Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

Tests of Light-Lepton Universality in Angular Asymmetries of B^{0}→D^{*-}ℓν Decays

We present the first comprehensive tests of the universality of the light leptons in the angular distributions of semileptonic B^{0}-meson decays to charged spin-1 charmed mesons. We measure five angular-asymmetry observables as functions of the decay recoil that are sensitive to lepton-universality-violating contributions. We use events where one neutral B is fully reconstructed in ϒ(4S)→BB[over ¯] decays in data corresponding to 189  fb^{-1} integrated luminosity from electron-positron collisions collected with the Belle II detector. We find no significant deviation from the standard model expectations.

Precise Measurement of the D_{s}^{+} Lifetime at Belle II

We measure the lifetime of the D_{s}^{+} meson using a data sample of 207  fb^{-1} collected by the Belle II experiment running at the SuperKEKB asymmetric-energy e^{+}e^{-} collider. The lifetime is determined by fitting the decay-time distribution of a sample of 116×10^{3} D_{s}^{+}→ϕπ^{+} decays. Our result is τ_{D_{s}^{+}}=(499.5±1.7±0.9)  fs, where the first uncertainty is statistical and the second is systematic. This result is significantly more precise than previous measurements.

Search for a τ^{+}τ^{-} Resonance in e^{+}e^{-}→μ^{+}μ^{-}τ^{+}τ^{-} Events with the Belle II Experiment

We report the first search for a nonstandard-model resonance decaying into τ pairs in e^{+}e^{-}→μ^{+}μ^{-}τ^{+}τ^{-} events in the 3.6-10  GeV/c^{2} mass range. We use a 62.8  fb^{-1} sample of e^{+}e^{-} collisions collected at a center-of-mass energy of 10.58 GeV by the Belle II experiment at the SuperKEKB collider. The analysis probes three different models predicting a spin-1 particle coupling only to the heavier lepton families, a Higgs-like spin-0 particle that couples preferentially to charged leptons (leptophilic scalar), and an axionlike particle, respectively. We observe no evidence for a signal and set exclusion limits at 90% confidence level on the product of cross section and branching fraction into τ pairs, ranging from 0.7 to 24 fb, and on the couplings of these processes. We obtain world-leading constraints on the couplings for the leptophilic scalar model for masses above 6.5  GeV/c^{2} and for the axionlike particle model over the entire mass range.

Measurement of CP Violation in B^{0}→K_{S}^{0}π^{0} Decays at Belle II

We report a measurement of the CP-violating parameters C and S in B^{0}→K_{S}^{0}π^{0} decays at Belle II using a sample of 387×10^{6}  BB[over ¯] events recorded in e^{+}e^{-} collisions at a center-of-mass energy corresponding to the ϒ(4S) resonance. These parameters are determined by fitting the proper decay-time distribution of a sample of 415 signal events. We obtain C=-0.04_{-0.15}^{+0.14}±0.05 and S=0.75_{-0.23}^{+0.20}±0.04, where the first uncertainties are statistical and the second are systematic.

Can we evidence-base injury prevention and management in women's football? A scoping review

This review aimed, as part of a larger FIFA project aiming to steer women's football research, to scope literature on any level of competitive football for women, to understand the current quantity of research on women's football injuries. The study reviewed all injury-related papers scoped by a recent scoping review mapping all published women's football research with an updated search performed on 23 February 2021. Eligibility criteria assessment followed the recent scoping review with injury-specific research focus. A total of 497 studies were scoped. Most studies contained an epidemiological (N = 226; 45%) or risk factors assessment (N = 105; 21%). Less assessed areas included financial burden (N = 1; <1%) and injury awareness (N = 5; 1%). 159 studies (32%) assessed injuries of the whole body. The most common single location assessed in the literature was the knee (N = 134, 27%), followed by head/face (N =108, 22%). These numbers were, however, substantially lowered, when subdivided by playing level and age-group. The volume of research focuses especially on descriptive research and specific body locations (head/face and knee). Although information can be taken from studies in other sports, more football-specific studies to support management and prevention of injuries are warranted.

Characteristics and lipid lowering treatment patterns in patients tested for lipoprotein(a): A real-world US study

Objective

Elevated lipoprotein(a) [Lp(a)] is a risk factor for atherosclerotic cardiovascular disease (ASCVD) and has no approved pharmacotherapies. Limited real-world data exists on the proportion of patients with available Lp(a) test results, characteristics of these patients, and their use of lipid lowering therapies (LLTs) for secondary prevention (SP) and primary prevention (PP) of ASCVD.

Methods

Patients with measured Lp(a) receiving LLTs for SP or PP of ASCVD were identified in the Optum Clinformatics® Data Mart database. Lp(a) distribution and LLT utilization including persistence and adherence were assessed. Logistic regression was used to assess the association between Lp(a) levels and low-density lipoprotein cholesterol (LDL-C) levels after index LLT, adjusting for baseline characteristics.

Results

Overall, 2154 SP and 7179 PP patients met eligibility criteria. Of patients with available laboratory data, only 0.7% (SP) and 0.6% (PP) had Lp(a) test results. In the SP cohort, Lp(a) levels ≥125 nmol/L and ≥175 nmol/L were 26.4% and 17.6%, respectively, and the mean (SD) Lp(a) levels (overall SP cohort 90.4 [97.9] nmol/L) were highest in Black patients (123.4 [117.4]; p<0.001). Statin monotherapy was the most frequently prescribed LLT in SP patients overall (89.4%). Median (interquartile range [IQR]) persistence of LLTs was 227 (91, 649) days and 33.6% achieved ≥80% proportion of days covered (PDC). Patients with Lp(a) ≥175 nmol/L had 2.1 times greater odds of having elevated LDL-C (≥70 mg/dL) post-LLT than those with Lp(a) <175 nmol/L (p = 0.031). Similar findings were observed in the PP population.

Conclusions

Lp(a) screening was rare. Elevated Lp(a) was observed in more than one-quarter of patients receiving LLTs, with the highest mean Lp(a) levels observed in Black patients. Low adherence to LLTs was prevalent and at least half of patients failed to achieve their respective LDL-C target thresholds despite treatment. Finally, high Lp(a) levels were associated with worse LDL-C control.

Tunability of spin-wave spectra in a 2D triangular shaped magnonic fractals

Reprogramming the structure of the magnonic bands during their operation is important for controlling spin waves in magnonic devices. Here, we report the tunability of the spin-wave spectra for a triangular shaped deterministic magnonic fractal, which is known as Sierpinski triangle by solving the Landau-Lifshitz-Gilbert equation using a micromagnetic simulations. The spin-wave dynamics change significantly with the variation of iteration number. A wide frequency gap is observed for a structure with an iteration number exceeding some value and a plenty of mini-frequency bandgaps at structures with high iteration number. The frequency gap could be controlled by varying the strength of the magnetic field. A sixfold symmetry in the frequency gap is observed with the variation of the azimuthal angle of the external magnetic field. The spatial distributions of the spin-wave modes allow to identify the bands surrounding the gap. The observations are important for the application of magnetic fractals as a reconfigurable aperiodic magnonic crystals.

Inflammation begets isolated atrioventricular conduction disturbances in young an observation from indian registry data

Background

High grade AV block is less commonly encountered in patients &lt;60 years. The aetiological role of inflammatory conditions is not well studied in this group of patients.

Purpose

To determine the prevalence of myocardial inflammation in young patients presenting with High grade AV block and assess its response to immunosuppression.

Methodology

This is a prospective, registry based, observational study conducted at two centers from Jan 2020 to Dec 2021. Myocardial inflammation was detected using Cardiac PET, and/or histopathological examination. Those with evidence of inflammation were started on graded immunosuppression.

Results

318 patients were enrolled. Mean EF was 55.2±7.0%. Cardiac PET was performed in 87/318 (27.3%). Myocardial inflammation was seen in 57/87 (65%). LV basal septum was most commonly involved. 44/57 (77%) were started on immunosuppressive therapy after excluding indolent tuberculosis.8 patients died during follow-up with all deaths being sudden in nature. 5/44 (11.3%) had reversal of CHB with resolution of cPET findings.

Conclusion

Significant proportion of young patients with High grade AV block have segmental myocardial inflammation. Immunosuppression helps restore AV conduction in some of these patients. Long-term studies are required to assess adverse impact of inflammation on cardiac contractile function.

Funding Acknowledgement

Type of funding sources: None.

Artificial intelligence-enabled electrocardiographic algorithm for the detection of left ventricular dysfunction in emergency department patients undergoing high-sensitivity cardiac troponin T

Background

Artificial intelligence-augmented electrocardiogram (AI-ECG) algorithms have been developed from the standard 12-lead ECG and validated for the recognition of left ventricular systolic dysfunction (LVSD), defined as LV ejection fraction (LVEF)≤35%. Whether AI-ECG facilitates identification of LVSD and is associated with adverse outcomes in emergency department (ED) patients undergoing high-sensitivity cardiac troponin (hs-cTnT) testing is uncertain.

Purpose

To investigate the diagnostic and prognostic performance of AI-ECG in ED patients undergoing hs-cTnT measurement.

Methods

Observational US cohort study of ED patients undergoing hs-cTnT measurement. Cases with hs-cTnT increases &gt;sex-specific 99th percentiles were adjudicated following the Fourth Universal Definition of Myocardial Infarction (MI). Post-discharge major adverse cardiac events (MACE) included death, MI, heart failure (HF) hospitalization, stroke or transient ischemic attack, and new onset atrial fibrillation/flutter during 2-years follow-up. The AI-ECG network output, which is a continuous number between 0–1, that provides a probability of LVSD, was obtained for each patient from the first ECG during the index presentation. An AI-ECG threshold of ≥0.256 indicates a positive screen that correlates with a high probability of LVSD.

Results

Among 1977 patients, 1729 (87%) had a negative AI-ECG screen, while 248 (13%) had a positive AI-ECG screen. Patients with a positive AI-ECG screen were older and had more comorbidities. As compared to patients with hs-cTnT≤99th percentile in whom AI-ECG was positive in 5.8%, those with hs-cTnT&gt;99th percentile had a positive AI-ECG in 22% of cases (p&lt;0.0001). Based on adjudicated diagnoses, the frequency of a positive AI-ECG was 20% in myocardial injury, 38% in type 1 MI, and 20% in type 2 MI. At 2-years follow-up, as compared to patients with a negative AI-ECG, those with a positive AI-ECG had a higher risk for MACE (48% vs. 21%, p&lt;0.0001, adjusted HR 1.39, 95% CI 1.11–1.75) (Figure 1), mainly because of more deaths (43% vs. 30%, p=0.004) and HF hospitalizations (36% vs. 13%, p&lt;0.0001). A positive AI-ECG was associated with a higher risk for MACE (60% vs. 41%, p&lt;0.0001, adjusted HR 1.30, 95% CI 1.02–1.64) in those with hs-cTnT increases &gt;99th percentile, but not in those without hs-cTnT increases. Among patients with an echocardiogram during index presentation or within 30-days (n=452), the diagnostic accuracy of AI-ECG for LVEF ≤35% was 81.4% (95% CI 77.5, 84.9) with a negative predictive value of 96.5% (95% CI 94.0, 98.2). A normal LVEF (&gt;50%) was observed in 87% of those with a negative AI ECG, whereas in those with a positive AI-ECG LVEF was reduced (&lt;50%) in 60%.

Conclusions

Among ED patients evaluated with hs-cTnT, a positive AI-ECG screen for LVSD identifies patients at high risk of MACE. These findings are largely because of more deaths and HF hospitalizations in those with hs-cTnT increases &gt;sex-specific 99th percentiles.

Funding Acknowledgement

Type of funding sources: None.

CASE REPORT ON RARE OUTCOME OF A RETROPERITONEAL MASS: MANAGEMENT CHALLENGES AND LESSONS LEARNT

Background. Gastrointestinal stromal tumours (GIST) are non-epithelial mesenchymal solid neoplasm with varied presentation. The study reports the case of a retroperitoneal GIST in a 21‑year‑old male presented with an abdominal lump for six months. The lesion was initially thought to be a retroperitoneal sarcoma. Exploratory laparotomy revealed an abdominopelvic mass covering the entire right side of abdomen and pelvis. The tumour was adherent to the terminal ileum and ascending colon. There were dense adhesions between the retroperitoneum with involvement of the middle third of the right ureter. The tumour was resected with right hemicolectomy with ileotransverse anastomosis. Post-operative histopathology revealed it as high-grade spindle cell type GIST. The patient is presently on post-operative chemotherapy with Imatinib mesylate. Objective. Atypical presentations of GIST are seldom discussed but frequently encountered in clinical practice. This article depicts different challenges the surgeon has to face while diagnosing such atypical entity. Methods. Case report of atypical GIST presenting as retroperitoneal lump. Results. The patient underwent surgical resection and is presently on post-operative chemotherapy with good overall outcome for a one year follow up. Conclusions. GISTs presenting as retroperitoneal lumps are very rare, they should be considered in their differential diagnosis of an atypical retroperitoneal mass.

Quantitative systems pharmacology modeling sheds light into the dose response relationship of a trispecific T cell engager in multiple myeloma

In relapsed and refractory multiple myeloma (RRMM), there are few treatment options once patients progress from the established standard of care. Several bispecific T-cell engagers (TCE) are in clinical development for multiple myeloma (MM), designed to promote T-cell activation and tumor killing by binding a T-cell receptor and a myeloma target. In this study we employ both computational and experimental tools to investigate how a novel trispecific TCE improves activation, proliferation, and cytolytic activity of T-cells against MM cells. In addition to binding CD3 on T-cells and CD38 on tumor cells, the trispecific binds CD28, which serves as both co-stimulation for T-cell activation and an additional tumor target. We have established a robust rule-based quantitative systems pharmacology (QSP) model trained against T-cell activation, cytotoxicity, and cytokine data, and used it to gain insight into the complex dose response of this drug. We predict that CD3-CD28-CD38 killing capacity increases rapidly in low dose levels, and with higher doses, killing plateaus rather than following the bell-shaped curve typical of bispecific TCEs. We further predict that dose–response curves are driven by the ability of tumor cells to form synapses with activated T-cells. When competition between cells limits tumor engagement with active T-cells, response to therapy may be diminished. We finally suggest a metric related to drug efficacy in our analysis—“effective” receptor occupancy, or the proportion of receptors engaged in synapses. Overall, this study predicts that the CD28 arm on the trispecific antibody improves efficacy, and identifies metrics to inform potency of novel TCEs.

Real-world disease-modifying therapy pathways from administrative claims data in patients with multiple sclerosis

BACKGROUND

Over a dozen disease-modifying therapies (DMTs) have been approved for treatment of multiple sclerosis (MS). Treatment guidelines focus on when to initiate, change, and discontinue treatment but provide little guidance on how to select or sequence DMTs. This study assessed sequencing patterns of DMTs in patients with newly diagnosed MS.

METHODS

Adults newly diagnosed with MS in the United States were identified from January 2007 to October 2017 using IBM MarketScan database. Patients had ≥12 months of continuous enrollment prior to diagnosis and ≥ 2 years of follow-up. Treatment pathways consisting of up to 3 DMT courses were reported, and each treatment course ended with discontinuation, switch, or end of follow-up.

RESULTS

In total, 14,627 MS patients were treated with DMTs and had ≥2 years of follow-up. More than 400 DMT treatment pathways were observed. Glatiramer acetate was the most common DMT; 40% of patients initiated this treatment. Among these, 51.3% had 2 DMT courses during follow-up and 26.5% had 3 DMT courses. Approximately 70% of patients switched or discontinued their initial DMT, and rates of switch and discontinuation differed by initial DMT. Injectable DMTs were used most commonly over the study period (87.5% as first course to 66.6% as third course). Oral DMTs were more common as second or third treatment courses (29.9% and 31.8%, respectively).

CONCLUSIONS

A wide variety in treatment patterns were observed among patients newly diagnosed with MS. Further examination of DMT prescribing practices is needed to understand the reasons behind treatment discontinuation and treatment cycling.

POS1138 PERSISTENCY OF DEPRESSIVE SYMPTOMS AND PHYSICAL PERFORMANCE IN KNEE OSTEOARTHRITIS

Background

Knee osteoarthritis (OA) is the most prevalent arthritic disorder, characterized by joint paint, which is exacerbated by chronic depressive episodes. Depression in knee OA is also associated with declines in physical activity level and greater disability; however, the impact of persistent depressive symptoms on physical performance remains unclear.

Objectives

To determine how the persistence of depressive symptoms affects functional capacity in knee OA.

Methods

Participants (n=2,212) were from the Osteoarthritis Initiative cohort and included individuals with radiographic disease (Kellgren-Lawrence grade ≥ 2) and complete data on study measures at baseline. Depressive symptoms were assessed using the Center for Epidemiologic Studies Depression Scale (CES-D; range 0-60) at baseline and the first three follow-up visits. Physical Performance was measured using 20-meter gait speed (meters per second) during follow-up at the first four annual visits. Persistency of depressive symptoms was operationalized as a cumulative exposure using average severity over time. Gait speed was standardized so that outcome estimates could be interpreted in standard deviations. Time-invariant confounders measured at study enrollment included demographic, socioeconomic, and lifestyle factors. Time-varying confounders assessed concurrent to CES-D scores were body mass index, analgesic medications, pain, and other knee OA signs and symptoms. Marginal structural models accounting for time-dependent confounding and selective attrition were the primary method of analysis. The outcome model included all potential statistical interactions between depressive symptoms and follow-up time indicators. Post-estimation linear combinations estimated time-specific effects of time-averaged CES-D scores on standardized gait speed and differences in physical performance between participants with (i.e., CES-D=16) and without (i.e., CES-D=0) depressive symptoms satisfying screening criteria for major depression.

Results

The interaction between depressive symptoms and time was statistically significant (P=<0.001). Time-specific associations indicated that the largest negative impact of depressive symptoms on physical performance was from baseline through year one (β = -0.0077; 95% CI: -0.0125, 0.0030). However, the effect of persistent depressive symptoms decreased over time and reversed in magnitude and directionality, evidenced by the time-specific associations between time-averaged CES-D scores from baseline through year one and year two and gait speed at year two (β = -0.0033; 95% CI: -0.0084, 0.0019) and year three (β = 0.0014; 95% CI: -0.0046, 0.0074), respectively. Consequently, the strongest negative affect of depressive symptoms on gait speed (β = -0.1232; 95% CI: -0.1998, -0.0473) between participants with and without depressive symptoms satisfying screening criteria for major depression was when depressive symptoms were first measured closest to the initial gait speed assessment.

Conclusion

In the contrast to the dose-dependent relationship between chronic depressive episodes and pain in knee OA, study findings imply that the negative effect of depressive symptoms on physical performance decreases over time with increasing depression persistency. These results may reflect diminishing marginal effects, where the largest impact on physical performance in knee OA is during the first depressive episode closest to initial gait speed assessment, especially when averaged against improvement in symptoms over the same duration.

Acknowledgements

The OAI is a public-private partnership comprised of five contracts (N01-AR-2-2258; N01-AR-2-2259; N01-AR-2-2260; N01-AR-2-2261; N01-AR-2-2262) funded by the National Institutes of Health, a branch of the Department of Health and Human Services, and conducted by the OAI Study Investigators. Private funding partners include Merck Research Laboratories; Novartis Pharmaceuticals Corporation, GlaxoSmithKline; and Pfizer, Inc. Private sector funding for the OAI is managed by the Foundation for the National Institutes of Health. This manuscript was prepared using an OAI public use data set and does not necessarily reflect the opinions or views of the OAI investigators, the NIH, or the private funding partners.

Disclosure of Interests

Rhea Mehta: None declared, Michelle Shardell: None declared, Alice Ryan: None declared, Yu Dong: None declared, Brock Beamer: None declared, Joseph Gallo: None declared, Elizabeth Stuart: None declared, Megan Schuler: None declared, Marc Hochberg Shareholder of: Dr. Marc C. Hochberg is the President of Rheumcon Corporation., Consultant of: Dr. Marc C. Hochberg receives consulting fees from Bioiberica SA, Bristol-Myers Squibb, Eli Lilly, EMD Serono, Galapagos, IBSA Biotechniq SA, Novartis Pharma AG, Pfizer, Plexxikon, Samumed LLC, Theralogix LLC, and TissueGene Inc., Alan Rathbun: None declared

Urinary levels of energy metabolism hormones in association with the proportional intake of maternal milk and weight gain in very preterm neonates

BACKGROUND

This study prospectively investigated the levels of energy metabolism hormones in very preterm neonates to identify their change over time, association with intake of maternal milk, and weight gain velocity.

METHODS

We measured and compared the leptin, adiponectin, ghrelin, and insulin-like growth factor I (IGF-1) levels in the urine of 70 very preterm neonates, before the initiation of any enteral feeding (baseline level) and twice within 14 days on full enteral feeding (FEF). Regression models identified the role of intake of maternal milk on the levels of the tested energy metabolism hormones in the enteral-fed infants. We also analyzed the adequacy of the weight gain velocity defined by the fetal-infant growth reference (FIGR). We also collected and analyzed the infants' clinical and feeding characteristics during the birth hospitalization.

RESULTS

The preterm infants' baseline levels of the energy metabolism hormones significantly predicted their increase at the end of two weeks of observation on FEF. The leptin level was associated with increased intake of maternal milk, whereas the feeding volume was associated with increased ghrelin and IGF-1, and decreased leptin and adiponectin. Infants with comparable FIGR had higher leptin levels than those with inadequate weight gain velocity.

CONCLUSION

Early postnatal levels of leptin, adiponectin, ghrelin, and IGF-1 predicted the increase of these hormones in the fully enteral fed very preterm neonates. Moreover, greater intake of maternal milk by the study infants contributed to an increased leptin-associated weight gain velocity.

Retrospective Claims Analysis of Treatment Patterns, Relapse, Utilization, and Cost Among Patients with Multiple Sclerosis Initiating Second-Line Disease-Modifying Therapy

Background

Real-world studies of disease-modifying therapies (DMTs) in multiple sclerosis (MS) have reported suboptimal adherence.

Objective

We aimed to describe treatment patterns, relapses, healthcare resource utilization, and costs in MS patients experiencing their first observed DMT switch.

Methods

In this retrospective, claims database study, adult patients were selected if they had an MS diagnosis and DMT claim during the study period (1 January 2009–31 March 2019). Patients who switched to a new DMT between 1 January 2010 and 31 March 2018 were included. Adherence, persistence, relapses, and all-cause and MS-related healthcare utilization and costs were reported pre- and post-index.

Results

In total, 1554 MS patients were identified; the mean age was 46 years and most (74%) were female. The majority of patients switched from an injectable DMT (n = 1116; 71.8%), and patients generally switched to an oral DMT (n = 878; 57%). Among patients who switched DMTs, 46.0% (n = 715) were nonadherent, 42% (n = 645) were nonpersistent, and 21.5% (n = 334) relapsed in the 12 months post-switch. An increase in all-cause and MS-related healthcare costs was observed pre- to post-index for all patients. Cost drivers included outpatient visit costs and pharmacy prescriptions. Compared with patients who switched to an injectable DMT, those who switched to an oral DMT had significantly higher persistence and adherence. No significant difference was observed in post-index relapse or all-cause and MS-related total cost of care.

Conclusion

Low adherence and poor persistence remain following an initial DMT switch; however, patients who switched to oral DMTs had higher persistence and adherence.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40801-021-00251-w.

Multiple sclerosis (MS) is a disabling disease that is treated with disease-modifying therapies (DMTs). Little is known about how patients with MS take their medication, how disease progression may change with treatment, or what the impact of switching to a new DMT is on the cost of care. In an analysis of commercially insured individuals, patients with MS were examined before and after switching to a new DMT. Results showed that the patients most often switched from an injectable medication to an oral DMT; however, a large proportion of patients did not take the prescription as directed by their physician. Additionally, a large proportion of patients did not stay on their new therapy. Nearly one-third of patients experienced an MS relapse after they switched to a new treatment, and healthcare costs increased following the treatment switch. A higher proportion of patients switching to an oral DMT took their medication as prescribed by their physicians, stayed on therapy, and incurred smaller increases in cost compared with patients switching to injectable medications. Despite such improvements, additional treatments are needed for patients with MS.

MO273A NOVEL APPROACH TO ASSESS THE DEMOGRAPHIC AND CLINICAL CHARACTERISTICS OF IMMUNOGLOBULIN A NEPHROPATHY (IGAN) PATIENTS IN A US REAL-WORLD SETTING

Background and Aims

Immunoglobulin A nephropathy (IgAN) is a chronic glomerular disease that affects approximately 100,000-200,000 people in the US. Approximately 15-40% of IgAN patients will eventually progress to end stage kidney disease (ESKD) within 10-20 years of diagnosis, and there is currently no targeted therapy for this disease. Decreased kidney function, persistent proteinuria and hypertension are some of the clinical manifestations of IgAN, and with demographic aspects (e.g. ethnicity) are considered as predictors of disease progression. The aim of this study is to better understand the demographic and clinical characteristics of IgAN patients in the US identified via physician notes.

Method

This is a descriptive, retrospective study of adult (≥ 18 years) IgAN patients in Optum® Electronic Health Records (EHRs), between January 2007 and December 2019. Optum® EHRs contain de-identified clinical and medical administrative data from 96 million people in 50 states that come from more than 140,000 providers at 740 hospitals and over 7,000 clinics. Identification of IgAN patients is challenging because there are no specific ICD codes for this disease so we used natural language processing of physician notes and chose patients with at least two IgAN records with the first one considered to be the index date, and no negative mention, as well as a biopsy procedure. Here, we present the baseline demographic and clinical characteristics of the identified patients up to 12 months before and at the index date.

Results

A total of 1803 patients with a biopsy record (22% of all patients with at least two IgAN records in their EHRs in our study) were included in this analysis; results are presented in Table 1. The mean age was 48 years, and the majority of patients were male (60.9%) and white (75.7%). Proteinuria levels of ≥1 g/day were found in 34% of patients. The mean eGFR was 45 ml/min/1.73m2 and 21.6% of patients had severe deterioration of kidney function (eGFR &lt;15). The mean creatinine level was 3 mg/dL. Pain, edema and fatigue/tiredness were reported in 39.6%, 18.1% and 13.4% of patients, respectively. Hypertension was reported in 73% of patients. Based on the ICD 9 (585.6) and ICD-10 (N18.6) codes for diagnosis, 17.5% of patients had ESKD in our study.

Conclusion

In our cohort, a significant proportion of patients were found to have high proteinuria levels and severe deterioration of kidney function or ESKD. Moreover, edema and fatigue were recorded for a noticeable proportion of patients. In addition to the commonly reported symptoms, our study also found that pain was reported in a high proportion of patients. These findings highlight the clinical and symptom burden to patients with IgAN, suggesting that future targeted interventions are needed to reduce the burden and delay the progression of this disease.

A15 EFFICACY AND SAFETY OF FILGOTINIB AS INDUCTION THERAPY FOR PATIENTS WITH MODERATELY TO SEVERELY ACTIVE ULCERATIVE COLITIS: RESULTS FROM THE PHASE 2B/3 SELECTION STUDY

Aims

The SELECTION (NCT02914522) Induction Studies evaluated the efficacy/safety of filgotinib (FIL), a preferential JAK1 inhibitor, as induction therapy for patients (pts) with moderately to severely active ulcerative colitis (UC) who were biologic-naïve but failed conventional therapy (Induction Study A) or failed prior biologics (Induction Study B).

Methods

Pts were randomized 2:2:1 to once–daily FIL 200mg, FIL 100mg or placebo (PBO). The primary (clinical remission), key secondary (Mayo Clinic Score [MCS] remission, endoscopic remission, and histologic remission), and exploratory endpoints (MCS response and endoscopic improvement) were assessed at Week 10.

Results

In both studies, baseline demographics and disease characteristics were similar across treatment groups. In Study A, 659 pts were randomized and treated. Baseline mean MCS was 8.6 and 56% had a Mayo endoscopic subscore (ES)=3. A significantly higher proportion of biologic-naïve pts on FIL 200mg achieved clinical remission vs PBO and all key secondary endpoints (Table). In Study B, 689 pts were randomized and treated. Baseline mean MCS was 9.3 and 78% had ES=3. Prior treatment failures were: anti-TNF (86%), vedolizumab (52%) and both (dual-refractory; 43%). A significantly higher proportion of biologic-experienced pts on FIL 200mg achieved clinical remission vs PBO. In Studies A and B, a greater proportion of pts on FIL 200 mg achieved an MCS response and endoscopic improvement vs PBO.

The rates of AEs, serious AEs and discontinuations due to AEs were similar across FIL and PBO groups during induction. In the PBO, FIL 100mg and FIL 200mg groups, serious infections occurred in 0.7%, 0.7% and 0.4% pts in Study A and 1.4%, 1.4% and 0.8% pts in Study B; H Zoster occurred in &lt;1% in both groups for both cohorts.

Conclusions

SELECTION included a high proportion of dual-refractory pts, and pts with severe endoscopic disease. Both doses of FIL were well tolerated. Filgotinib 200mg was effective induction therapy for both biologic-naïve/-experienced pts with moderately to severely active UC.

Funding Agencies

None

Productivity Loss and Associated Costs Among Employed Patients Receiving Disease-Modifying Treatment for Multiple Sclerosis

OBJECTIVES

The aim of this study was to examine the indirect burden of employed multiple sclerosis (MS) patients initiating disease-modifying therapies (DMTs) in the US.

METHODS

DMT-treated MS patients (DMT users) and direct-matched controls without MS (1:3) were captured using the IBM MarketScan Commercial Claims and Encounters Database and the Health and Productivity Management Database between 1 January 2009 and 1 January 2017. DMT users were also stratified by route of administration. Time loss and costs from absenteeism, short-term disability, and long-term disability were assessed for DMT users and matched controls.

RESULTS

A total of 3022 DMT users were matched to 9066 controls. Compared with injectable DMT users, oral DMT users took twice as long to initiate therapy but had numerically lower absenteeism costs and significantly lower long-term disability costs in the first year after DMT initiation. The mean (standard deviation) indirect costs of absenteeism, short-term disability, and long-term disability were US$6474 (US$6779), US$2368 (US$5777), and US$280 (US$2578), respectively, for DMT users and US$4468 (US$3814), US$328 (US$1950), and US$36 (US$938), respectively, for controls in the first year (all p < 0.001).

CONCLUSIONS

Employed DMT users in the US incurred incremental increased indirect burden ($2007 in absenteeism, $2040 in short-term disability, and $244 in long-term disability) compared with matched controls. Despite evidence of delays in treatment initiation, oral DMT users had evidence of reduced work loss compared with injectable users, suggesting that open access to all treatment options may reduce the indirect burden of MS. Additional research into the impact of route of administration on the burden of long-term disability among MS patients is needed.

Evaluating Treatment Patterns, Relapses, Healthcare Resource Utilization, and Costs Associated with Disease-Modifying Treatments for Multiple Sclerosis in DMT-Naïve Patients

Purpose

Early diagnosis and treatment of multiple sclerosis (MS) with disease-modifying therapy (DMT) can reduce relapse number and severity, which has cost implications. We describe treatment patterns, healthcare utilization, and cost among MS patients newly initiating DMTs (index).

Patients and Methods

DMT-naïve adults with 12 months' continuous enrollment pre- and post-index and ≥2 MS claims (2009‒2018) were identified from the Optum Clinformatics Data Mart database. Treatment adherence and persistence were measured as time on index DMT. Relapses were identified using a validated claims-based algorithm. All-cause and MS-related healthcare expenditures and utilization were captured pre- and post-index. Outcomes were stratified by route of administration. Multivariate analyses assessed differences in outcomes and costs.

Results

The analysis included 5906 MS patients (mean age, 46.6 years). The majority initiated injectable (63.5%) followed by oral (28.8%) and infusion (7.7%) DMTs. Post-index, 45.3% of patients were nonadherent and 39.4% were nonpersistent. Relapse rates decreased from pre- to post-index (oral: 24.3%‒16.1%; injectable: 25.0%‒17.1%; infusion: 29.3%‒15.5%). Post-index mean (SD) all-cause total costs were lowest with oral ($70,970 [$36,681]) vs injectable ($82,521 [$58,569]) and infusion ($80,871 [$49,627]) DMTs. MS-related total costs were lowest with oral ($65,149 [$65,133]) vs injectable ($76,197 [$60,204]) and infusion ($72,703 [$47,287]) DMTs. Multivariate analysis showed no differences between oral and injectable DMTs in adherence, persistence, or relapse rate; however, oral DMTs had significantly lower all-cause and MS-related costs.

Conclusion

With similar outcomes across DMT administration routes, initiating the least costly DMT may be warranted for many patients. In newly treated MS patients, the need exists to improve adherence and persistence.

A Study Comparing Patient and Clinician Perspectives of Treatments for Multiple Sclerosis via Group Concept Mapping

BACKGROUND

Clinicians treating multiple sclerosis (MS) should consider patient preferences when making treatment decisions. An online mixed-methods approach to elicit patient-centered concepts, group concept mapping (GCM), was used to generate statements reflecting the patient experience in relapsing-remitting MS and identify the most important patient-centered outcomes from patient and clinician perspectives.

PATIENTS AND METHODS

Twenty patients and 12 MS specialists in the United States provided statements describing what an ideal treatment would do to improve symptoms and daily functioning. Statements were sorted by participants into meaningful domains and rated on importance on an 11-point scale.

RESULTS

Sixty-four unique statements supporting 6 domains of clustered concepts were generated. Patient and clinician ratings of importance were highly correlated (r=0.82); however, patients rated the domains of Activities of Daily Living, Prevent & Cure, and Address Symptoms as highest in importance, whereas clinicians rated Prevent & Cure, Safe & Effective, and Activities of Daily Living as highest in importance. Statements rated above the domain mean by both patients and clinicians included "Improve cognitive function" and "Improve motor function" in the Activities of Daily Living domain and "Help with memory issues" and "Help preserve cognition" in the Address Symptoms domain. The statement "Improve short term memory" was 1 of 3 statements rated above the domain mean by patients but below the domain mean by clinicians.

CONCLUSION

High levels of agreement of concept importance were found between patients and MS specialists, although certain domains and statements were rated more highly by one group. Overall, concepts such as cognitive function, physical and emotional functioning, and activities of daily living were perceived as having great importance for treatment outcomes versus symptom-focused outcomes like gait or tingling sensations. This comprehensive concept model for the MS patient experience can be used for further development of patient-centered outcome measures in MS treatment.

Treatment Patterns and Relapses Among Newly Treated Multiple Sclerosis Patients From a Retrospective Claims Analysis

PURPOSE

Although all disease-modifying therapies (DMTs) reduce risk of relapse in multiple sclerosis (MS), many factors, including route of administration, influence selection of first-line DMT. Knowledge of real-world treatment patterns and effectiveness in reducing relapses across DMTs is important to understanding factors influencing this choice. This study sought to describe treatment patterns and relapses among newly treated adults with MS and by DMT route of administration (oral, injectable, and infusion).

METHODS

IBM MarketScan research databases were used to identify MS adults newly initiating DMTs (index event) from January 1, 2011-April 1, 2016, who had 12 months of continuous preindex and postindex medical and pharmacy benefits. Newly treated patients were those with ≥2 nondiagnostic claims with an International Classification of Diseases, Ninth Revision, Clinical Modification (340) or Tenth Revision, Clinical Modification (G35) code and no DMT prescription claims in the 12 months' preindex. Persistence and adherence were measured from index until the earliest of ≥60 days without DMT, switching DMTs, or end of follow-up. Relapses were defined using a validated claims-based algorithm and measured in the 12-month preindex and postindex periods. Regression analysis adjusting for patient characteristics and prior relapses was used to determine the association between DMT route of administration and odds of 12-month persistence, odds of postindex relapse, and number of postindex relapses.

FINDINGS

Of 9378 newly treated MS patients meeting inclusion criteria; average age was 46.7 years, and 73.3% were female. Most patients initiated an injectable (65.5%) or oral (26.1%) DMT. Relapses decreased markedly from preindex to postindex (32.9%-24.0%), which was highest among oral users (35.8%-21.6%). Patients with no (vs ≥3) relapses preindex were more likely to be relapse free postindex (81.6% vs 31.4%). Nonpersistence (39.1% overall) was lowest among oral users (33.4%) and higher among those with versus without a postindex relapse (50.6% vs 35.5%). Patients initiating oral versus injectable agents were more likely to be persistent at 12 months (odds ratio [OR], 1.45; p < 0.0001) and less likely to relapse (OR, 0.75; p < 0.0001) postindex. Switches were uncommon (~10%) across cohorts. Preindex relapses were associated with increased odds of postindex relapses (OR, 1.73; p < 0.0001) but not with odds of persistence at 12 months.

IMPLICATIONS

The 12-month nonpersistence rate was high among all MS patients but lower among oral users. Oral users were also less likely to relapse postindex. Despite the effectiveness of DMTs in reducing relapses, the low persistence, lack of switching to a new DMT, and continued relapses highlight an unmet need in the MS treatment landscape.

Over-under cartilage tympanoplasty: technique, results and a call for improved reporting

OBJECTIVE

This study aimed to describe the microscopic over-under cartilage tympanoplasty technique, provide hearing results and detail clinically significant complications.

METHOD

This was a retrospective case series chart review study of over-under cartilage tympanoplasty procedures performed by the senior author between January 2015 and January 2019 at three tertiary care centres. Cases were excluded for previous or intra-operative cholesteatoma, if a mastoidectomy was performed during the procedure or if ossiculoplasty was performed. Hearing results and complications were obtained.

RESULTS

Sixty-eight tympanoplasty procedures met the inclusion criteria. The median age was 13 years (range, 3-71 years). The mean improvement in pure tone average was 6 dB (95 per cent confidence interval 4-9 dB; p < 0.0001). The overall perforation closure rate was 97 per cent (n = 66). Revision surgery was recommended for a total of 6 cases (9 per cent) including 2 post-operative perforations, 1 case of middle-ear cholesteatoma and 3 cases of external auditory canal scarring.

CONCLUSION

Over-under cartilage tympanoplasty is effective at improving clinically meaningful hearing with a low rate of post-operative complications.

Over-under cartilage tympanoplasty: technique, results and a call for improved reporting

OBJECTIVE

This study aimed to describe the microscopic over-under cartilage tympanoplasty technique, provide hearing results and detail clinically significant complications.

METHOD

This was a retrospective case series chart review study of over-under cartilage tympanoplasty procedures performed by the senior author between January 2015 and January 2019 at three tertiary care centres. Cases were excluded for previous or intra-operative cholesteatoma, if a mastoidectomy was performed during the procedure or if ossiculoplasty was performed. Hearing results and complications were obtained.

RESULTS

Sixty-eight tympanoplasty procedures met the inclusion criteria. The median age was 13 years (range, 3-71 years). The mean improvement in pure tone average was 6 dB (95 per cent confidence interval 4-9 dB; p < 0.0001). The overall perforation closure rate was 97 per cent (n = 66). Revision surgery was recommended for a total of 6 cases (9 per cent) including 2 post-operative perforations, 1 case of middle-ear cholesteatoma and 3 cases of external auditory canal scarring.

CONCLUSION

Over-under cartilage tympanoplasty is effective at improving clinically meaningful hearing with a low rate of post-operative complications.

The combination of insulin resistance and visceral adipose tissue estimation improves the performance of metabolic syndrome as a predictor of type 2 diabetes

AIMS

To assess the performance of metabolic syndrome as a predictor of type 2 diabetes in a model that also includes both a measure of insulin resistance and a metabolic score for visceral fat, and to propose a novel metabolic syndrome definition.

METHODS

In a prospective Metabolic Syndrome Cohort (n=6143), we evaluated improvements in type 2 diabetes risk prediction using International Diabetes Federation-defined and Adult Treatment Panel III-defined metabolic syndrome, after inclusion in the model of updated homeostatic model assessment of insulin resistance and a metabolic score for visceral fat. We also developed a modified metabolic syndrome construct, 'MS-METS', which used the metabolic score for visceral fat instead of waist circumference to evaluate improved predictive performance for risk of developing type 2 diabetes.

RESULTS

Participants who had metabolic syndrome as defined by both the Adult Treatment Panel III and the International Diabetes Federation criteria had a higher risk of type 2 diabetes compared to participants who did not meet these criteria. Addition of updated homeostatic model assessment of insulin resistance and metabolic score for visceral fat to both metabolic syndrome definitions increased predictive performance for type 2 diabetes risk. Homeostatic model assessment of insulin resistance was the only additional predictor of type 2 diabetes in participants without metabolic syndrome. Conversely, in participants with metabolic syndrome, the use of the metabolic score for visceral fat was the stronger added predictor for type 2 diabetes. When evaluating participants using the MS-METS definition we observed the largest improvement in predictive ability for type 2 diabetes risk and a significant reduction in risk overestimation compared to evaluation using metabolic syndrome defined according to the International Diabetes Federation and Adult Treatment Panel III criteria alone.

CONCLUSION

Inclusion of updated homeostatic model assessment of insulin resistance and metabolic score for visceral fat increases performance of metabolic syndrome in prediction of type 2 diabetes. Assessment of insulin resistance could be more useful than conventional metabolic syndrome and assessment of visceral adipose tissue could be more useful in people with metabolic syndrome. Metabolic syndrome as defined using our modified MS-METS construct improved the accuracy of type 2 diabetes prediction.

Treatment Patterns Among Patients with Multiple Sclerosis Initiating Second-Line Disease-Modifying Therapy

OBJECTIVE

Disease-modifying therapies (DMTs) can reduce multiple sclerosis (MS) relapse rates; however, effectiveness of treatments may vary. It is important to understand real-world treatment patterns in the context of MS relapses. We describe MS relapses related to treatment patterns among patients who switch treatment after their first DMT.

METHODS

IBM MarketScan research databases were used to identify adult patients with MS who switched DMTs (index-first switch) after being newly treated with a DMT from January 2009 through March 2017, with 12 months of continuous enrollment pre- and post-index. Non-persistence was defined as discontinuing (at least 60 days without DMT) or switching DMTs. MS relapses were defined using a validated claims-based algorithm. Multivariable analysis was used to examine odds of 12-month persistence, odds of post-index relapse, and number of relapses.

RESULTS

In total, 4121 patients with MS met all inclusion criteria (mean age 46.4 years; female 76.2%). Overall, 49.6% switched to an oral DMT, 36.5% to an injectable DMT, and 13.9% to an infusion DMT. Switching DMTs resulted in a 32.4% reduction in relapses between pre- and post-index. Only 54.6% of patients were persistent throughout the first year. Patients who switched to oral DMTs had 95% higher adjusted odds of persistence and 18% lower adjusted odds of a post-index period relapse than patients who switched to injectable DMTs. The number of baseline relapses was not associated with persistence but with 68% higher odds of a post-index relapse, with each additional baseline relapse associated with a 44% increase in number of post-index relapses.

CONCLUSIONS

Among patients with MS who switched DMTs, persistence was consistently low regardless of treatment. Although persistence with oral DMTs was slightly higher than with injectable DMTs, overall results indicate poor persistence to second-line therapy and highlight the need to improve long-term persistence with DMTs.

Causal inference and adjustment for reference-arm risk in indirect treatment comparison meta-analysis

Aim: To illustrate that bias associated with indirect treatment comparison and network meta-analyses can be reduced by adjusting for outcomes on common reference arms. Materials & methods: Approaches to adjusting for reference-arm effects are presented within a causal inference framework. Bayesian and Frequentist approaches are applied to three real data examples. Results: Reference-arm adjustment can significantly impact estimated treatment differences, improve model fit and align indirectly estimated treatment effects with those observed in randomized trials. Reference-arm adjustment can possibly reverse the direction of estimated treatment effects. Conclusion: Accumulating theoretical and empirical evidence underscores the importance of adjusting for reference-arm outcomes in indirect treatment comparison and network meta-analyses to make full use of data and reduce the risk of bias in estimated treatments effects.

0139 Associations of Actigraphic Sleep Parameters with Maximal Oxygen Consumption and Resting Metabolism in Well-Functioning Older Adults

Introduction

Both poor sleep and poor cardiorespiratory fitness are common in older age and associated with negative health outcomes. Additionally, among older adults, higher resting metabolic rate (RMR) has been associated with increased morbidity and mortality risk. To evaluate whether, and in what ways, sleep may affect these relationships, we investigated the association of actigraphic sleep indices with cardiorespiratory fitness and RMR in older adults.

Methods

We studied 393 community-dwelling participants in the Baltimore Longitudinal Study of Aging (mean age 73.5±10.3 years, 52% women) who completed 6.7±0.9 nights of wrist actigraphy, RMR testing, and a maximal graded exercise test. Primary predictors included mean actigraphic total sleep time (TST, minutes), sleep efficiency (SE, %), wake after sleep onset (WASO, minutes), and average wake bout length (WBL, minutes). Cardiorespiratory fitness, as measured by maximal oxygen consumption (V O2MAX; ml/kg/min), and RMR (kcal/day) were the primary outcomes.

Results

After adjustment for age, sex, race, body mass index, comorbidity index, and depressive symptoms, longer WBL was associated with lower V O2MAX (β=-0.12, 95% confidence interval (CI)=-0.20, -0.04), greater WASO was associated with lower V O2MAX (β=-0.09, 95% CI=-0.17, -0.01), and greater SE was associated with higher V O2MAX (β=0.12, 95% CI=0.03, 0.20). In addition, longer TST was associated with lower RMR (β=-0.10, 95% CI=-0.19, -0.01) and longer WBL was linked to higher RMR (β=0.12, 95% CI=0.04, 0.21).

Conclusion

In well-functioning older adults, indices of greater wakefulness after sleep onset are linked with poorer cardiorespiratory fitness and higher resting metabolism, while longer and more efficient sleep are associated with better fitness and lower resting metabolic rate. Our findings suggest that sleep disturbance may be linked to disrupted energy homeostasis, evidenced by excessive energy expenditure at rest and inefficient energy utilization in response to maximal demands. Prospective analyses are necessary to determine the nature of these associations.

Support

This study was supported in part by National Institute on Aging (NIA) grants R01AG050507 and T32-AG027668, the NIA Intramural Research Program (IRP), and Research and Development Contract HHSN-260-2004-00012C.

Profile of osteoarticular tuberculosis in children

OBJECTIVE

To determine clinical profile of osteoarticular tuberculosis (TB) in children.

METHODS

Cross-sectional analysis from 2007 to 2013. All patients diagnosed with bone TB, spinal TB or TB abscesses were included.

RESULTS

Out of 1318 children with TB, 39 (2.96%) had osteoarticular TB, of which 16 (42%) had osteomyelitis, 8 (20.5%) had spinal involvement, 7 (17.9%) had TB synovitis, 2 (5.1%) had psoas abscess and 6 (15.4%) had abscesses. The mean age of presentation was 7.1 ± 3.5 years (range 2-14 years). Of the 33 cases in which a culture was done, 25 (64%) showed a positive culture. Drug sensitivity tests were done in 21 patients of which 10 (47.6%) tested were drug resistant, of which 4 (36.4%) were multidrug resistant (MDR), 2 (18.2%) were extensively drug resistant (XDR), 3 were pre-XDR (27.3%) and 1 was polyresistant (9.1%). Nine (23.1%) patients had TB in the past with a treatment duration of 8.3 ± 5.3 months. Contact with a TB patient had occurred in 10 (25.6%) cases. Associated pulmonary TB were seen in 6 (15.39%) and TB meningitis were seen in 1 (2.6%) patients. Surgical intervention was needed in 11 (28.2%) patients of which 5 (45.5%) underwent curettage, drainage was done in 1 (9.1%), arthrotomy in 4 (36.4%) and spinal surgery in 1 (9.1%) patient.

CONCLUSION

Drug resistant osteoarticular TB is an emerging problem in children.

Hepatocellular carcinoma tumour burden score to stratify prognosis after resection

BACKGROUND

Although the Barcelona Clinic Liver Cancer (BCLC) staging system has been largely adopted in clinical practice, recent studies have emphasized the need for further refinement and subclassification of this system.

METHODS

Patients who underwent hepatectomy with curative intent for BCLC-0, -A or -B hepatocellular carcinoma (HCC) between 2000 and 2017 were identified using a multi-institutional database. The tumour burden score (TBS) was calculated, and overall survival (OS) was examined in relation to TBS and BCLC stage.

RESULTS

Among 1053 patients, 63 (6·0 per cent) had BCLC-0, 826 (78·4 per cent) BCLC-A and 164 (15·6 per cent) had BCLC-B HCC. OS worsened incrementally with higher TBS (5-year OS 77·9, 61 and 39 per cent for low, medium and high TBS respectively; P < 0·001). No differences in OS were noted among patients with similar TBS, irrespective of BCLC stage (61·6 versus 58·9 per cent for BCLC-A/medium TBS versus BCLC-B/medium TBS, P = 0·930; 45 versus 13 per cent for BCLC-A/high TBS versus BCLC-B/high TBS, P = 0·175). Patients with BCLC-B HCC and a medium TBS had better OS than those with BCLC-A disease and a high TBS (58·9 versus 45 per cent; P = 0·005). On multivariable analysis, TBS remained associated with OS among patients with BCLC-A (medium TBS: hazard ratio (HR) 2·07, 95 per cent c.i. 1·42 to 3·02, P < 0·001; high TBS: HR 4·05, 2·40 to 6·82, P < 0·001) and BCLC-B (high TBS: HR 3·85, 2·03 to 7·30; P < 0·001) HCC. TBS could also stratify prognosis among patients in an external validation cohort (5-year OS 79, 51·2 and 28 per cent for low, medium and high TBS respectively; P = 0·010).

CONCLUSION

The prognosis of patients with HCC varied according to the BCLC stage but was largely dependent on the TBS.

Comparative safety and efficacy of ozanimod versus fingolimod for relapsing multiple sclerosis

Aim: Ozanimod and fingolimod are sphingosine 1-phosphate receptor-modulating therapies for relapsing multiple sclerosis. Patients & methods: Comparative effectiveness was assessed by matching adjusted indirect comparisons of safety and efficacy trial outcomes at first-dose cardiac monitoring, 1 year and 2 years. Results: After adjustment, baseline characteristics were similar. Ozanimod was associated with a lower risk of extended first-dose monitoring, conduction abnormalities including atrioventricular block. One-year risks of any adverse event (AE), mean lymphocyte count reductions and abnormal liver enzymes were lower with ozanimod. Two-year risks of AEs leading to discontinuation, any AEs, herpetic infections, bradycardia and abnormal liver enzymes were lower with ozanimod. Analyses of efficacy outcomes were similar. Conclusion: Ozanimod appears to have a favorable benefit-risk profile versus fingolimod.

Abstract P3-01-16: Micro-cavity array system for size-based enrichment of circulating tumor cells and circulating cancer associated fibroblasts from blood of patients with breast cancer

Background:Circulating Tumor Cells(CTCs) have prognostic implications in patients with metastatic breast cancer(MBC).During the Epithelial Mesenchymal Transition(EMT), CTCs acquire a more mesenchymal phenotype. Hence, methodologies such as the Cell search that rely on the expression of an epithelial marker EpCAM in CTCs fail to capture a subset of CTCs undergoing the process of EMT and therefore do not adequately represent the true circulatory metastatic load. Hitachi chemicals has invented a size based micro cavity array (MCA) system that allows for the isolation of tumor cells based on the differences in size and deformability between tumor and blood cells. Photolithography and the metal plating can precisely control the filter pore size of our system. Our platform is more sensitive than the Cell Search method in detecting CTCs in Lung Cancer. Cancer Associated Fibroblasts (CAFs) are a major component of the breast tumor microenvironment. Using a micro filter capture technique, our co-authors have demonstrated that CAFs can be enumerated as circulating CAFs (cCAFs). Hitachi's Micro cavity Array System has not been evaluated in the detection of CTCs and cCAFs in patients with Breast Cancer. The purpose of this study is to demonstrate that CTCs and cCAFs can be enumerated using our platform and the cCAFs can serve as biomarkers of metastasis simultaneously with CTCs.

Method:We undertook a Pilot study of 20 patients each with breast cancer across Stage I, Stage II, Stage III and Stage IV. A total of 10ml of peripheral blood was obtained from each patient. Enumeration of CTCs and cCAFs was carried out by the size based mircocavity array system invented by Hitachi Chemicals. Identification of these cells was done by a triple Immunofluorescence staining for pan-CK (cytokeratin), FAP (Fibroblast Activated Protein) and CD45. CTCs were identified as CK+, CD45-, FAP- cells and cCAFs were identified as FAP+, CK- and CD 45 negative cells.

Result:Our method had a high cell recovery rate (90%or higher) and efficient white blood cells depletion rate (99.99%). We present the data from a total of 13 patients in this abstract, (two with stage III and eleven with stage IV breast cancer) . Data from rest of the subjects will be presented at the actual meeting. We detected the presence of CTCs in 11/11(100%) in patients with stage IV(mean of 44) and in 2 out of 2 (100%) patients with Stage III Breast Cancer. We detected the presence of cCAFs in 1 out of 2 patients( 50%) with stage III and in 8 of 11(81.8%) (mean of 9)patients with stage IV breast cancer( Fisher's exact test p-value= 0.42). The number of CTCs and cCAFs was significantly elevated in patients with MBC and the number was clinically associated with a high metastatic burden.

Conclusions:CTCs and cCAFs can be enumerated using a size based size based micro cavity array invented by Hitachi Chemicals that does not rely on the expression of epithelial markers in CTCs. CTCs and cCAFs can be detected in patients with stage III and stage IV breast cancer. CTCs and cCAFs were associated with high metastatic burden and their numbers were significantly elevated in patients with MBC. cCAFs could serve as biomarkers alongside of CTCs in MBC.

Citation Format: Parajuli R, Ly R, Ziogas A, Eapen A, Lane K, Chen J, Lin E, Mehta R, Tsai A. Micro-cavity array system for size-based enrichment of circulating tumor cells and circulating cancer associated fibroblasts from blood of patients with breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P3-01-16.

Abstract PD4-05: Molecular breast imaging and tomosynthesis to eliminate the reservoir of undetected cancer in dense breasts: The Density MATTERS trial

Background

High mammographic breast density is the primary reason for missed cancers or delayed detection on mammography, and is associated with a higher rate of advanced and interval cancers which increase breast cancer mortality. Digital breast tomosynthesis (DBT) has been shown to reduce false positive findings relative to 2D mammography but does not eliminate the potential for tumor masking in dense breasts due to the similar x-ray attenuation characteristics of tumors and normal fibroglandular tissue. Molecular Breast Imaging (MBI) performed with a dedicated gamma camera to detect functional uptake of a radiotracer, Tc-99m sestamibi, has been shown to reveal breast cancers obscured by density on mammography. In single-institution studies, adding MBI to 2D mammography in women with dense breasts detected an additional 5 to10 invasive cancers per 1000 screened, with modest increases in recall rate (6 to 8%) at a lower cost-per-cancer detected than mammography alone. Despite this promising evidence, the lack of multicenter trial data has limited wider acceptance. Also, MBI has yet to be compared to DBT, which in some centers has replaced 2D mammography screening. We present interim results from a multicenter trial comparing cancer detection rate of DBT and MBI in screening of women with mammographically dense breasts.

Methods

In this ongoing, prospective, multicenter clinical trial, asymptomatic women aged 40-75 years with dense breasts on prior mammogram and no prior history of supplemental screening are invited to undergo two annual rounds of concurrent DBT and MBI. MBI is performed with injection of 300 MBq Tc-99m sestamibi with a dual-head semiconductor-based gamma camera. Screening tests are interpreted independently. Here, preliminary cancer detection rates (cancers per 1000 women screened), recall rates, and biopsy rates of DBT and MBI for initial screening are reported.

Results

In 537 women out of a planned 3000 who have completed the first round of screening, 7 cancers were detected: one by DBT only and 6 by MBI only, giving cancer detection rates of 1.9 for DBT vs. 11.2 for MBI and incremental cancer detection rate of 9.3 for MBI. The one DBT-only cancer was a node-negative 0.8 cm invasive lobular carcinoma. All 6 cancers detected by MBI were invasive; 5 of 6 were node negative (median size 1.0 cm; range 0.6 to 2.6 cm). Recall rate was 11% (60/537) for DBT alone; 16% (84/537) for MBI alone, and 21% (115/537) for the combination. Biopsy was prompted by DBT in 13 patients (PPV 8% [1/13]); by MBI in 23 patients (PPV 26% [6/23]); and by the combination of modalities in 33 (PPV 21% [7/33]).

Conclusion

These preliminary results demonstrate that MBI detects invasive breast cancers occult on DBT in dense breasts. Data from a second screening round will allow calculation of sensitivity and specificity, and determination of the impact of screening MBI in reducing advanced (&gt; 2 cm) and interval cancers. Additional planned analyses will evaluate a denoising algorithm for further reduction in MBI radiation dose to match that of DBT.

Citation Format: Rhodes D, Hunt K, Conners A, Zingula S, Whaley D, Ellis R, Gasal Spilde J, Mehta R, Polley M-Y, O'Connor M, Hruska C. Molecular breast imaging and tomosynthesis to eliminate the reservoir of undetected cancer in dense breasts: The Density MATTERS trial [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr PD4-05.

Fibroblast Growth Factor 21 and Browning of White Adipose Tissue

Interest has been focused on differentiating anatomical, molecular, and physiological characteristics of the types of mammalian adipose tissues. White adipose tissue (WAT) and brown adipose tissue (BAT) are the two main forms of adipose tissue in humans. WAT functions as an endocrine organ and serves as a reservoir of energy in the form of triglycerides. The hormones released by WAT are called adipokines. BAT consists of a group of specialized cells with abundant uncoupling protein 1 (UCP1) in the inner mitochondrial membrane and also fulfills endocrine functions. Following the identification of functional (BAT) in human adults, there has been a great deal of interest in finding out how it is induced, its localization, and the mechanisms by which it regulates thermogenesis. Fibroblast growth factor 21 (FGF21) is a key regulator of the differentiation to brown adipocytes. The main mechanisms occur through enhancing UCP1 expression. In addition, following exposure to cold or exercise, FGF21 induces upregulation of local peroxisome proliferator-activated receptor gamma co-activator (PGC)-1-alfa and thus promotes thermogenesis in adipose tissue and skeletal muscle. FGF21 integrates several pathways allowing the regulation of human energy balance, glucose levels, and lipid metabolism. Such mechanisms and their clinical relevance are summarized in this review.