted County, Minnesota residents with incident RA (age ≥18 years, 1987 ACR criteria met in 1980-2009) and non-RA subjects from the same underlying population with similar age, sex and calendar year of index. All subjects were followed until death, migration, or 04/30/2019. Incident HF was defined using Framingham criteria. Patients with HF prior to RA incidence/index date were excluded. Cox proportional hazards models were used to compare incident HF events by decade, adjusting for age, sex and cardiovascular risk factors: smoking, obesity, diabetes mellitus, hypertension, dyslipidemia. Cumulative incidence of HF adjusted for death was also computed.

Results:

The study included 905 patients with RA (mean age 55.9 years; 69% female; median follow-up 13.4 years). The 10-year cumulative incidence of HF in RA cohort in the 1980s was 8.5% (95%CI 5.3-13.6%), 1990s was 10.8% (95%CI 7.7-15.1%), and 2000s was 7.1% (95%CI 4.9-10.3%). There was no difference in incidence of HF in 1990s (hazard ratio [HR] 0.91, 95% Confidence Interval [CI] 0.62-1.35) and 2000s (HR 0.73; 95%CI 0.46-1.18) compared to 1980s. Patients with incident RA were then compared to 903 individuals without RA (mean age 56.0 years; 69% female; median follow-up 13.8 years). The 10-year cumulative incidence of HF in these individuals in the 1980s was 7.4% (95%CI 4.5-12.3%), 1990s was 7.5% (95%CI 4.9-11.3%), and 2000s was 7.3% (95%CI 5.0-10.7%). Similar to RA, there was no statistically significant difference in incidence of HF in 1990s (HR 0.96, 95%CI 0.60-1.51) and 2000s (HR 0.75, 95%CI 0.44-1.30) compared to the 1980s. When comparing the risk of HF in RA and non-RA subjects, patients with RA in 2000s had no excess in HF risk as compared to the general population (HR 1.14, 95%CI 0.73-1.78, Figure 1). This is in contrast to the 2-fold excess risk of HF in patients with RA in 1980s (HR 2.20, 95%CI 1.44-3.34) and ~1.5-fold increase in risk of HF in 1990s (HR 1.54, 95%CI 1.04-2.29).

Figure 1.

Cumulative incidence of any HF event in RA and non-RA patients by decade of RA incidence/index

Conclusion:

We found a reduction in excess HF risk in patients with RA compared to individuals without RA in 2000s compared to 1980s. There were no statistically significant changes in incidence of HF in patients with RA and in individuals without RA over time. More studies are needed to understand the reasons and implications of these trends.

References:

[1]Nicola PJ, et al. The risk of congestive heart failure in rheumatoid arthritis: a population-based study over 46 years. Arthritis Rheum 2005;52:412–20.

Acknowledgements:

This work was supported by a grant from the National Institutes of Health, NIAMS (R01 AR46849) and NHLBI (HL120859). Research reported in this publication was supported by the National Institute of Aging of the National Institutes of Health under Award Number R01AG034676. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Disclosure of Interests:

Elena Myasoedova: None declared, John M Davis III Grant/research support from: Pfizer, Sara Achenbach: None declared, Kerry Wright: None declared, Reto Kurmann: None declared, Rekha Mankad: None declared, Veronique Roger: None declared, Cynthia S. Crowson: None declared

The Epidemiology of Psoriatic Arthritis Over Five Decades: A Population-Based Study

OBJECTIVE

To determine the incidence of psoriatic arthritis (PsA) in a US population and describe trends in incidence and mortality over 5 decades.

METHODS

The previously identified population-based cohort that included Olmsted County, Minnesota residents ≥18 years of age who fulfilled PsA criteria during 1970-1999 was extended to include patients with incident PsA during 2000-2017. Age- and sex-specific incidence rates and point prevalence, adjusted to the 2010 US White population, were reported.

RESULTS

There were 164 incident cases of PsA in 2000-2017 (mean ± SD age 46.4 ± 12.0 years; 47% female). The overall age- and sex-adjusted annual incidence of PsA per 100,000 population was 8.5 (95% confidence interval [95% CI] 7.2-9.8) and was higher in men (9.3 [95% CI 7.4-11.3]) than women (7.7 [95% CI 5.9-9.4]) in 2000-2017. Overall incidence was highest in the 40-59 years age group. The incidence rate was relatively stable during 2000-2017, with no evidence of an overall increase or an increase in men only (but a modest increase of 3% per year in women), compared to 1970-1999 when a 4%-per-year increase in incidence was observed. Point prevalence was 181.8 per 100,000 population (95% CI 156.5-207.1) in 2015. The percentage of women among those with PsA increased from 39% in 1970-1999 and 41% in 2000-2009 to 54% in 2010-2017 (P = 0.08). Overall survival in PsA did not differ from the general population (standardized mortality ratio 0.85 [95% CI 0.61-1.15]).

CONCLUSION

The incidence of PsA in this predominantly White US population was stable in 2000-2017, in contrast to previous years. However, an increasing proportion of women with PsA was found in this study.

Diagnostic Delay in Psoriatic Arthritis: A Population-based Study

OBJECTIVE

To examine demographic and clinical characteristics associated with diagnostic delay in psoriatic arthritis (PsA).

METHODS

We characterized a retrospective, population-based cohort of incident adult (≥ 18 yrs) patients with PsA from Olmsted County, Minnesota, from 2000-2017. All patients met the classification criteria. Diagnostic delay was defined as the time from any patient-reported PsA-related joint symptom to a physician diagnosis of PsA. Factors associated with delay in PsA diagnosis were identified through logistic regression models.

RESULTS

Of the 164 incident PsA cases from 2000 to 2017, 162 had a physician or rheumatologist diagnosis. Mean (SD) age was 41.5 (12.6) years and 46% were female. Median time from symptom onset to physician diagnosis was 2.5 years (IQR 0.5-7.3). By 6 months, 38 (23%) received a diagnosis of PsA, 56 (35%) by 1 year, and 73 (45%) by 2 years after symptom onset. No significant trend in diagnostic delay was observed over calendar time. Earlier age at onset of PsA symptoms, higher BMI, and enthesitis were associated with a diagnostic delay of > 2 years, whereas sebopsoriasis was associated with a lower likelihood of delay.

CONCLUSION

In our study, more than half of PsA patients had a diagnostic delay of > 2 years, and no significant improvement in time to diagnosis was noted between 2000 and 2017. Patients with younger age at PsA symptom onset, higher BMI, or enthesitis before diagnosis were more likely to have a diagnostic delay of > 2 years, whereas patients with sebopsoriasis were less likely to have a diagnostic delay.

Effects of Therapies on Cardiovascular Events in Ankylosing Spondylitis: A Systematic Review and Meta-Analysis

INTRODUCTION

Non-steroidal anti-inflammatory drugs (NSAIDs) and tumor necrosis factor inhibitors (TNFi) are the most common therapies used in AS, however, the associated long-term cardiovascular risk is unclear. We performed a systematic review and meta-analysis on the association of therapies used for ankylosing spondylitis (AS) such as NSAIDs and TNFi on cardiovascular events (CVE) in AS.

METHODS

A comprehensive search was performed from database inception to May 29, 2020 to include controlled studies of AS treated with NSAIDs, oral small molecules, or biologics reporting CVE. Study-specific risk ratios (RR) were pooled using a random effects model.

RESULTS

Nine non-randomized studies from 1570 studies screened fulfilled inclusion criteria. Among NSAID users as a whole versus no NSAIDs, no increased risk of CVE (composite outcome) was observed; however, the risk of cerebrovascular accident was significantly lower (RR 0.58, 95% CI 0.37-0.93, I2 = 66%). Cox-2 inhibitor use was associated with reduced risk of all CVE (RR 0.48, 95% CI 0.33-0.70, I2 = 0%). Non-selective NSAIDs were not associated with any increased/decreased risk of any CVE. Meta-analysis of three studies of MI did not show a significant association with TNFi (RR 0.88, 95% CI 0.57-1.35, I2 = 76%).

CONCLUSIONS

In this meta-analysis of non-randomized studies, NSAID users as a whole and users of non-selective NSAIDs did not seem to have a higher risk of any CVE. Limited data suggest a lower risk of composite CVE outcome with Cox-2 inhibitors, unlike the increased risk reported in the general population. No significant association between TNFi and MI was observed. The certainty in evidence was very low due to all studies being observational. More studies are needed to study the association between TNFi use and CVE in general to evaluate a possible protective role in AS.

Concomitant botanical medicine use among patients participating in commercial prostate cancer trials

OBJECTIVES

Patients with cancer frequently use botanical medications. The concomitant use of such medications by patients on commercial trials has not been well-described, despite the importance of these trials for evaluating the safety and efficacy of new agents. We sought to describe the use of botanical medications taken by patients with prostate cancer enrolled on global commercial trials.

DESIGN

Retrospective study.

SETTING

Regulatory repository of commercial clinical trial data.

INTERVENTIONS

Anti-cancer therapy.

MAIN OUTCOME MEASURES

Botanical and medication use data were pooled across six international commercial randomized trials for metastatic prostate cancer with detailed information on medication and indications. Botanical products were considered to have potential for drug interaction if they led to a change in drug exposure in human trials. Potential for interaction was ascertained by PubMed review. Descriptive statistics were used for analysis.

RESULTS

Of 7318 enrolled patients, 700 (10 %) reported botanical use at any time and 653 (9%) reported use of botanical products while on trial. Nearly half of botanical product types were not classified by plant (43 %). The highest proportion of botanical use was among patients in Asian countries (32 %), followed by patients in North America (13 %). Eighty-six different types of botanical products were used; of these, nineteen had a patient-reported anti-cancer indication.

CONCLUSIONS

Botanical medicine use among patients with prostate cancer in commercial trials is moderate, although it varies by region. Practitioners should be aware of the use of botanical interventions in a clinical trial context.

Correction to Effect of vitamin K on bone mineral density and fractures in adults: an updated systematic review and meta-analysis of randomised controlled trials

Following the work of Avenell et al. that has raised concerns about the integrity of the Yamaguchi Osteoporosis Prevention Study (YOPS) conducted by Ishida and Kawai we issue here an adjustment to all meta-analysis estimates that contained this work within our systematic review.

Phenotypic plasticity of circadian entrainment under a range of light conditions

The response to a zeitgeber, particularly the light/dark cycle, may vary phenotypically. Phenotypic plasticity can be defined as the ability of one genome to express different phenotypes in response to environmental variation. In this opinion paper, we present some evidence that one of the most prominent effects of the introduction of electric light to the everyday life of humans is a significant increase in phenotypic plasticity and differences in interindividual phases of entrainment. We propose that the healthy limits of phenotypic plasticity have been surpassed in contemporary society.

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Electric light increased phenotypic plasticity in humans and differences in interindividual phases of entrainment.

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Healthy limits of phenotypic plasticity have been surpassed in contemporary society.

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The correlation between biological time (DLMO) and behavioral time (MSFsc) is reduced in the population without access to electrical light.

Distinct Single Cell Gene Expression in Peripheral Blood Monocytes Correlates With Tumor Necrosis Factor Inhibitor Treatment Response Groups Defined by Type I Interferon in Rheumatoid Arthritis

Previously, we demonstrated in test and validation cohorts that type I IFN (T1IFN) activity can predict non-response to tumor necrosis factor inhibitors (TNFi) in rheumatoid arthritis (RA). In this study, we examine the biology of non-classical and classical monocytes from RA patients defined by their pre-biologic treatment T1IFN activity. We compared single cell gene expression in purified classical (CL, n = 342) and non-classical (NC, n = 359) monocytes. In our previous work, RA patients who had either high IFNβ/α activity (>1.3) or undetectable T1IFN were likely to have EULAR non-response to TNFi. In this study comparisons were made among patients grouped according to their pre-biologic treatment T1IFN activity as clinically relevant: “T1IFN undetectable (T1IFN ND) or IFNβ/α >1.3” (n = 9) and “T1IFN detectable but IFNβ/α ≤ 1.3” (n = 6). In addition, comparisons were made among patients grouped according to their T1IFN activity itself: “T1IFN ND,” “T1IFN detected and IFNβ/α ≤ 1.3,” and “IFNβ/α >1.3.” Major differences in gene expression were apparent in principal component and unsupervised cluster analyses. CL monocytes from the T1IFN ND or IFNβ/α >1.3 group were unlikely to express JAK1 and IFI27 (p < 0.0001 and p 0.0005, respectively). In NC monocytes from the same group, expression of IFNAR1, IRF1, TNFA, TLR4 (p ≤ 0.0001 for each) and others was enriched. Interestingly, JAK1 expression was absent in CL and NC monocytes from nine patients. This pattern most strongly associated with the IFNβ/α>1.3 group. Differences in gene expression in monocytes among the groups suggest differential IFN pathway activation in RA patients who are either likely to respond or to have no response to TNFi. Additional transcripts enriched in NC cells of those in the T1IFN ND and IFNβ/α >1.3 groups included MYD88, CD86, IRF1, and IL8. This work could suggest key pathways active in biologically defined groups of patients, and potential therapeutic strategies for those patients unlikely to respond to TNFi.

SAT0404 INCIDENCE OF PSORIATIC ARTHRITIS FROM 2000-2017: A POPULATION-BASED STUDY

Background:

Psoriatic arthritis (PsA) is a chronic inflammatory musculoskeletal disease with an estimated prevalence of 0.05% to 0.25% in the population and 6% to 41% in psoriasis patients. There is disparity in the reported incidence patterns in the general population in more recent years, with increasing incidence seen in Denmark, but relatively stable rates seen in Canada. However, no studies in the US have looked at the recent incidence patterns, and it would be important to see how newer therapies for psoriasis have impacted the incidence of PsA. Variability in the estimates of incidence and prevalence across different studies has been attributed to differences in case ascertainment and most studies have used ICD codes to identify PsA patients.

Objectives:

To determine the annual incidence of PsA (2000-17) and compare it to incidence of PsA in previous years (1970-1999)1in the Olmsted County, Minnesota, USA population.

Methods:

A retrospective, population-based cohort of PsA patients ≥18 years of age from Olmsted County, MN meeting ClASsification of Psoriatic ARthritis (CASPAR) criteria for PsA (2000-17) was identified from the Rochester Epidemiology Project (REP). REP ensures virtually complete ascertainment and follow-up of all clinically diagnosed cases of PsA in a geographically-defined area. The date of fulfillment of CASPAR criteria was taken as the PsA incidence date. Age- and sex-specific incidence rates, adjusted to 2010 US white population, were reported. Our previously reported cohort from REP (1970-1999)1also used the same CASPAR criteria, and trends from the current study were compared to the previous years.

Results:

There were 170 incident cases of PsA, with a mean age of 46.7 (SD=12.3) years and 47% females from 2000-17. The overall age and sex adjusted annual incidence of PsA per 100,000 population was 8.8 (95% CI 7.5-10.1), and higher in males (9.7, 95% CI 7.7-11.7) than females (8.0, 95% CI 6.2-9.8). Overall incidence was highest in the age range 40-59 years (Table 1). The incidence rate was relatively stable in the recent years 2000-2017 compared to 1970-19991where a rise in incidence was observed (3.6 to 9.8 per 100,000 persons from 1970-79 to 1990-99, p<0.001) (Figure 1).

Table 1.

Annual incidence rate, IR (per 100,000) of psoriatic arthritis by age and sex between 2000-17 in Olmsted County, MN.

MaleFemaleTotalAge Group, yrsNIRNIRNRate18-2994.141.6132.830-392413.4147.33810.240-492413.92614.05014.050-592113.52816.24914.960-6976.987.1157.070-7935.000.032.280+26.000.022.2Total (95% CI)909.7 (7.7-11.7)†808.0 (6.2-9.8)†1708.8 (7.5-10.1)††

† Age-adjusted to the 2010 US White population. †† Age- and sex-adjusted to the 2010 US White population

Conclusion:

In the Olmsted County population, the increasing PsA incidence seen in previous years 1970-19991seems to have leveled off after 2000. This is in contrast to increasing incidence in recent years reported from Denmark, Taiwan and Israel. However, similar to our study, incidence rates for PsA from 2008-2015 were reported to be stable in Canada.

References:

[1]Wilson FC, Icen M, Crowson CS, McEvoy MT, Gabriel SE, Kremers HM. Time trends in epidemiology and characteristics of psoriatic arthritis over 3 decades: a population-based study.J Rheumatol. 2009;36(2):361-367.

Acknowledgments:

This project was supported by CTSA Grant Number UL1 TR002377 from the National Center for Advancing Translational Science (NCATS).

Disclosure of Interests:

Paras Karmacharya: None declared, Cynthia S. Crowson Grant/research support from: Pfizer research grant, Delamo Bekele: None declared, Sara Achenbach: None declared, John M Davis III Grant/research support from: Research grants from Pfizer, Consultant of: Served on advisory boards for Abbvie and Sanofi-Genzyme, Alexis Ogdie Grant/research support from: Pfizer, Novartis, Consultant of: Abbvie, Amgen, BMS, Celgene, Corrona, Janssen, Lilly, Pfizer, Novartis, Ali Duarte-Garcia: None declared, Hilal Maradit-Kremers: None declared, Megha Tollefson: None declared, Floranne C. Ernste: None declared, Kerry Wright: None declared

0056 Identification of a Stable Human Metabolomics-Based Biomarker of Insufficient Sleep and its Association with Cognitive Performance

Introduction

There are numerous potential benefits of developing objective biomarkers of insufficient sleep including providing screening and diagnostic tools, increasing our understanding of poor sleep health, and supporting sleep-based countermeasures. We analyzed plasma metabolites in humans during two separate occasions of experimental sleep restriction to identify stable biomarkers of insufficient sleep, and assessed the association of these biomarkers with cognitive performance.

Methods

12 healthy adults (6M/6F), aged 24±5y (mean±SD), completed two 18-day protocols separated by 10 days. For each 18-day protocol, participants maintained habitual 9h sleep schedules for two weeks at home, and then completed 4-day laboratory visits with sleep opportunities of: 9h on night 1, 5h on nights 2 and 3, and recovery sleep on night 4. Energy balanced diets were provided 2 days before and throughout laboratory visits. Blood was collected every 2h during scheduled wakefulness on days 1–2 (baseline) and days 3–4 (insufficient sleep), and was analyzed by untargeted liquid chromatography/mass-spectrometry. Sustained attention was assessed every 2 h during scheduled wakefulness with the Psychomotor Vigilance Test (PVT).

Results

After filtering, we detected 6,822 metabolites. Elastic-net regression identified 21 metabolites consistently altered by insufficient sleep in both 18-day protocols. We developed a logistic regression-based biomarker fingerprint of insufficient sleep using 11 of these 21 metabolites with consistent responses to insufficient sleep. This biomarker fingerprint has 74.4% accuracy and 0.822 (0.782–0.858; 95%CI) area under the receiver operator curve. Median reaction time was slower (P&lt;0.05) during insufficient sleep versus baseline. Mediation analyses show our biomarker fingerprint accounts for ~6% of the slower reaction time.

Conclusion

We identified a plasma metabolomics-based biomarker of insufficient sleep with “good” performance. However, this biomarker only accounts for ~6% of reduced PVT performance during insufficient sleep. Our findings suggest that specific biomarkers for insufficient sleep versus cognitive deficits associated with insufficient sleep may be required.

Support

This work was supported by NIH R01HL132150, NIH K01HL145099, NIH F32DK111161, NIH/NCATS Colorado CTSA Grant UL1TR002535, Sleep Research Society Foundation 011-JP-16, and the University of Colorado Boulder Undergraduate Research Opportunities Grant.

Effect of Therapy on Radiographic Progression in Axial Spondyloarthritis: A Systematic Review and Meta-Analysis

OBJECTIVE

To investigate the effect of therapies on radiographic progression in patients with axial spondyloarthritis (SpA).

METHODS

A comprehensive database search for studies assessing radiographic progression in axial SpA (particular treatment versus no treatment of interest) was performed. Study-specific standardized mean differences in treatment outcomes at 2 and ≥4 years were estimated and combined using random-effects models.

RESULTS

Twenty-four studies in patients with axial SpA were identified, of which 18 involved tumor necrosis factor inhibitors (TNFi), 8 involved nonsteroidal antiinflammatory drugs (NSAIDs), and 1 involved secukinumab. Spinal radiographic progression, as measured by the modified Stoke Ankylosing Spondylitis Spine Score (mSASSS), was not significantly different between TNFi-treated and biologics-naive patients at 2 years (mSASSS difference -0.73 [95% confidence interval (95% CI) -1.52, 0.12], I2 = 28%) and ≥4 years (mSASSS difference -2.03 [95% CI -4.63, 0.72], I2 = 63%). Sensitivity analyses restricted to studies with a low risk of bias showed a significant difference in spinal radiographic progression between TNFi-treated and biologics-naive patients at ≥4 years (mSASSS difference -2.17 [95% CI -4.19, -0.15]). No significant difference in spinal radiographic progression was observed between NSAID-treated and control patients (mSASSS difference -0.30 [95% CI -2.62, 1.31], I2 = 71%) or between secukinumab-treated and biologics-naive patients (mSASSS difference -0.34 [95% CI -0.85, 0.17]). With regard to treatment differences in patients with nonradiographic axial SpA or in patients with radiographic progression measured using the sacroiliac joint score, an insufficient number of studies were available for analysis.

CONCLUSION

Although no significant protective effect of TNFi treatment on spinal radiographic progression was seen over the course of 2 years or ≥4 years in patients with axial SpA, our analysis restricted to studies with a low risk of bias showed a protective effect of TNFi after ≥4 years. Therefore, long-term TNFi exposure might confer beneficial effects on spinal radiographic progression in axial SpA. No difference in radiographic progression at 2 years was seen in either the NSAID or secukinumab treatment groups compared to their controls. Future studies should explore the effects of biologic treatment on radiographic progression, as well as the effects of long-term biologics exposure, in patients with early axial SpA or those with nonradiographic axial SpA.

Benchmarking an 11-qubit quantum computer

The field of quantum computing has grown from concept to demonstration devices over the past 20 years. Universal quantum computing offers efficiency in approaching problems of scientific and commercial interest, such as factoring large numbers, searching databases, simulating intractable models from quantum physics, and optimizing complex cost functions. Here, we present an 11-qubit fully-connected, programmable quantum computer in a trapped ion system composed of 13 ¹⁷¹Yb⁺ ions. We demonstrate average single-qubit gate fidelities of 99.5\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\%$$\end{document}%, average two-qubit-gate fidelities of 97.5\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\%$$\end{document}%, and SPAM errors of 0.7\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\%$$\end{document}%. To illustrate the capabilities of this universal platform and provide a basis for comparison with similarly-sized devices, we compile the Bernstein-Vazirani and Hidden Shift algorithms into our native gates and execute them on the hardware with average success rates of 78\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\%$$\end{document}% and 35\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\%$$\end{document}%, respectively. These algorithms serve as excellent benchmarks for any type of quantum hardware, and show that our system outperforms all other currently available hardware.

The growing complexity of quantum computing devices makes presents challenges for benchmarking their performance as previous, exhaustive approaches become infeasible. Here the authors characterise the quality of their 11-qubit device by successfully computing two quantum algorithms.

Effect of vitamin K on bone mineral density and fractures in adults: an updated systematic review and meta-analysis of randomised controlled trials

Vitamin K may affect bone mineral density and fracture incidence. Since publication of a previous systematic review the integrity of some of the previous evidence has been questioned and further trials have been published. Therefore an update to the systematic review was required.

INTRODUCTION

This systematic review was designed to assess the effectiveness of oral vitamin K supplementation for increasing bone mineral density and reducing fractures in adults.

METHODS

MEDLINE, EMBASE, CENTRAL, CINAHL, clinicaltrials.gov, and WHO-ICTRP were searched for eligible trials. Randomised controlled trials assessing oral vitamin K supplementation that assessed bone mineral density or fractures in adult populations were included. A total of 36 studies were identified. Two independent reviewers extracted data using a piloted extraction form.

RESULTS

For post-menopausal or osteoporotic patients, meta-analysis showed that the odds of any clinical fracture were lower for vitamin K compared to controls (OR, 0.72, 95%CI 0.55 to 0.95). Restricting the analysis to low risk of bias trials reduced the OR to 0.76 (95%CI, 0.58 to 1.01). There was no difference in vertebral fractures between the groups (OR 0.96, 95%CI 0.83 to 1.11). In the bone mineral density meta-analysis, percentage change from baseline at the lumbar spine was higher at 1 year (MD 0.93, 95%, CI - 0.02 to 1.89) and 2 years (MD 1.63%, 95%CI 0.10 to 3.16) for vitamin K compared to controls; however, removing trials at high risk of bias tended to result in smaller differences that were not statistically significant. At 6 months, it was higher in the hip (MD 0.42%, 95%CI 0.01 to 0.83) and femur (MD 0.29%, 95%CI 0.17 to 0.42). There was no significant difference at other anatomical sites.

CONCLUSIONS

For post-menopausal or osteoporotic patients, there is no evidence that vitamin K affects bone mineral density or vertebral fractures; it may reduce clinical fractures; however, the evidence is insufficient to confirm this. There are too few trials to draw conclusions for other patient groups.

Implementation and evaluation of nationwide scale-up of the Surgical Safety Checklist

Background

The WHO Surgical Safety Checklist improves surgical outcomes, but evidence and theoretical frameworks for successful implementation in low‐income countries remain lacking. Based on previous research in Madagascar, a nationwide checklist implementation in Benin was designed and evaluated longitudinally.

Methods

This study had a longitudinal embedded mixed‐methods design. The well validated Consolidated Framework for Implementation Research (CFIR) was used to structure the approach and evaluate the implementation. Thirty‐six hospitals received 3‐day multidisciplinary training and 4‐month follow‐up. Seventeen hospitals were sampled purposively for evaluation at 12–18 months. The primary outcome was sustainability of checklist use at 12–18 months measured by questionnaire. Secondary outcomes were CFIR‐derived implementation outcomes, measured using the WHO Behaviourally Anchored Rating Scale (WHOBARS), safety questionnaires and focus groups.

Results

At 12–18 months, 86·0 per cent of participants (86 of 100) reported checklist use compared with 31·1 per cent (169 of 543) before training and 88·8 per cent (158 of 178) at 4 months. There was high‐fidelity use (median WHOBARS score 5·0 of 7; use of basic safety processes ranged from 85·0 to 99·0 per cent), and high penetration shown by a significant improvement in hospital safety culture (adapted Human Factors Attitude Questionnaire scores of 76·7, 81·1 and 82·2 per cent before, and at 4 and 12–18 months after training respectively; P < 0·001). Acceptability, adoption, appropriateness and feasibility scored 9·6–9·8 of 10. This approach incorporated 31 of 36 CFIR implementation constructs successfully.

Conclusion

This study shows successfully sustained nationwide checklist implementation using a validated implementation framework.

Implementation works

Interventional management of hyperhidrosis in secondary care: a systematic review

BACKGROUND

Hyperhidrosis is uncontrollable excessive sweating, which occurs at rest, regardless of temperature. The symptoms of hyperhidrosis can significantly affect quality of life.

OBJECTIVES

To undertake a systematic review of the clinical effectiveness and safety of treatments available in secondary care for the management of primary hyperhidrosis.

METHODS

Fifteen databases (including trial registers) were searched to July 2016 to identify studies of secondary-care treatments for primary hyperhidrosis. For each intervention randomized controlled trials (RCTs) were included where available; where RCT evidence was lacking, nonrandomized trials or large prospective case series were included. Outcomes of interest included disease severity, sweat rate, quality of life, patient satisfaction and adverse events. Trial quality was assessed using a modified version of the Cochrane Risk of Bias tool. Results were pooled in pairwise meta-analyses where appropriate, otherwise a narrative synthesis was presented.

RESULTS

Fifty studies were included in the review: 32 RCTs, 17 nonrandomized trials and one case series. The studies varied in terms of population, intervention and methods of outcome assessment. Most studies were small, at high risk of bias and poorly reported. The interventions assessed were iontophoresis, botulinum toxin (BTX) injections, anticholinergic medications, curettage and newer energy-based technologies that damage the sweat gland.

CONCLUSIONS

The evidence for the effectiveness and safety of treatments for primary hyperhidrosis is limited overall, and few firm conclusions can be drawn. However, there is moderate-quality evidence to support the use of BTX for axillary hyperhidrosis. A trial comparing BTX with iontophoresis for palmar hyperhidrosis is warranted.