Does Gender Impact a Diagnosis of Ankylosing Spondylitis?

OBJECTIVE: The study objective was to explore differences in ankylosing spondylitis (AS) diagnosis experiences between men and women by examining the coding of health events over the 2 years preceding AS diagnosis. METHODS: Claims data (January 2006-April 2019) from the MarketScan databases were examined. Patients who had received two or more AS diagnoses at least 30 days apart and had at least 2 years of insurance enrollment before their first AS diagnosis were analyzed. Men were matched 1:1 to women by age, diagnosis date, insurance type, and enrollment duration. Health events (diagnosis and provider codes) were examined over 2 years before AS diagnosis and stratified by gender. Data were analyzed using univariate χ2 tests. RESULTS: Among 7744 patients, 274 of 1906 AS-related codes showed statistically significant differences between men and women. Women received more diagnosis codes than men across diagnoses and providers; the largest difference in diagnosis codes among women versus men was in peripheral symptom coding (57.7% vs. 43.9%, respectively). More women than men received diagnosis codes for depression (21.2% vs. 9.8%) and other musculoskeletal symptoms (52.8% vs. 40.0%); only gout was more common in men (6.5%) than in women (2.2%). Among men, backache codes gradually increased 12 months before AS diagnosis, whereas axial and sacroiliitis coding increased sharply immediately before diagnosis. The greatest difference in physician types visited was for rheumatologists: 64.2% of women had visits compared with 45.1% of men. CONCLUSION: Further investigation into the dissimilarities in diagnostic experiences between men and women is needed to determine whether differences are due to disease phenotype or potential cognitive bias influencing diagnostic decision-making.

Longitudinal analysis of the patient pathways to diagnosis of psoriatic arthritis.

BACKGROUND: The occurrence of health events preceding a psoriatic arthritis (PsA) diagnosis may serve as predictors of diagnosis. We sought to assess patients' real-world experiences in obtaining a PsA diagnosis. METHODS: This retrospective cohort study analyzed MarketScan claims data from January 2006 to April 2019. Included were adult patients with ≥ 2 PsA diagnoses (ICD-9-CM/ICD-10-CM) ≥ 30 days apart with ≥ 6 years of continuous enrolment before PsA diagnosis. Controls were matched 2:1 to patients with PsA. Health events (diagnoses and provider types) were analyzed before PsA diagnosis and additionally stratified by presence of psoriasis. RESULTS: Of 13,661 patients, those with PsA had an increased history of coding for arthritis and dermatologic issues (osteoarthritis [48% vs 22%], rheumatoid arthritis [18% vs 2%], and psoriasis [61% vs 2%]) vs those without PsA. Diagnoses of arthritis, axial symptoms, and tendonitis/enthesitis increased over time preceding PsA diagnosis; notably, a sharp rise in psoriasis diagnoses was observed 6 months before PsA diagnosis. Rheumatology consults were more common immediately preceding a PsA diagnosis. Dermatologists were unlikely to code for arthritis and musculoskeletal issues, while rheumatologists were unlikely to code for psoriasis; general practitioners focused on axial and musculoskeletal symptoms. PsA was most commonly diagnosed by rheumatologists (40%), general practitioners (22%), and dermatologists (7%). CONCLUSIONS: Rheumatologists, general practitioners, and dermatologists diagnosed two thirds of patients with PsA. Musculoskeletal symptoms were common preceding a PsA diagnosis. Greater awareness of patterns of health events may alert healthcare providers to suspect a diagnosis of PsA.

Effect of Nucleating Additives on Short- and Long-Term Tensile Strength and Residual Stresses of Welded Polypropylene Samples.

Additives such as nucleating agents are often used in the processing of plastic products not only for improving production efficiency but also for enhancing mechanical performance. In this work, the short- and long-term tensile strength, the morphology as well as the residual stresses of the welded polypropylene (PP) samples with different fillers (carbon black and special beta-nucleating agents) and different dimensionless joining paths are analyzed. Results obtained are then compared with those that are representative of the initial, filler-free samples. It is shown that, upon using the special beta-nucleating agent, superior long-term tensile strength can be achieved compared to the samples without additives or with carbon black agent (e.g., for the dimensionless joining path of 0.95, the long-term tensile strength of a PP nature sample is characterized by around 400 MPa, whereas by adding beta-nucleating agent 1% the value can be increased by 400% to reach around 2050 MPa). However, adding beta-nucleating agent 1% yields inferior short-term tensile strength. The hole drilling method (HDM) is used for the analysis of residual stresses. It is found that the residual stresses in the weld seam are characterized by low values of the tensile stresses. The residual stresses in the weld seam also can be converted from tensile into compressive stresses by adding the beta nucleating agent. However, this has the disadvantage that with a higher proportion by weight of the beta nucleating agent, the short-term tensile strength of the welded joint becomes lower than that of the other tested bonds.

Long-Term (3 Years) Outcomes of Ranolazine Therapy for Refractory Angina Pectoris (from the Ranolazine Refractory Registry).

Ranolazine is approved for patients with chronic stable angina but has not been formally studied in patients with refractory angina pectoris (RAP). Patients with RAP have limited therapeutic options and significant limitations in their quality of life. The Ranolazine Refractory Angina Registry was designed to evaluate the safety, tolerability, and effectiveness of ranolazine in RAP patients in order to expand treatment options for this challenging patient population. Using an extensive prospective database, we enrolled 158 consecutive patients evaluated in a dedicated RAP clinic. Angina class, medications, major adverse cardiac events including death, myocardial infarction, and revascularization were obtained at 12, 24, and 36 months. At 3 years, 95 (60%) patients remained on ranolazine. A ≥2 class improvement in angina was seen in 48% (38 of 80 patients with known Canadian Cardiovascular Society class) of those who remained on ranolazine. Discontinuation due to side effects, ineffectiveness, cost, and progression of disease were the principle reasons for discontinuation, but primarily occurred within the first year. In conclusion, ranolazine is an effective antianginal therapy at 3-year follow-up in patients with RAP and may reduce cardiac readmission.

Management of Gout in the United States: A Claims-based Analysis.

OBJECTIVE: Gout is the most common inflammatory arthritis in the United States. Although numerous guidelines exist for the management of gout, they are not routinely implemented. This study evaluated the real-world practice patterns in gout patients using large administrative claims databases. METHODS: An analysis of patients diagnosed with gout from October 2015 to November 2018 was carried out using the Symphony Integrated Dataverse and Truven Marketscan administrative claims databases. Patients were identified as having gout if they were more than18 years of age and had 2 or more primary gout diagnoses on different days, separated by 3 or more months. Patients were further identified as having either acute gout or advanced forms of gout including chronic nontophaceous, tophaceous, and uncontrolled gout. Percent and frequency of serum urate testing, rheumatology specialist visits, prescriptions for urate lowering therapies (ULTs), and emergency room (ER) visits for gout flares were evaluated. RESULTS: We identified 1 162 747 gout patients. Gout patients were seen most frequently by internists and family medicine practitioners. Neither urate testing nor prescriptions for ULTs were uniform. Patients with acute gout were infrequently seen by rheumatologists, whereas rheumatologist care progressively increased in patients with advanced gout. The frequency of serum urate testing and prescriptions for ULTs significantly increased, whereas the frequency of ER visits decreased in gout patients seen by a rheumatologist. CONCLUSION: Measurement of serum urate and prescriptions for ULTs are not consistent in gout patients. Rheumatologist care increases the frequency of urate measurement and ULT prescriptions and may also improve outcomes for gout patients.

Use of machine learning techniques in the development and refinement of a predictive model for early diagnosis of ankylosing spondylitis.

OBJECTIVE: To develop a predictive mathematical model for the early identification of ankylosing spondylitis (AS) based on the medical and pharmacy claims history of patients with and without AS. METHODS: This retrospective study used claims data from Truven databases from January 2006 to September 2015 (Segment 1) and October 2015 to February 2018 (Segment 2). Machine learning identified features differentiating patients with AS from matched controls; selected features were used as inputs in developing Model A/B to identify patients likely to have AS. Model A/B was trained and developed in Segment 1, and patients predicted to have AS in Segment 1 were followed up in Segment 2 to evaluate the predictive capability of Model A/B. RESULTS: Of 228,471 patients in Segment 1 without any history of AS, Model A/B predicted 1923 patients to have AS. Ultimately, 1242 patients received an AS diagnosis in Segment 2; 120 of these were correctly predicted by Model A/B, yielding a positive predictive value (PPV) of 6.24%. The diagnostic accuracy of Model A/B compared favorably with that of a clinical model (PPV, 1.29%) that predicted AS based on spondyloarthritis features described in the Assessment of SpondyloArthritis international Society classification criteria. A simplified linear regression model created to test the operability of Model A/B yielded a lower PPV (2.55%). CONCLUSIONS: Model A/B performed better than a clinically based model in predicting a diagnosis of AS among patients in a large claims database; its use may contribute to early recognition of AS and a timely diagnosis.

Revascularization in "no option" patients with refractory angina: Frequency, etiology and outcomes.

BACKGROUND: A significant proportion of patients with complex, advanced coronary artery disease have refractory angina (RA) despite maximal pharmacological therapy and are deemed suboptimal candidates for revascularization. These patients are frequently termed "no-option" patients. However, despite this designation, many subsequently undergo coronary revascularization. We sought to determine the incidence, etiology and outcome of revascularization in "no-option" patients. METHODS AND RESULTS: We examined a comprehensive, prospective RA database to identify 342 of 1363 (25.1%) patients who subsequently underwent revascularization after a median interval of 2.2 years from the "no-option" diagnosis. Coronary revascularization was achieved by percutaneous coronary intervention (PCI) (n = 274, 20.1%), coronary bypass graft surgery (n = 44, 3.2%) or both (n = 24, 1.8%). During a median follow-up of 5.1 years, patients who underwent revascularization had lower annual mortality (2% vs. 4.4%, P < .001). Detailed paired angiographic records were available for 181 PCI patients with a combined 302 lesions. Of these interventions, 48% were for a new lesion, 31% for an existing lesion and 21% for restenosis. The location was a native vessel in 77% and a bypass graft in 23%. CONCLUSIONS: The "no-option" or non-revascularizable designation is frequently based on angiography at a single time-point. However, coronary artery disease is a progressive and dynamic process and new lesions often develop in such patients. Given the association between revascularization and better survival, careful consideration should be given to repeat revascularization in patients with refractory angina previously classified as "no-option".

Ranolazine refractory angina registry: 1-year results.

Patients with refractory angina (RA) have limited therapeutic options and significant limitations in their quality of life. Ranolazine is approved for patients with chronic stable angina but has not been studied in patients with RA. The Ranolazine Refractory Angina Registry was designed to evaluate the safety, tolerability, and effectiveness in RA patients. In a dedicated RA clinic using an extensive prospective database, 100 patients were enrolled. Angina class, medications, major adverse cardiac events including death, myocardial infarction, and revascularization were obtained at 1, 6, and 12 months. Overall 43% of patients had a ≥2 class improvement in angina. At 1 year, 57% patients remained on ranolazine (91.2%; 500 mg BID), including 58% with a ≥2 class improvement in angina. Reasons for discontinuation included: side effects (n = 16), major adverse cardiac events (n = 10), cost (n = 5), ineffective (n = 6), cost and ineffective (n = 3), and unknown (n = 3). In conclusion, ranolazine is an effective antianginal therapy in patients with RA; still at 1 year only 57% of patients remained on ranolazine because of side effects, suboptimal effectiveness, cost, or progression of disease.

Long-term survival in patients with refractory angina.

AIMS: An increasing number of patients with severe coronary artery disease (CAD) are not candidates for traditional revascularization and experience angina in spite of excellent medical therapy. Despite limited data regarding the natural history and predictors of adverse outcome, these patients have been considered at high risk for early mortality. METHODS AND RESULTS: The OPtions In Myocardial Ischemic Syndrome Therapy (OPTIMIST) program at the Minneapolis Heart Institute offers traditional and investigational therapies for patients with refractory angina. A prospective clinical database includes detailed baseline and yearly follow-up information. Death status and cause were determined using the Social Security Death Index, clinical data, and death certificates. Time to death was analysed using survival analysis methods. For 1200 patients, the mean age was 63.5 years (77.5% male) with 72.4% having prior coronary artery bypass grafting, 74.4% prior percutaneous coronary intervention, 72.6% prior myocardial infarction, 78.3% 3-vessel CAD, 23.0% moderate-to-severe left-ventricular (LV) dysfunction, and 32.6% congestive heart failure (CHF). Overall, 241 patients died (20.1%: 71.8% cardiovascular) during a median follow-up 5.1 years (range 0-16, 14.7% over 9). By Kaplan-Meier analysis, mortality was 3.9% (95% CI 2.8-5.0) at 1 year and 28.4% (95% CI 24.9-32.0) at 9 years. Multivariate predictors of all-cause mortality were baseline age, diabetes, angina class, chronic kidney disease, LV dysfunction, and CHF. CONCLUSION: Long-term mortality in patients with refractory angina is lower than previously reported. Therapeutic options for this distinct and growing group of patients should focus on angina relief and improved quality of life.

Enhanced external counterpulsation improves systolic blood pressure in patients with refractory angina.

BACKGROUND: Enhanced external counterpulsation (EECP) is a noninvasive treatment of patients with refractory angina. The immediate hemodynamic effects of EECP are similar to intra-aortic balloon pump counterpulsation, but EECP's effects on standard blood pressure measurements during and after treatment are unknown. METHODS: We evaluated systolic blood pressure (SBP) and diastolic blood pressure (DBP) for 108 consecutive patients undergoing EECP. Baseline SBP, DBP, and heart rate were compared for each patient before and after each EECP session, at the end of the course of EECP, and 6 weeks after the final EECP session. RESULTS: One hundred eight patients (mean age 66.4 +/- 11.2 years, 81% male) completed 36.5 +/- 5.1 EECP sessions per patient. Overall, based on 3,586 individual readings, EECP resulted in a decrease in mean SBP of 1.1 +/- 15.3 mm Hg at the end of each EECP session (P < .001), 6.4 +/- 18.2 mm Hg at the end the course of EECP (P < .001), and 3.7 +/- 17.8 mm Hg 6 weeks after the final EECP session (P = .07), with no significant change in DBP or heart rate. Stratifying by baseline SBP, a differential response was demonstrated: SBP increased in the 2 lowest strata (<100 mm Hg and 101-110 mm Hg) and decreased in the remaining strata (P < .001). Stratified differences were sustained after individual EECP sessions, at the end of the course of EECP, and 6 weeks after the final EECP session and were independent of changes in cardiovascular medications. CONCLUSIONS: Enhanced external counterpulsation improved SBP in patients with refractory angina. On average, EECP decreased SBP during treatment and follow-up; but for patients with low baseline SBP (<110 mm Hg), EECP increased SBP. The improvements in SBP may contribute to the clinical benefit of EECP.

A controlled comparison study of the efficacy of training medical students in evidence-based medicine literature searching skills.

PURPOSE: Many educational programs seek to develop skills in evidence-based medicine (EBM). The authors examined the efficacy of teaching the EBM skill of efficiently searching the research literature. They compared students who received brief training in EBM searching skills with those who did not, and assessed the quality of literature searching one month after that training. METHOD: The authors used a nonrandomized control group study design to quantify the impact of a single, brief (two-hour) instructional intervention on EBM-based techniques for searching Medline for evidence related to a clinical problem provided to the students. Ninety-two fourth-year medical students (34 intervention, 58 control) at the University of Michigan participated in a four-week EBM elective between 2001 and 2003. The authors conducted a pre-intervention assessment of searching skills, followed by a repeat assessment one month after the intervention. Search quality was judged by medical librarians using a structured clinical scenario and scoring algorithm. RESULTS: Data for 30 intervention and 40 control students could be analyzed. Intervention students had fewer search errors and correspondingly higher quality searches than did control students. The educational intervention accounted for approximately 8% of the variance in both of these outcomes. The most common search errors were a lack of Medical Subject Headings (MeSH) explosion, missing MeSH terms, lack of appropriate limits, failure to search for best evidence, and inappropriate combination of all search concepts. CONCLUSIONS: This study provides evidence that a single, brief training session can have a marked beneficial effect on the quality of subsequent, short-term EBM literature searching performance outcomes.