Two sides of the self-love coin: Self-compassion text-only posts and body positive photo-based content both positively affect body image.

Although body-positive content is associated with increased positive body image, concerns regarding the continued focus on appearance have emerged. Therefore, the purpose of this study was to examine whether self-compassion text-only content provided benefits beyond traditional photo-based body positivity content. Undergraduates (n = 283; 179 women, 104 men) were randomly assigned to view body positive photos, self-compassion text-only content, or architectural images (control condition). Participants assigned to both experimental conditions demonstrated a significant increase in measures of state body appreciation, state body satisfaction, and state self-compassion, however they did not differ significantly from each other. The self-compassion condition also differed significantly from the control condition. Trait appearance comparisons moderated the relationship between experimental condition and state body appreciation and state body satisfaction, and gender did not affect the relationship between condition and the outcome measures. Results of this study support the inclusion of body-positivity images and self-compassion text-only content in social media interventions for improving body image for men and women.

Evidence-informed recommendations on managing breast screening atypia: perspectives from an expert panel consensus meeting reviewing results from the Sloane atypia project.

Evidence-based clinical guidelines are essential to maximize patient benefit and to reduce clinical uncertainty and inconsistency in clinical practice. Gaps in the evidence base can be addressed by data acquired in routine practice. At present, there is no international consensus on management of women diagnosed with atypical lesions in breast screening programmes. Here, we describe how routine NHS breast screening data collected by the Sloane atypia project was used to inform a management pathway that maximizes early detection of cancer and minimizes over-investigation of lesions with uncertain malignant potential. A half-day consensus meeting with 11 clinical experts, 1 representative from Independent Cancer Patients' Voice, 6 representatives from NHS England (NHSE) including from Commissioning, and 2 researchers was held to facilitate discussions of findings from an analysis of the Sloane atypia project. Key considerations of the expert group in terms of the management of women with screen detected atypia were: (1) frequency and purpose of follow-up; (2) communication to patients; (3) generalizability of study results; and (4) workforce challenges. The group concurred that the new evidence does not support annual surveillance mammography for women with atypia, irrespective of type of lesion, or woman's age. Continued data collection is paramount to monitor and audit the change in recommendations.

The first clinical implementation of real-time 6 degree-of-freedom image-guided radiotherapy for liver SABR patients.

PURPOSE: Multiple survey results have identified a demand for improved motion management for liver cancer IGRT. Until now, real-time IGRT for liver has been the domain of dedicated and expensive cancer radiotherapy systems. The purpose of this study was to clinically implement and characterise the performance of a novel real-time 6 degree-of-freedom (DoF) IGRT system, Kilovoltage Intrafraction Monitoring (KIM) for liver SABR patients. METHODS/MATERIALS: The KIM technology segmented gold fiducial markers in intra-fraction x-ray images as a surrogate for the liver tumour and converted the 2D segmented marker positions into a real-time 6DoF tumour position. Fifteen liver SABR patients were recruited and treated with KIM combined with external surrogate guidance at three radiotherapy centres in the TROG 17.03 LARK multi-institutional prospective clinical trial. Patients were either treated in breath-hold or in free breathing using the gating method. The KIM localisation accuracy and dosimetric accuracy achieved with KIM + external surrogate were measured and the results were compared to those with the estimated external surrogate alone. RESULTS: The KIM localisation accuracy was 0.2±0.9 mm (left-right), 0.3±0.6 mm (superior-inferior) and 1.2±0.8 mm (anterior-posterior) for translations and -0.1◦±0.8◦ (left-right), 0.6◦±1.2◦ (superior-inferior) and 0.1◦±0.9◦ (anterior-posterior) for rotations. The cumulative dose to the GTV with KIM + external surrogate was always within 5% of the plan. In 2 out of 15 patients, >5% dose error would have occurred to the GTV and an organ-at-risk with external surrogate alone. CONCLUSIONS: This work demonstrates that real-time 6DoF IGRT for liver can be implemented on standard radiotherapy systems to improve treatment accuracy and safety. The observations made during the treatments highlight the potential false assurance of using traditional external surrogates to assess tumour motion in patients and the need for ongoing improvement of IGRT technologies.

In situ correlation between microplastic and suspended particulate matter concentrations in river-estuary systems support proxies for satellite-derived estimates of microplastic flux.

Rivers are key pathways for transporting microplastics from land to the oceans, yet microplastic flux estimates remain uncertain. Remote sensing allows repeated broad-scale measurements and can be used to extrapolate limited in situ observations. This study investigated the relationship between suspended particulate matter (SPM), a satellite-observable water quality parameter, and microplastic concentration in a partially mixed estuary (Tamar, UK). Microplastic concentrations ranged from 0.04 to 0.99 microplastics/m3, decreasing downstream. A significant correlation was found between SPM and microplastic concentration over two seasons. This relationship was used to compute a multiyear timeseries of proxy microplastic concentration from satellite imagery and produce estimates of annual proxy microplastic flux. This approach could be applied to investigate microplastic flux in other major rivers worldwide where such a relationship between microplastics and SPM exists. To apply this workflow elsewhere, the establishment of local SPM-to-microplastic relationships from in situ observations and local validation of remote sensing SPM algorithms are essential.

The influence of emotion regulation strategies and sleep quality on depression and anxiety.

Chronic stress is a major risk factor for a number of mental health disorders, including depression and pathological anxiety. Adaptive cognitive emotion regulation (CER) strategies (i.e. positively-focused thought processes) can help to prevent psychiatric disturbance when enduring unpleasant and stressful experiences, but little is known about the inter-individual factors that govern their success. Sleep plays an important role in mental health, and may moderate the effectiveness of adaptive CER strategies by maintaining the executive functions on which they rely. In this study, we carried out a secondary analysis of self-reported mental health and sleep data acquired during a protracted and naturally-occurring stressor - the COVID-19 pandemic - to firstly test the hypothesis that adaptive CER strategy use is associated with positive mental health outcomes and secondly, that the benefits of adaptive CER strategy use for mental health are contingent on high-quality sleep. Using established self-report tools, participants estimated their depression (N = 551) and anxiety (N = 590)2 levels, sleep quality and tendency to engage in adaptive and maladaptive CER strategies during the Spring and Autumn of 2020. Using a linear mixed modelling approach, we found that greater use of adaptive CER strategies and higher sleep quality were independently associated with lower self-reported depression and anxiety. However, adaptive CER strategy use was not a significant predictor of self-reported anxiety when accounting for sleep quality in our final model. The positive influence of adaptive CER strategy use on depression was observed at different levels of sleep quality. These findings highlight the importance of adaptive CER strategy use and good sleep quality in promoting resilience to depression and anxiety when experiencing chronic stress.

The patterns and position of snacking in children in aged 2-12 years: A scoping review.

BACKGROUND: Childhood obesity is associated with serious comorbidities during childhood and into adulthood. One potential risk factor for childhood obesity is consumption of unhealthy, energy-dense foods. This scoping review examines evidence on snacking in children aged 2-12 years of age and presents the patterns and position of snacking in children's diets. METHODS: A search of electronic databases (MEDLINE, Web of Science, PubMed, Embase) for articles published from March 2011 to November 2022 was conducted. Articles providing insight into the position of snacking (e.g., energy contribution), or patterns (e.g., location, timing), in children aged 2-12 years were included. A quality assessment was conducted and data was synthesised according to data source (nationally representative or other). RESULTS: Twenty-one articles were included, most (n = 13) reporting nationally representative data. The average number of daily snacks was 3, with 92.9-100.0% of children consuming snacks. Most were consumed in the afternoon (75.2-84.0%) and at home (46.5-67.3%). Snacks frequently consumed were 'fruits and vegetables', 'baked desserts', 'sweets, candy and confectionery', and 'dairy products'. Snacks contributed 231-565 kcal daily, up to a third of daily carbohydrate intake, a quarter of fat intake, and a fifth of protein intake. Snacks provided up to one third of vitamin C intake, one quarter of vitamin E, potassium and magnesium intake, and a fifth of calcium, folic acid, vitamins D and B12, iron and sodium intake. DISCUSSION: This scoping review provides insight into patterns and position of snacking within children's diets. Snacking plays a significant role in children's diets with multiple snacking occasions occurring throughout a child's day, the overconsumption of which has the potential to increase risk of childhood obesity. Further research is required into the role of snacking, particularly specific foods playing a role in micronutrient intake, and clear guidance for snacking intake in children.

Improving plan quality in cervical brachytherapy using a simple knowledge-based prediction tool for OAR dose (D2cm3).

PURPOSE: Toxicity from cervical brachytherapy has been demonstrated to correlate with the D2cm3 of the bladder, rectum, and bowel. This suggests a simplified version of knowledge-based planning investigating the relationship of the overlap distance for 2cm3 and the D2cm3 from planning may be possible. This work demonstrates the feasibility of simple knowledge-based planning to predict the D2cm3, detect suboptimal plans, and improve plan quality. METHODS AND MATERIALS: The overlap volume histogram (OVH) method was used to determine the distance for 2cm3 of overlap between the OAR and CTV_HR. Linear plots modeled the OAR D2cm3 and 2cm3 overlap distance. Two datasets of 20 patients (plans from 43 insertions in each dataset) were used to create two independent models, and the performance of each model was compared using cross-validation. Doses were scaled to ensure consistent CTV_HR D90 values. The predicted D2cm3 is entered as the maximum constraint in the inverse planning algorithm. RESULTS: Mean bladder D2cm3 decreased by 2.9% for the models from each dataset, mean rectal D2cm3 decreased 14.9% for the model from dataset 1 and 6.0% for the model from dataset 2, mean sigmoid D2cm3 decreased 10.7% for the model from dataset 1 and 6.1% for the model from dataset 2, mean bowel D2cm3 decreased 4.1% for the model from dataset 1 but no statistically significant difference was observed for the model from dataset 2. CONCLUSIONS: A simplified knowledge-based planning method was used to predict D2cm3 and was able to automate optimization of brachytherapy plans for locally advanced cervical cancer.

Multi-spatiotemporal analysis of changes in mangrove forests in Palawan, Philippines: predicting future trends using a support vector machine algorithm and the Markov chain model.

Multi-temporal remote sensing imagery can be used to explore how mangrove assemblages are changing over time and facilitate critical interventions for ecological sustainability and effective management. This study aims to explore the spatial dynamics of mangrove extents in Palawan, Philippines, specifically in Puerto Princesa City, Taytay and Aborlan, and facilitate future predictions for Palawan using the Markov Chain model. The multi-date Landsat imageries during the period 1988-2020 were used for this research. The support vector machine algorithm was sufficiently effective for mangrove feature extraction to generate satisfactory accuracy results (>70% kappa coefficient values; 91% average overall accuracies). In Palawan, a 5.2% (2693 ha) decrease was recorded during 1988-1998 and an 8.6% increase in 2013-2020 to 4371 ha. In Puerto Princesa City, a 95.9% (2758 ha) increase was observed during 1988-1998 and 2.0% (136 ha) decrease during 2013-2020. The mangroves in Taytay and Aborlan both gained an additional 2138 ha (55.3%) and 228 ha (16.8%) during 1988-1998 but also decreased from 2013 to 2020 by 3.4% (247 ha) and 0.2% (3 ha), respectively. However, projected results suggest that the mangrove areas in Palawan will likely increase in 2030 (to 64,946 ha) and 2050 (to 66,972 ha). This study demonstrated the capability of the Markov chain model in the context of ecological sustainability involving policy intervention. However, as this research did not capture the environmental factors that may have influenced the changes in mangrove patterns, it is suggested adding cellular automata in future Markovian mangrove modelling.

Fresh Beef and Lamb Consumption in Relation to Nutrient Intakes and Markers of Nutrition and Health Status among the Population Aged 5-90 Years in Ireland.

The dietary role of meat is under scrutiny for health and environmental reasons, yet a growing body of evidence proposes that advice to limit red meat consumption is unnecessarily restrictive. The aim of this study was to investigate the role of 'fresh beef and lamb' in the diet of the population (5-90 years) in Ireland and its association with markers of nutrition and health status. Analyses are based on data from three nationally representative dietary surveys in the Republic of Ireland. Dietary intake data were estimated using food records, and nutrient intakes were estimated based on UK and Irish food composition tables. Biochemical samples were collected and analysed using standard procedures. 'Fresh beef and lamb' (defined as beef/lamb that had not undergone any preserving process other than chilling/freezing/quick-freezing) was consumed by 68-84% of the population and intakes ranged from 19 to 43 g/d across age groups. It made important contributions to intakes of protein, monounsaturated fat, vitamins D, B12, niacin, iron and zinc while also contributing relatively small proportions of total fat, saturated fat and salt. Higher consumption of 'fresh beef and lamb' was associated with higher intakes of protein, niacin, vitamins B6, B12, zinc and potassium (but also total fat) and lower intakes of carbohydrate and total sugars (but also dietary fibre). In adults, older adults and WCBA, higher consumption of 'fresh beef and lamb' was not associated with increased risk factors of cardio-metabolic diseases nor was it associated with better or poorer nutritional status for vitamins D, B12 or iron. This study adds to the evidence base on the contribution of 'fresh beef and lamb' in the diet and may be useful to policymakers updating guidance for healthy diets from sustainable food systems.

Characterization of Shiga toxin-producing Escherichia coli presence, serogroups and risk factors from private groundwater sources in western Ireland.

Over recent years, Ireland has reported the highest crude incidence rates of Shiga toxin-producing Escherichia coli (STEC) enteritis in Europe. Unregulated private groundwater sources have emerged as an important potential transmission route for STEC, with up to 750,000 Irish residents reliant on these sources for domestic waters. This study aimed to investigate the prevalence and serogroup profile of STEC contamination from domestic private wells in western Ireland. Fifty-two groundwater sources were analysed during two sampling campaigns in the autumn (September/October) of 2019 (n = 21) and 2021 (n = 31). Untreated groundwater samples (30 L) were collected and analysed using the "CapE" (capture, amplify, extract) method. Extracted DNA was tested using multiplex real-time PCR for Shiga toxin stx1 and/or stx2 and eae genes. STEC positive DNA samples were tested for clinically relevant serogroups by real-time PCR. Data relating to 27 potential groundwater contamination risk factors were geospatially linked to each well and assessed for association with E. coli, stx1 and/or stx2 and eae presence/absence. Overall, 20/52 wells (38.4 %) were positive for E. coli (median concentration 8.5 MPN/100 mL as assessed by Colilert-18 method). Stx1 and/or stx2 was detected in 10/52 (19.2 %) wells overall and 8/20 E. coli positive wells, equating to a STEC to "generic" E. coli detection ratio of 40 %. Six of these wells (30 %) were also positive for eae. One or more serogroup-specific gene targets were identified in all but one stx1 and/or stx2 positive sample, with O145 (n = 6), O157 (n = 5) and O103 (n = 4) most prevalent. STEC presence was significantly associated with decreasing well depth (U = -2.243; p = 0.024) and increasing 30-day mean antecedent rainfall (U = 2.126; p = 0.034). Serogroup O104 was associated with increased sheep density (U = 2.089; p = 0.044) and detection of stx1 and/or stx2 + eae with increased septic tank density (U = 2.246 p = 0.023). Findings indicate high detection rates of clinically relevant STEC in E. coli contaminated groundwater sources in Ireland.

Impact of COVID-19 on the practice of breast pathologists: a survey of breast pathologists in the UK and Ireland.

AIMS: There is little information on the impact of COVID-19 on breast pathologists. This survey assessed the effect of the COVID-19 pandemic on UK and Ireland-based breast pathologists to optimise working environments and ensure preparedness for potential future pandemics. METHODS: A 35-question survey during the first wave of COVID-19 infections in the UK including questions on workload, working practices, professional development, training, health and safety and well-being was distributed to consultant breast pathologists and responses collected anonymously. RESULTS: There were 135 responses from breast pathologists based in the UK and Ireland. Most participants (75.6%) stated that their workload had decreased and their productivity dropped. 86/135 (63.7%) were given the option of working from home and 36% of those who did reported improved efficiency. Multidisciplinary team meetings largely moved to virtual platforms (77.8%) with fewer members present (41.5%). Online education, including webinars and courses, was utilised by 92.6%. 16.3% of pathologists reported shortages of masks, visors or gowns as the the most common health and safety concern. COVID-19 had a significant negative impact on the physical and mental health of 33.3% of respondents. A small number of pathologists (10.4%) were redeployed and/or retrained. CONCLUSION: The UK and Ireland breast pathologists adapted to the rapid change and maintained service delivery despite the significant impact of the pandemic on their working practices and mental health. It is important to apply flexible working patterns and environments that improve productivity and well-being. The changes suggested should be considered for long-term shaping of breast pathology services.

The Impact of COVID-19 on Sleep in Autistic Adults: Longitudinal Comparisons pre and During Lockdown.

Background: The longer-term impact of the pandemic on autistic adults' sleep are yet to be revealed, with studies concentrating on sleep in autistic children or mental health outcomes and coping strategies of autistic adults. Given the prevalence of sleep problems experienced by autistic adults and the changes in routine that have occurred as a result of COVID-19 societal restrictions, this study assessed the impact of the COVID-19 pandemic on sleep problems via a longitudinal subjective assessment method. Methods: Sleep data were gathered at three time points from 95 autistic adults, namely prior to the pandemic, at the start of COVID-19 and several months into COVID-19 to obtain a rich longitudinal dataset ascertaining how/if sleep patterns have changed in autistic adults over these several months. Results: In comparison to pre-lockdown, several sleep components were shown to improve during the lockdown. These improvements included reduced sleep latency (time taken to fall asleep), longer sleep duration, improved sleep efficiency, improved sleep quality, as well as improved daytime functioning. Pre-sleep cognitive arousal scores were found to decrease compared to pre-lockdown, meaning cognitive arousal improved. Approximately 65% of participants reported that they felt their sleep had been impacted since COVID-19 since Time 1, with the most common reasons reported as waking up exhausted (36.92%), not being able to get to sleep (33.85%), waking up in the night (29.23%), having a disrupted sleep pattern (27.69%), and nightmares (18.46%). Conclusions: Improvements in sleep may be related to societal changes (e.g., working from home) during the pandemic. Some of these changes are arguably beneficial for autistic adults in creating a more autism-inclusive society, for example telehealth opportunities for care. Further exploration of the associations between mental health and sleep are warranted.

Anxiety, Insomnia, and Napping Predict Poorer Sleep Quality in an Autistic Adult Population.

Autistic adults have a high prevalence of sleep problems and psychiatric conditions. In the general population sleep problems have been associated with a range of demographic and lifestyle factors. Whether the same factors contribute to different types of disturbed sleep experienced by autistic adults is unknown and served as the main aim of this study. An online survey was conducted with 493 autistic adults. Demographic information (e.g., age, gender), about lifestyle (e.g., napping), and information about comorbid conditions was collected. The Pittsburgh Sleep Quality Index (PSQI) was used to assess sleep quality and the Epworth Sleepiness Scale (ESS) was used to assess daytime somnolence. Stepwise multiple regression analyses were used to examine predictors of each subscale score on the PSQI, as well as PSQI and ESS total scores. Results indicated that individuals who reported having a diagnosis of anxiety and insomnia were more likely to have poorer sleep quality outcomes overall. Furthermore, individuals who reported habitually napping had higher daytime dysfunction, increased sleep disturbances, and increased daytime sleepiness. These results provide novel insights into the demographic and lifestyle factors that influence sleep quality and daytime somnolence in autistic adults and can be used for targeted sleep interventions.

The treatment of sleep problems in autistic adults in the United Kingdom.

LAY ABSTRACT: Sleep problems are one of the most common complaints by autistic adults. This study aimed to report the perspectives of autistic adults on treatment of their sleep problems; 288 autistic adults living in the United Kingdom completed an online survey which assessed their sleep quality. We also gathered data on experiences and preferences of sleep treatment with UK healthcare professionals and their experiences of self-management of their sleep; 58% of autistic adults never had a visit with a healthcare professional regarding their sleep problem, despite 90% meeting the criteria for poor sleep quality. Some of those who attended a consultation for their sleep were prescribed medication (72%), but 60% were not satisfied with the outcome. The participants also reported that sleep self-management was not effective (80%); 41% reported a preference for non-medication including education, advice and talking therapies for sleep treatment. This report highlights the need for a fundamental shift in treatment of sleep problems in autistic adults. The current treatments are not resolving sleep issues; hence, it is imperative to develop management strategies that considers autistic adults' preferences, reduces sleep problems and thus improves quality of life for autistic adults.

Sleep Disturbances and Patterns in Children With Neurodevelopmental Conditions.

Background: Children with neurodevelopmental conditions (NDC) often experience sleep problems which are long-lasting and more complex than typically developing children. These sleep problems impact their families and there is little guidance for management specifically for sleep for families of children with neurodevelopmental conditions. The present study aims to use parental report to evaluate sleep disturbances and sleep patterns in a large sample of children with NDC. We aim to identify associations with age, diagnosis, and medication groups. Methods: Data on 601 children aged between 2 and 17 years was analyzed from a UK non-profit service for sleep for families of children with NDC. Parents/carers completed the children's sleep habit questionnaire, a 7 day sleep diary, and information on child age, diagnosis, and medication. Parents also reported previous sleep management techniques they had tried. Results: Overall, we found differences between age, diagnosis, and medication use groups for sleep disturbances and sleep diary parameters in these populations. Sensory conditions were associated with high night time waking duration. Parents reported their child's short sleep duration was the most common problem for them. Conclusions: Key areas for further research are outlined including the long term considerations for parental presence at bedtime for sleep anxiety, melatonin use and efficacy, and consideration for interventions to reduce daytime fatigue in children aged 7-11 years old.

A review of indications and comorbidities in which warfarin may be the preferred oral anticoagulant.

WHAT IS KNOWN AND OBJECTIVE: Direct oral anticoagulants (DOACs) are increasingly prescribed instead of warfarin for chronic anticoagulation for ease of dosing, fewer interactions, and less stringent monitoring. However, it is important to consider indications and comorbidities for which warfarin is still the preferred anticoagulant. This review aims to capture these clinical scenarios in which warfarin may still be preferred over DOACs. METHODS: We undertook a comprehensive literature search using the PubMed database. Key search terms were based on DOAC clinical trial exclusion criteria, as well as indications and conditions in which the use of DOACs for anticoagulation has suggested harm. Society guidelines and tertiary literature were used to inform expert opinion where necessary. Studies were included if they investigated the use of DOACs or warfarin in the identified indications or conditions. RESULTS AND DISCUSSION: Currently, evidence for the use of warfarin over DOACs for anticoagulation is strongest for patients with prosthetic valves, antiphospholipid syndrome, or a high risk of gastrointestinal bleeding. For several clinical situations, including mitral stenosis, obesity, altered gastrointestinal anatomy, pulmonary arterial hypertension, renal or hepatic impairment, and left ventricular thrombus, evidence is lacking but may eventually support the use of DOACs. Depending on indication and condition, appropriateness of DOAC use may vary by agent. WHAT IS NEW AND CONCLUSION: New evidence continues to support new indications and conditions in which DOACs may be appropriate to use for anticoagulation. There are key clinical scenarios, however, in which emerging literature continues to support warfarin as the preferred anticoagulant.

A single-institution review of image-guided brachytherapy for vaginal malignancies using customized molded applicators and interstitial needles.

PURPOSE: To review a single-institution's pattern of practice, dosimetry results, and clinical outcomes for patients with unresectable malignancies of vagina, vulva, or urethra, receiving brachytherapy using customized vaginal moulds with or without interstitial needles. MATERIAL AND METHODS: Twenty-one consecutive patients were reviewed. Patients were treated using customized moulds with or without interstitial needles, implanted with a free-hand technique. Technical implementation, such as type of implant and imaging used were recorded. D90 and D98 of clinical target volume (CTV), D0.1cc of urethra, and D2cc and D0.1cc of bladder and rectum were analyzed. Any adverse clinical outcomes were reported. RESULTS: Eleven patients experienced endometrial cancer recurrences, one a cervical cancer recurrence and nine vaginal or peri-urethral primary disease. After a median follow-up of 3.5 years, local control was achieved in 14 patients (67%). Median D98 and D90 to CTV was 73.7 Gy and 78.3 Gy, respectively. One patient died from disease progression, one developed distant metastasis, and seven failed locally. Median D2cc to bladder was 64.8 Gy, with low-grade toxicity reported. Median D2cc to rectum was 62.9 Gy, with low-grade toxicity and one case of rectal proctitis was observed. Median urethral D0.1cc was 66 Gy, with no toxicity reported. One patient suffered from a sacral insufficiency fracture. It was presumed that vaginal mucosa proximal to CTV received the total dose, with two patients developing vaginal ulcers, which both resolved; 10 patients reported mild telangiectasia, fibrosis, or stenosis. CONCLUSIONS: A review of patients treated with a customized vaginal mould and interstitial needles showed acceptable doses to CTV, with local control achieved in 67% of patients, and reasonable doses to organs at risk (OARs) and acceptable toxicity.

Pain and Fatigue in Patients With Ankylosing Spondylitis Treated With Tumor Necrosis Factor Inhibitors: Multinational Real-World Findings.

BACKGROUND/OBJECTIVE: Patients with ankylosing spondylitis (AS) experience symptoms and comorbidities that impact their health-related quality of life (HRQoL) and ability to work. This real-world, global survey was conducted among AS patients receiving tumor necrosis factor inhibitors (TNFis) to evaluate both the frequency and severity of persistent symptoms, and the impact of pain and fatigue on HRQoL, employment status, and work activity. METHODS: Patients with AS and their treating physicians from 13 countries across 5 continents completed questionnaires capturing demographics, patient symptoms, current disease status, HRQoL, current therapy, employment status, and Work Productivity and Activity Impairment. RESULTS: Seven hundred five patients who had been receiving a TNFi for 3 months or more and completed both Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) pain and fatigue domains were included in the analysis; of these, 37.6% reported high BASDAI pain scores and 41.3% high BASDAI fatigue scores. Medical Outcomes Study-Short Form, 36-item version 2 domain, 5-dimensional EuroQoL Questionnaire, and 5-dimensional EuroQoL visual analog scale scores were significantly lower (p < 0.0001), and Work Productivity and Activity Impairment scores significantly higher (p < 0.0001), in patients with high levels of pain or fatigue than low levels. CONCLUSIONS: Globally, levels of pain and fatigue remained high in AS patients receiving TNFi treatment, which were significantly associated with reduced HRQoL and work productivity. Such persistent symptoms in usual care suggest a substantial unmet need in AS pharmacologic and nonpharmacologic therapeutic pathways.

Relationship of pain and fatigue with health-related quality of life and work in patients with psoriatic arthritis on TNFi: results of a multi-national real-world study.

BACKGROUND/OBJECTIVE: The incidence of pain and/or fatigue in people with psoriatic arthritis (PsA) is associated with reduced health-related quality of life (HRQoL) and the ability to work, despite modern advanced therapeutic approaches. This real-world, international study examined these relationships in patients with PsA treated with tumour necrosis factor inhibitors (TNFi). METHODS: Data from 13 countries were analysed. Patients with PsA and their physicians completed questionnaires capturing demographics, current therapy, current disease status, HRQoL and work status via Medical Outcomes Study 36-Item Short-Form version 2 (SF-36v2), 3-level 5-dimension EuroQoL questionnaire, Health Assessment Questionnaire Disability Index, and Work Productivity and Activity Impairment (WPAI) questionnaire. RESULTS: 640 patients with PsA were included who had been receiving TNFi for ≥3 months and had completed SF-36v2 bodily pain and vitality domains. Of these, 33.1%, 29.2% and 37.7% of patients reported no, moderate and severe pain, respectively, and 31.9%, 22.5% and 45.6% of patients reported low, moderate and severe fatigue, respectively. Scores across HRQoL variables and WPAI were significantly different across pain and fatigue cohorts (all p<0.0001), with HRQoL and WPAI measures considerably worse in patients with moderate to severe pain or fatigue than those with low pain or fatigue. CONCLUSIONS: Despite treatment with biologic agents such as TNFi, data from this global study demonstrated that substantial pain and/or fatigue persist in patients with PsA and that these are significantly associated with reduced HRQoL, physical function and work productivity. These findings suggest that there is an unmet need for additional PsA therapies.

Biologic Disease-Modifying Antirheumatic Drug Prescription Patterns Among Rheumatologists in Europe and Japan.

INTRODUCTION: Tumor necrosis factor inhibitors (TNFi) are commonly used as first-line therapy (biologic disease-modifying antirheumatic drug [bDMARD] and targeted synthetic DMARD [tsDMARD]: defined as targeted therapy) for patients with moderate-to-severe rheumatoid arthritis (RA), usually combined with conventional synthetic DMARDs (csDMARDs) but sometimes as monotherapy. If treatment fails, patients cycle to another TNFi (cycling) or switch to a targeted therapy with a different mode of action (MOA; switching). The study aimed to examine prescribing patterns and reasons for current RA treatment practice in Europe (EU5: France, Germany, Italy, Spain, UK) and Japan. METHODS: Data were collected from the Adelphi Disease Specific Programme™ (DSP; Q1-Q2 2017). Rheumatologists seeing ≥ 10 (EU5) and ≥ 5 (Japan) patients with RA a month completed Patient Record Forms. Patients ≥ 18 years old, with RA diagnosis and complete RA-targeted therapy history were included. Patients were grouped based on first-line targeted therapy class, and on whether first-line targeted therapy was monotherapy (targeted therapy alone) or combination therapy (targeted therapy and csDMARD). Those patients receiving TNFi at first-line and with ≥ 1 targeted therapy were classified as TNFi cyclers or MOA switchers. Univariate analysis compared factors across groups. Patient demographics and characteristics compared across groups; physician reasoning for targeted therapy change; and time to discontinuation of targeted therapy. RESULTS: In EU5 and Japan, respectively, 1741 and 147 patients were included; at first-line, 80.8% and 64.6% received TNFi and 76.0% and 77.6% received combination therapy. Overall in EU5, more combination therapy than monotherapy patients reached maximum csDMARD dose before first-line targeted therapy (P < 0.05); disease severity was higher in patients initiating TNFi versus non-TNFi (P < 0.05). In Japan, trends were similar but not significant. The most common reason physicians gave for changing therapy following first-line targeted therapy was 'secondary lack of efficacy' (EU5: 46.2%; Japan: 53.8%). In EU5 and Japan, respectively, of 365 and 22 patients who received second-line targeted therapy, 52.1% and 54.5% were MOA switchers. In EU5, TNFi cyclers had longer time from diagnosis to second-line targeted therapy initiation than MOA switchers (P = 0.04). CONCLUSIONS: TNFis were the most commonly prescribed targeted therapy at first-line. Between 10 and 20% of patients prescribed a TNFi as first-line targeted therapy did so without concomitant csDMARD. Almost half of patients cycled to another TNFi at second-line.