SARS-CoV-2 variant proportions in a population can be estimated through genomic sequencing of clinical specimens or wastewater samples. We demonstrate strong pairwise correlation between statewide variant estimates in Oregon, USA, derived from both methods (correlation coefficient 0.97). Our results provide crucial evidence of the effectiveness of community-level genomic surveillance.
Background:Psoriatic arthritis (PsA) is a chronic inflammatory arthritis characterized by joint and entheseal inflammation seen in 30% patients with psoriasis (Pso). In 90% of patients, Pso precedes PsA. Inhibitors of tumor necrosis factor (TNFi) are efficacious treatment options for both, though whether they prevent development of incident PsA in Pso patients is unknown.Objectives:To determine if the use of TNFi reduces the risk of developing psoriatic arthritis in Pso patients compared to those treated with methotrexate alone.Methods:Records on all Pso patients seen at dermatology clinic at our University from January 2006 - June 2019 were reviewed. Patients with any musculoskeletal symptoms were referred to rheumatology and were considered to have PsA if they were diagnosed by a rheumatologist. We used Student’s t-test to compare continuous covariates and Pearson’s chi-squared test or Fisher’s exact test to compare categorical covariates. Variables that were found to be significantly associated with PsA diagnosis were included as potential confounders in the multivariate model. We used Cox proportional hazards models to compare the risk of incident PsA diagnosis for those who initiated TNFi compared to those who initiated methotrexate. A propensity score of TNFi therapy compared to methotrexate therapy was calculated using variables associated with treatment choice and adjusted for in the model. Variables that were associated with both treatment choice and PsA risk were not included in the propensity score. We used backwards stepwise variable selection to build the final model.Results:Out of 154 Pso patients who did not have PsA at baseline, and were started exclusively on a TNFi or methotrexate during the study period,, 85 (55.2%) initiated methotrexate and 69 (44.8%) initiated a TNFi. Mean duration of therapy for those on TNFi was 3.95 (standard error: 0.50) years while mean duration of therapy for those on methotrexate was 1.93 years (standard error: 0.28). Mean follow-up time for those on TNFi was 5.18 years (standard error: 0.49) and for those on methotrexate was 2.71 years (standard error: 0.37) Seventy nine (51.3%) of the cohort were women. Thirty five (22.7%) of subjects developed PsA over the course of the study. After adjusting for propensity score, nail pitting, body surface area (BSA) involved in psoriasis, and depression, TNFi did not significantly reduce the risk of PsA as compared to methotrexate (HR: 0.68 [95% CI: 0.32, 1.41]).Conclusion:Use ofTNFi was not associated with a statistically significant decreased risk of incident PsA compared to methotrexate in this study, but a larger cohort with longer follow up will have better power to estimate the true association.Table 1.Characteristics of the psoriasis cohort starting exclusively TNFi or methotrexateIncident PsAn = 35PsA negativen = 119p-valueTreatment [n (%)]0.37TNFi18 (51.4)51 (42.9)Methotrexate17 (48.6)68 (57.1)Sex [n (%)]0.24Female21 (60.0)58 (48.7)Male14 (40.0)61 (51.3)Age [median (IQR)]47.0 (39.4, 59.7)48.9 (35.3, 61.7)0.71Pso manifestations [n (%)]Nail pitting27 (77.1)51 (42.9)<0.01Scalp psoriasis31 (88.6)105 (89.0)0.95Inverse psoriasis14 (40.0)37 (31.09)0.33BSA [median (IQR)]6 (3, 15)12 (5, 22)0.06BMI [median (IQR)]31.7 (25.9, 40.4)29.1 (26.3, 34.7)0.30Therapy duration (years)TNFi [median (IQR)]4.38 (1.34, 8.13)2.26 (0.76, 5.82)0.29Methotrexate [median (IQR)]2.44 (0.06, 3.44)0.94 (0.27, 2.39)0.43Disclosure of Interests:Noah Lininger: None declared, Sarah Siegel: None declared, Sonam Kiwalkar: None declared, Kevin Winthrop Grant/research support from: Bristol-Myers Squibb, Consultant of: AbbVie, Bristol-Myers Squibb, Eli Lilly, Galapagos, Gilead, GSK, Pfizer Inc, Roche, UCB, Alex Ortega Loayza Consultant of: Adviser board for Janssen, Atul Deodhar Grant/research support from: AbbVie, Eli Lilly, GSK, Novartis, Pfizer, UCB, Consultant of: AbbVie, Amgen, Boehringer Ingelheim, Bristol Myer Squibb (BMS), Eli Lilly, GSK, Janssen, Novartis, Pfizer, UCB, Speakers bureau: AbbVie, Amgen, Boehringer Ingelheim, Bristol Myer Squibb (BMS), Eli Lilly, GSK, Janssen, Novartis, Pfizer, UCB
Greater psoriasis disease severity is associated with higher prevalence of co-morbidities and differences in prescribing patterns. To understand effects caused by different therapies, researchers need to accurately account for disease severity. To address this gap in knowledge, using a gold standard for psoriasis severity, we developed and validated a score to predict severity in a large administrative database. Two registries, the Center for Excellence in Psoriasis and Psoriatic Arthritis (CEPPA) at Oregon Health & Science University (OHSU) and the Corrona national psoriasis registry, were linked with Medicare data for 2006-2017. Both direct linkage using social security number and probabilistic linkage utilizing date of birth, sex, dermatology provider name, and most recent dermatology encounter date were used to link data with Medicare. Registries were combined, and analyses limited to patients with !12 months of continuous Medicare coverage and !1 dermatologist-assigned psoriasis diagnostic code. Validated claims-based algorithms were used to identify potential covariates. Outcome was body surface area (BSA) dichotomized as mild (<3%) vs. moderate-to-severe (!3%). LASSO regression was used for variable selection with 0.15 cut-off. Model fit was assessed by classification error. Sixty-four CEPPA and 172 Corrona patients met eligibility criteria (Table 1). We developed an indirect score for psoriasis severity using diagnoses of anxiety, depression, diabetes, lower back pain, and psoriatic arthritis as well as adalimumab and phototherapy use, joint surgery, lipid testing, dermatology and outpatient visits, and gender. Our model correctly predicted moderate-to-severe BSA 74.6% of the time. Misclassification was non-directional with 6 false negatives and 9 false positives. Our psoriasis disease severity score using indirect measures of BSA may be a potential method for accurately controlling for disease severity in the analysis of administrative databases.
Objective: The true incidence and risk factors for secondary bacterial infections in coronavirus disease 2019 (COVID-19) remains poorly understood. Knowledge of risk factors for secondary infections in hospitalized patients with COVID-19 is necessary to optimally guide selective use of empiric antimicrobial therapy. Design: Single-center retrospective cohort study of symptomatic inpatients admitted for COVID-19 from April 15, 2020, through June 30, 2021. Setting: Academic quaternary-care referral center in Portland, Oregon. Patients: The study included patients who were 18 years or older with a positive severe acute respiratory coronavirus virus 2 (SARS-CoV-2) PCR test up to 10 days prior to admission. Methods: Secondary infections were identified based on clinical, radiographic, and microbiologic data. Logistic regression was used to identify risk factors for secondary infection. We also assessed mortality, length of stay, and empiric antibiotics among those with and without secondary infections. Results: We identified 118 patients for inclusion; 31 (26.3%) had either culture-proven or possible secondary infections among hospitalized patients with COVID-19. Mortality was higher among patients with secondary infections (35.5%) compared to those without secondary infection (4.6%). Empiric antibiotic use on admission was high in both the secondary and no secondary infection groups at 71.0% and 48.3%, respectively. Conclusions: The incidence of secondary bacterial infection was moderate among hospitalized patients with COVID-19. However, a higher proportion of patients received empiric antibiotics regardless of an identifiable secondary infection. Transfer from an outside hospital, baseline immunosuppressant use, and corticosteroid treatment were independent risk factors for secondary infection. Additional studies are needed to validate risk factors and best guide antimicrobial stewardship efforts.
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