Depression and suicidality are well-described comorbidities in psoriasis (PSO). The prevalence of these comorbidities in psoriatic arthritis (PsA) and axial spondyloarthritis (axSpA) is less well described.
Objectives
To assess the prevalence of depression and suicidality in PsA and axSpA in the recent literature, and compare rates to PSO.
Methods
For PsA and axSpA, we evaluated the recent English-language literature identified through a PubMed search; we used a recent review and performed a targeted review of the period since the publication in order to establish the rates for PSO for comparison.1 Review articles were also examined to identify key publications.
Results
Rates of depression in PSO vary widely, depending on the outcome definition and method of ascertainment. Dowlatshahi et al. reported a pooled rate of 9.0–55.0%, with rates from the literature after the review period ranging from 9.0–39.8%. Rates for suicidality also varied widely, with 2.5–17.3% of patients (pts) reporting suicidal ideation. The limited data available provide ranges for depression in PsA of 3.4–28.6%, and in axSpA of 3.1–44.0%. The single study that differentiated between ankylosing spondylitis (AS) and non-radiographic (nr)-axSpA did not identify a difference between the two groups.2 Very limited data existed on suicidality in PsA and axSpA. For PsA, the incidence rates (IR) of suicidal ideation, attempts, and suicide per 1000 person-years in the UK were 0.4, 1.3, and <0.001, respectively;3 no prevalence data were identified. In a study in China, 2.5% of pts with axSpA reported a past suicide attempt,4 while a study in Turkey found 9.6% of pts with AS had thoughts of suicide in the past year, but without plans.5 Depending on the study, different definitions and tools were used to assess depression (eg. HADS, ICD9, antidepressant use), and even when the same tool was used, different cutoffs for defining depression were implemented (eg. cutoff for HADS ranged from ≥5 to ≥11), making comparisons across studies difficult. In a large observational study of AS with matched controls, the IR of depression per 1000 pt-years was 5.48 in AS versus 3.29 without AS, risk ratio 1.63.6
Conclusions
Although data are limited, rates of depression and suicidality in PsA and axSpA are comparable to those in PSO. Comparisons between studies and diseases are challenging due to a lack of standardized assessment tools and definitions of depression and suicidality. There are almost no data for nr-axSpA, which unlike AS has no gender predominance. Given that depression in PSO pts is more common in women,7 understanding the relative prevalence in AS versus nr-axSpA would be important. Generating additional data regarding the impact of depression and suicidality in PsA and axSpA should increase awareness among treating physicians.
References
Dowlatshahi EA. J. Invest Dermatol 2014;134:1542–51. Klic GE. Medicine (Baltimore) 2014;93:e337. Hagberg KW. Mod Rheumatol 2016;26:774–9. Chan CY. Int J Rheum Dis 2014; doi:10.1111/1756-185X.12456. Saygin C. Clin Exp Rheumatol 2015;33(6 Suppl 94):S30–5. Shen CC. J Rheumatol 2016;43:625–31. Lamb RC. Br J Dermatol 2016; doi:10.1111/bjd.14833.
Disclosure of Interest
A. Sheahan Employee of: UCB Pharma, R. Suruki Employee of: UCB Pharma, P. Taylor: None declared, V. Sloan Employee of: UCB Pharma
OBJECTIVE To determine the role of unit-based transmission that accounts for cases of early Clostridium difficile infection (CDI) during hospitalization for allogeneic stem cell transplant. SETTING Stem cell transplant unit at a tertiary care cancer center. METHODS Serially collected stool from patients admitted for transplant was screened for toxigenic C. difficile through the hospital stay and genotyping was performed by multilocus sequence typing. In addition, isolates retrieved from cases of CDI that occurred in other patients hospitalized on the same unit were similarly characterized. Transmission links were established by time-space clustering of cases and carriers of shared toxigenic C. difficile strains. RESULTS During the 27-month period, 1,099 samples from 264 patients were screened, 69 of which had evidence of toxigenic C. difficile; 52 patients developed CDI and 17 were nonsymptomatic carriers. For the 52 cases, 41 had evidence of toxigenic C. difficile on the first study sample obtained within a week of admission, among which 22 were positive within the first 48 hours. A total of 24 sequence types were isolated from this group; 1 patient had infection with the NAP1 strain. A total of 11 patients had microbiologic evidence of acquisition; donor source could be established in half of these cases. CONCLUSIONS Most cases of CDI after stem cell transplant represent delayed onset disease in nonsymptomatic carriers. Transmission on stem cell transplant unit was confirmed in 19% of early CDI cases in our cohort with a probable donor source established in half of the cases.
Abstract Objective To describe patients’ use of opioids in the year preceding and year following new diagnosis of ankylosing spondylitis (AS), psoriatic arthritis (PsA), or rheumatoid arthritis (RA), compared with patients without the/se diseases. Methods This study used US IBM ® MarketScan ® Commercial Claims and Encounters (CCAE) and Medicaid data and included three cohorts, comprised of incident cases of AS, PsA, or RA (2010–2017). Three matched comparator patients (without the incident disease) were selected for each patient within the disease cohort. Opioid use and appropriate treatment exposure (as defined by US guideline recommendations) in the 12-month baseline and follow-up periods were evaluated using descriptive analyses. Results Prevalence of claims for opioids was higher for disease cohorts vs. comparators in CCAE; 36.4% of patients with AS, 29.5% with PsA, and 44.4% with RA did not have any claim for guideline-appropriate therapy in follow-up. Prevalence of claims for opioids was also higher for disease cohorts vs. comparators in Medicaid; 30.6% of patients with AS, 36.6% with PsA, and 65.4% with RA did not have any claim for guideline-appropriate therapy in follow-up. Conclusions In patients with AS, PsA, or RA, there was high reliance on opioids at and around the time of diagnosis. Significant proportions of patients were not on appropriate treatment as defined by professional society post-diagnosis guidelines; this discordance between actual patient therapies and treatment recommendations may suggest a need for better awareness of appropriate pain management and treatment strategies in rheumatic diseases. Key Points • This study analysed opioid use among patients with ankylosing spondylitis (AS), psoriatic arthritis (PsA), or rheumatoid arthritis (RA), and adds to current knowledge by expanding beyond assessment of opioid use at diagnosis, to the year before and after diagnosis .• Opioid use was found to be highly prevalent in AS, PsA, and RA in the year prior to diagnosis and, interestingly, was still seen during the year after diagnosis .• Opioids are neither disease modifying, nor a targeted/recommended treatment for chronic autoimmune diseases. In addition to their association with significant economic costs, opioids are potentially hazardous and are not better than alternative treatments with superior safety profiles .• The reasons behind opioid prescribing patterns should be explored further to support movement to targeted therapies .
Introduction Rapid HIV serological tests are a cost-effective, point-of-care test among HIV exposed infants but cannot distinguish between maternal and infant antibodies. The lack of data on the timing of decay of maternal antibodies in young infants hinders the potential use of rapid tests in exposed infants. We aimed to determine the time to seroreversion for two commonly used rapid tests in a prospective cohort of HIV-exposed breastfeeding infants ages 3-18 months of life. Methods We collected data on the performance of two commonly used rapid tests (Determine and Unigold) in Malawi between 2008 and 2012 or at the University of North Carolina between 2014 and 2015. Time to seroreversion was estimated for both rapid tests using the Kaplan-Meier product limit estimator which allows for interval censored data. Results At 3 months of age, 3 % of infants had seroreverted according to Determine and 7 % had seroreverted according to Unigold. About one in four infants had achieved seroreversion by 4 months using Unigold, but only about one in twelve infants by 4 months when using Determine. More than 95 % of all infants had seroverted by 7 months according to Unigold and by 12 months according to the Determine assay. Discussion We show that the time of seroreversion depends greatly on the type of test used. Our results highlight the need for recommendations to specify the timing and type of test used in the context of infant HIV detection in resource-poor settings, and base the interpretation of test result on knowledge of time to seroreversion of the selected test.
Recent reports related to in utero exposure of marketed immunosuppressive biologics led to clinical recommendations to delay live vaccinations for infants due to the concern of reduced vaccine effectiveness and/or increased risk of vaccine‐related disease. These delays can increase the risk of children contracting vaccine preventable diseases, yet the alternative cessation of biologics during pregnancy may result in increased autoimmune disease activity for the pregnant person, raising complex benefit–risk (B‐R) considerations and trade‐offs. Our goal is to develop a conceptual framework for B‐R assessment based on the key benefits and risks pregnant people would consider for themselves and their children when continuing (vs. discontinuing) a biologic during pregnancy. The proposed framework defines the decision contexts, key domains and attributes for potential benefits, and risks of biologic use during pregnancy, informed by a literature review of indications for biologics and refined with key clinical stakeholders. The framework includes both the pregnant person taking the biologic and the infant potentially exposed to the biologic in utero , with potential benefit and risk domains and attributes for each participant. To advance this conceptual framework, there are considerations of potential biases and uncertainty of available data that will be imperative to address when quantifying the B‐R framework. For these reasons, we recommend the formation of a consortium to ensure development of a robust, validated framework that can be adopted in the healthcare setting.
Background: Based on clinical trial results, the World Health Organization recommends infant HIV testing at age 4–6 weeks and immediate antiretroviral therapy (ART) initiation in all HIV-infected infants. Little is known about the outcomes of HIV-infected infants diagnosed with HIV in the first weeks of life in resource-limited settings. We assessed ART initiation and mortality in the first year of life among infants diagnosed with HIV by 12 weeks of age. Methods: Cohort of HIV-infected infants in Kinshasa and Blantyre diagnosed before 12 weeks to estimate 12-month cumulative incidences of ART initiation and mortality, accounting for competing risks. Multivariate models were used to estimate associations between infant characteristics and timing of ART initiation. Results: One hundred and twenty-one infants were diagnosed at a median age of 7 weeks (interquartile range, 6–8). The cumulative incidence of ART initiation was 46% [95% confidence interval (CI), 36%, 55%] at 6 months and 70% (95% CI 60%, 78%) at 12 months. Only age at HIV diagnosis was associated with ART initiation by age 6 months, with a subdistribution hazard ratio of 0.70 (95% CI 0.52, 0.91) for each week increase in age at DNA polymerase chain reaction test. The 12-month cumulative incidence of mortality was 20% (95% CI 13%, 28%). Conclusions: Despite early diagnosis of HIV, ART initiation was slow and mortality remained high, underscoring the complexity in translating clinical trial findings and World Health Organization’s guidance into real-life practice. Novel and creative health system interventions will be required to ensure that all HIV-infected infants achieve optimal treatment outcomes under routine care settings.
Timely, accurate and affordable testing algorithms at point-of-care are critical for early infant HIV diagnosis and initiation of antiretroviral therapy in the postpartum period. We aimed to assess the utility of HIV rapid tests for young, breast-fed HIV-exposed infants in resource limited, high HIV burden settings.We collected data on the performance of 2 commonly used rapid tests (Determine and Unigold) in Malawi between 2008 and 2012 or at the University of North Carolina between 2014 and 2015. For each 3-month interval between ages 3 and 18 months, we calculated the sensitivity, specificity, positive and negative predictive values of each test compared with the HIV DNA/RNA PCR gold standard. We also assessed the utility of each rapid test to diagnose incident HIV infection during the breastfeeding period.Among 121 HIV-exposed infants who were negative at age 6 weeks, 21 (17.2%) became infected by 18 months. At 3 months of age, both rapid tests had minimal clinical value with specificity values of 7.0% [95% confidence interval (CI): 2.3-15.7] for Determine and 19.4% (95% CI: 11.1-30.5) for Unigold. Starting at age 6 and 9 months, the Unigold test could be used as a screening tool in the follow-up of HIV-exposed infants with specificity values of 83.7% (95% CI: 74.4-89.9) and 97.7% (95% CI: 94.6-99.7), respectively. Starting at age 12 months, the type of test became less important as both tests performed well in identifying HIV-free children, although both tests failed to detect some incident HIV infections.Updated guidelines for the use of rapid tests in young HIV-exposed children that explicitly take type of test and infant age into account are urgently needed to ensure optimal care for the 1.5 million HIV-exposed infants born annually.
