OP0275 REAL-WORLD CLINICAL BURDEN AND GLUCOCORTICOID USE IN PATIENTS WITH GIANT CELL ARTERITIS

Background:

Giant cell arteritis (GCA) is a rare form of vasculitis usually manifesting in people aged ≥50 yr and is more common in women. Symptoms include headache, jaw claudication, fatigue, polymyalgia; and blindness if untreated. While risks of complications can be reduced with promptly administered high-dose glucocorticoids (GC; 20-60 mg for 2-4 wk, then slowly tapered), further risks of high GC exposure and related complications over the course of therapy remain.

Objectives:

To compare GC use and GC-related complications in GCA patients (pts) vs a general population (GnP) cohort.

Methods:

This retrospective, observational cohort study was based on Optum’s de-identified Clinformatics®Data Mart Database (01/01/06-30/06/18, study period). The GCA cohort included pts with ≥1 inpatient or ≥2 outpatient claims ≥30 days apart with GCA-related diagnosis codes (ICD-9: 446.5x/ICD-10: M31.6x) between 01/01/06-30/06/17 (pt identification period) during which first occurrence of a GCA-related medical claim was set as index date (ID). The GnP cohort included pts without any medical claims for rheumatoid arthritis, GCA or polymyalgia rheumatica diagnosis codes during the study period, with their ID set as 12 mo from start of continuous health plan enrollment. Pts in both cohorts were required to be age ≥50 yr (on the ID) with continuous health plan enrollment ≥12 mo pre- and post-ID. Cohorts were 1:1 propensity score matched. GC use and incidence of GC-related complications were assessed from GC initiation, starting from the baseline period (12-mo pre-ID) to the end of GC use during the post-index period (ie the end of data availability, end of the study period, or death, whichever occurred first). Descriptive analyses included mean, standard deviation (SD) and median values for continuous variables, and frequency (n and %) for categorical variables. Continuous variables were compared between matched cohorts usingt-tests and Wilcoxon sum rank tests. Categorical variables were compared between matched cohorts using Chi-square tests or Fisher’s exact tests. Duration of GC use was analyzed using the Kaplan-Meier method and compared between matched cohorts using log-rank tests.

Results:

There were 6071 pts included in each of the GCA and matched GnP cohorts; median age per cohort was 76 yr, median Elixhauser comorbidity index score was 3.0, and the majority (~75%) were women. The median follow-up duration was 44 and 48 mo in the GCA and GnP cohorts, respectively. A higher proportion of pts in the GCA cohort than the GnP cohort (90.6 vs 63.8%;p<0.001) used GC. The mean (SD) duration of GC therapy was 230.5 (±326.8) days in the GCA cohort vs 36.3 (±107.2) days in the GnP cohort (p<0.001). Although the mean (SD) daily dose of GC (prednisone equivalent) was similar in both cohorts (27.6 [±28.20] vs 27.7 [±25.18] mg), the mean (SD) cumulative GC dose was significantly higher in the GCA cohort than the GnP cohort (3503.0 (±4622.6) mg vs 503.7 (±1593.51) mg;p<0.001). This indicates that GCA pts had chronic GC exposure over the study period while GnP pts likely utilized higher dose GC burst therapy less frequently. The number of incident complications associated with GC use were significantly greater in the GCA cohort, and included hypertension, diabetes, skin toxicity, infections, neuropsychiatric effects, gastrointestinal complications, ocular effects, and cardiovascular disease (p<0.05).

Conclusion:

The overall GC burden in pts with GCA is significantly higher than the general population and may result in downstream complications related to GC exposure. The incidence of GC-related complications was statistically significantly higher in GCA pts compared with GnP pts, even with a short duration of GC use. The early onset of these complications may be a significant contributor to long-term healthcare costs in GCA pts.

Acknowledgments:

Study and medical writing (provided by Gauri Saal, MA, Economics, Prime, Knutsford, UK, under the direction of authors) were funded by Sanofi, Inc.

Disclosure of Interests:

Rajeshwari Punekar Shareholder of: Sanofi, Employee of: Sanofi, Patrick LaFontaine Shareholder of: Sanofi, Employee of: Sanofi, John H. Stone Grant/research support from: Roche, Consultant of: Roche

OP0271 REAL-WORLD CLINICAL BURDEN AND GLUCOCORTICOID USE IN PATIENTS WITH POLYMYALGIA RHEUMATICA

Background:

Polymyalgia rheumatica (PMR) is a chronic inflammatory condition characterized by aching and morning stiffness in the neck, shoulders and pelvic girdle. It is a common inflammatory rheumatic disease in patients age >50 years, particularly women. While giant cell arteritis (GCA) is present in 9–21% of PMR cases, many PMR patients have symptoms independent of GCA. Current treatment options are limited to long-term glucocorticoid (GC), however, with risks of GC-related complications, including cardiovascular disease, osteoporosis, and diabetes mellitus.

Objectives:

To compare GC use and subsequent GC-related complications in patients with PMR vs a general population (GnP) cohort.

Methods:

This retrospective, observational cohort study was based on Optum’s de-identified Clinformatics®Data Mart Database (study period 01Jan2006-30June2018). The PMR cohort included patients with ≥1 inpatient or ≥2 outpatient claims ≥30 days apart with PMR related diagnosis codes (ICD-9: 725.xx or ICD-10: M35.3x) between 01Jan2006–30June2017 (patient identification period) during which first occurrence of a PMR-related medical claim was set as the index date (ID). Patients with ≥1 medical claim related to rheumatoid arthritis (RA) or GCA during the study period were excluded. The GnP cohort included patients without any RA, GCA or PMR diagnosis codes during the study period, with their ID set as 12 months from the start of continuous health plan enrollment. Patients in both cohorts were required to be age ≥50 years (on ID) with continuous health plan enrollment ≥12 months pre- and post-ID. Cohorts were 1:1 propensity score matched. GC use and incidence of GC-related complications were assessed from GC initiation, starting from the baseline period (12-months pre-ID) through to the end of GC use during the post-index period (i.e. the end of data availability, end of the study period or death [whichever occurred first]). Mean, standard deviation (SD) and median values for continuous variables, and frequency (n and %) for categorical variables were compared between the matched cohorts. Wilcoxon sum rank tests andt-tests on continuous variables and Chi-square tests or Fisher’s exact tests on categorical variables between matched cohorts were conducted. Duration of GC use was analyzed using the Kaplan-Meier method and compared between matched cohorts using log-rank tests.

Results:

In each of the PMR and GnP cohorts, 16,865 patients were included. In both matched cohorts, median age was 76 years, median Elixhauser comorbidity index score was 2.0, and the majority (~65%) were women. The median follow-up duration was 45 months and 51 months in the PMR and GnP cohorts, respectively. A higher proportion of patients in the PMR cohort than the matched GnP cohort (90.4% vs 62.8%;p<0.001) used GC. The mean (SD) duration of GC therapy was significantly longer in the PMR cohort than in the matched GnP cohort (242.1 [±317.2] days vs 35.5 [±124.6] days;p<0.001). Although patients in the PMR cohort had a lower average daily dose of GC (prednisone equivalent) vs the GnP cohort (mean [SD] mg 16.3 [± 21.9] vs 27.8 [±24.5], respectively [p<0.0001)], the cumulative GC dose was significantly higher in the PMR cohort than the GnP cohort (2125.4 [±3689.5] mg vs 476.6 [±1450.9] mg;p<0.001). This indicates PMR patients used chronic low dose GC while the GnP patients utilized higher dose GC burst therapy less frequently. The number of incident complications associated with GC use were significantly greater in the PMR cohort, and included hypertension, diabetes, skin toxicity, infections, neuropsychiatric effects, endocrine abnormalities, renal dysfunction/ failure, ocular effects, and cardiovascular disease (p<0.05).

Conclusion:

The overall GC burden in patients with PMR is high. With a higher incidence of GC-related comorbidities among PMR patients, early onset of these complications may be a significant contributor to long-term healthcare costs in these patients.

Acknowledgments:

This study was funded by Sanofi, Inc. Medical writing, under the direction of authors, was provided by Gauri Saal, MA Economics, Prime, Knutsford, UK, and funded by Sanofi.

Disclosure of Interests:

Rajeshwari Punekar Shareholder of: Sanofi, Employee of: Sanofi, Patrick LaFontaine Shareholder of: Sanofi, Employee of: Sanofi, John H. Stone Grant/research support from: Roche, Consultant of: Roche

Gunshot wounds to the ureter: a 40-year experience at Grady Memorial Hospital

PURPOSE

Because of the morbidity associated with missed ureteral injuries, a high index of suspicion must be present to diagnose this type of injury. We reviewed our 40 years of trauma experience at Grady Memorial Hospital.

MATERIALS AND METHODS

We retrospectively reviewed the records of 118 patients with ureteral injuries secondary to a gunshot wound to the ureter from 1960 to 1999. All cases were reviewed for the mechanism of injury, location, initial urinalysis, imaging modalities, associated injuries, operative procedures and complications.

RESULTS

Our population consisted of patients 14 to 71 years old, of whom 66 had right ureteral, 51 had left ureteral and 1 had bilateral injury. Urinalysis revealed no evidence of blood in the urine in 15% of the patients in whom the test was performed. Excretory urography had a false-negative rate of 33%. The injury was located at the proximal, mid and distal ureter in 43, 38 and 37 cases, respectively. Multiple surgical approaches were used depending on the location and severity of the defect. Only 1 patient had an isolated ureteral injury, while the remainder had associated injuries. Complications were present in 24 cases.

CONCLUSIONS

To our knowledge this series of ureteral injuries is the largest reported to date. Because preoperative urinalysis and imaging studies are unreliable for ruling out injury, a high index of suspicion must be present. Furthermore, a predefined trauma protocol, as defined in our algorithm, decreases the number of missed ureteral injuries that may potentially complicate the outcome of an already critical case.

Distribution of cardiovascular disease risk factors by socioeconomic status among Canadian adults

BACKGROUND

This study was designed to describe the distribution of risk factors for cardiovascular disease by socioeconomic status in adult men and women across Canada using the Canadian Heart Health Surveys Database.

METHODS

The data were derived from provincial cross-sectional surveys done between 1986 and 1992. Data were obtained through a home interview and a clinic visit using a probability sample of 29,855 men and women aged 18-74 years of whom 23,129 (77%) agreed to participate. The following risk factors for cardiovascular disease were considered: elevated total plasma cholesterol (greater than 5.2 mmol/L), regular current cigarette smoking (one or more daily), elevated diastolic or systolic blood pressure (140/90 mm Hg), overweight (body mass index and lack of leisure-time physical activity [less than once a week in the last month]). Education and income adequacy were used as measures of socioeconomic status and mother tongue as a measure of cultural affiliation.

RESULTS

For most of the risk factors examined, the prevalence of the risk factors was inversely related to socioeconomic status, but the relationship was stronger and more consistent for education than for income. The inverse relationship between socioeconomic status and the prevalence of the risk factors was particularly strong for smoking and overweight, where a gradient was observed: 46% (standard error [SE] 1.4) of men and 42% (SE 4.3) of women who had not completed secondary school were regular smokers, but only 12% (SE 1.0) of men and 13% (SE 0.9) of women with a university degree were regular smokers. Thirty-nine percent (SE 1.4) of men and 19% (SE 3.8) of women who had not completed secondary school were overweight, compared with 26% (SE 2.6) of male and 19% of female university graduates. The prevalence of leisure-time physical inactivity and elevated cholesterol was highest in both men and women in the lowest socioeconomic category, particularly by level of education.

INTERPRETATION

The differences in the prevalence of risk factors for cardiovascular disease between socioeconomic groups are still important in Canada and should be considered in planning programs to reduce the morbidity and mortality from cardiovascular disease.

Gas chromatographic-mass spectrometric analysis of acids and phenols in distilled alcohol beverages. Application of anion-exchange disk extraction combined with in-vial elution and silylation

A GC-MS protocol for profiling spirits, based on 19 acids and phenolic compounds, has been proposed and evaluated. The method combined a simple preconcentration procedure based on solid-phase (anion-exchange) disk extraction, and in-vial elution and silylation of the analytes. The derivatized extract was directly injected into the GC-MS system. These analytes were: C6, C8, C10, C12 acids, pyruvic acid, 2-furoic acid, succinic acid, fumaric acid, glutaric acid, lactic acid, glycolic acid, malic acid, tartaric acid, citric acid, vanillin, syringaldehyde, coniferaldehyde, vanillic acid and gallic acid. The profiles of six different spirits were found reproducible from day-to-day with <20% RSD for measurements of most of the analytes at different concentrations. Recoveries of individual analytes appear to be affected by the level of tannins in the spirits, and they varied from sample to sample. The method of standard addition was used to quantify age-related analytes. Good linearity of response with correlation coefficients in the range of 0.992-0.999 was obtained. The results of the study indicate that for spirits of the same brand but of different ages, the amounts of these analytes appear to increase with the ageing period.

Brachial, radial, or femoral approach for elective Palmaz-Schatz stent implantation: a randomized comparison

From October 1994 to November 1995, 150 male eligible patients were randomly assigned to Palmaz-Schatz stent implantation through 6 French catheters using the femoral (puncture) (n = 56), radial (puncture) (n = 56), or brachial (cutdown) (n = 38) approach at 6 participating Belgian centers. Acenocoumarol was given for 1 month after stenting.

END POINTS

Primary-entry site complications (bleeding, haematoma, transfusion, occlusion, surgery) poststent implantation. Secondary-success rate, stent thrombosis, Q or non Q wave MI, repeat PTCA, CABG, CVA, haemorrage, death. There were no statistically significant differences between the three groups for base line and angiographic patient characteristics, procedural characteristics, in hospital outcome, average hospitalisation time after stenting, events during the month after stenting, or local complications at 1 month follow-up. The only statistically significant difference was the arterial time of the procedure: mean +/- SD (minutes) brachial 31.0 +/- 10.02 *P < 0.001, femoral 42.2 +/- 21.8, radial 55.8 +/- 31.3 **P < 0.0001 (*brachial vs. femoral, **brachial vs. radial). There was a clear trend toward more technical difficulties and more problems with the radial approach. In each group: vascular surgery at entry site: 0%, blood transfusion: 0%. In our study, local complications and length of hospital stay were similar with the three possible approaches, and brachial approach was associated with a shorter arterial time.

Characterization of digoxin and related cardiac glycosides by fast atom bombardment mass spectrometry

The potential of using fast atom bombardment mass spectrometry for the detection and the characterization of digoxin and a series of related cardenolide analogues was investigated. The spectra were dependent upon the type of support-matrix in which they were recorded; thioglycerol proved to be satisfactory for the characterization of digoxin and allowed for its detection in human urine extract spiked with ca 11 ng ml(-1).