John Robert Ward was one of the early academic rheumatologists in the United States. He was the founding father of rheumatology in the Intermountain West, the first Chief of the Division of Rheumatology in the Department of Internal Medicine at the University of Utah. Dr Ward became a national leader in the understanding and treatment of rheumatic disease. His foundational work established gold-standard techniques for the successful investigation of anti-rheumatic drugs. His leadership and scientific contributions clearly qualify him as a "giant in rheumatology."

IMPORTANCE Osteoarthritis (OA) is a major cause of disability in the US, with no approved treatments to slow progression, but animal models suggest that pulsed low-intensity ultrasonography (PLIUS) may promote cartilage growth. OBJECTIVE To evaluate the efficacy of PLIUS in providing symptom reduction and decreased loss of tibiofemoral cartilage thickness in patients with knee OA. DESIGN, SETTING, AND PARTICIPANTS A phase 2A, sham-controlled, parallel, double-blind randomized clinical trial was conducted at 2 Veterans Affairs hospitals in Salt Lake City, Utah, and San Diego, California, from May 22, 2015, to January 31, 2019. Data were analyzed from June 27, 2020, to October 20, 2020. Participants recruited through the US Department of Veterans Affairs (N = 132) with clinical and radiographic evidence of early knee OA were randomly assigned to receive PLIUS or a sham device, self-administered for 20 minutes daily over the medial compartment of the knee. All enrollees participated in a 4-week prerandomization sham run-in period, followed by a 48-week treatment period. Randomization was stratified by study site and Kellgren-Lawrence grades 1 (n = 15), 2 (n = 51). and 3 (n = 66). INTERVENTION Participants either received 48 weeks of PLIUS or sham ultrasonography. MAIN OUTCOMES AND MEASURES The trial incorporated 2 coprimary outcomes: symptomatic improvement assessed by Outcome Measures in Rheumatology Clinical Trials-Osteoarthritis Research Society International Responder Criteria (ie. met if either >50% improvement in pain and function with at least a 20% absolute improvement of at least 2 of the following 3 factors: improvement by at least 20% [pain, function, and patient global assessment] with at least a 10-mm absolute improvement), and cartilage preservation assessed as change in central medial femoral condyle cartilage thickness by magnetic resonance imaging. Intention-to-treat analysis was used. RESULTS The mean (SD) participant age was 63.6 (10.7) years and 119 were men (90.2%). The mean (SD) duration of OA symptoms was 13.4 (12.3) years. In the PLIUS group, 70.4% (95% CI, 58.2%-82.6%) of the participants experienced symptomatic improvement, compared with 67.3% (95% CI, 54.9%-79.7%) of participants in the sham group (P = .84); there was no statistically significant difference in response rates between the treatment groups, and the between-group rate difference of 3.1% (95% CI, -14.3% to 20.5%) did not meet the predefined 10% threshold for clinically significant symptomatic improvement from application of PLIUS. At 48 weeks of treatment, central medial femoral condyle cartilage thickness decreased by a mean (SD) of 73.8 (168.1) mu m in the PLIUS group and by 42.2 (297.0) mu m in the sham group. This 48-week mean change between the 2 groups did not reach statistical significance (P = .44), and the between-group 48-week difference of -31.7 mu m (95% CI, -129.0 mu m to 65.7 mu m) did not meet the predefined threshold. There were 99 nonserious adverse events in the PLIUS group and 89 in the sham group during the trial. No serious adverse events were deemed related to the study device. CONCLUSIONS AND RELEVANCE PLIUS, as implemented in this study, demonstrated neither symptomatic benefit nor a decrease in loss of tibiofemoral cartilage thickness in knee OA.

Although tumor necrosis factor inhibitors (TNFi) have favorably altered the treatment landscape for patients with axial spondyloarthritis (axSpA), there is limited data regarding TNFi persistence and reasons for discontinuation. This is an observational time-to-event study utilizing data collected for a prospective multiple-disease registry of US Veterans with axSpA treated with TNFi therapies and recruited over a 10 year period. Clinical, serological, and comorbid parameters were collected. Corporate Data Warehouse Pharmacy files provided courses of the 5 TNFi agents, and response to treatment was documented. Individual TNFi persistence was established utilizing univariate and multivariate Cox proportional models, and reasons for discontinuation were obtained by physician chart review. Two-hundred and fifty-five axSpA patients received 731 TNFi courses. A majority of patients (84.3%) had TNFi persistence at 12 months; 63.5% and 47.1% at 24 and 36 months, respectively. Compared to adalimumab, infliximab demonstrated greater persistence, certolizumab the least. Age, smoking status, BMI, comorbidity burden, inflammatory markers and HLA-B27 did not predict TNFi persistence or discontinuation. Stroke and peripheral arterial disease increased the probability of TNFi discontinuation. Secondary non-response (SNR) was the most common reason for discontinuation (46% of all courses); non-adherence (6%) and clinical remission (2%) were uncommon. Pain score at enrollment, myocardial infarction, African American race and inflammatory bowel disease (IBD) predicted TNFi response. While initial persistence of TNFi treatment was high, a large proportion of the patients discontinued initial TNFi therapy by 3 years, primarily due to loss of efficacy. While further research identifying potential predictors of TNFi discontinuation in axSpA is warranted, access to alternate disease-modifying therapies is needed.

Objective Observational research of axial spondyloarthritis (axSpA) is limited by a lack of methods for identifying diverse axSpA phenotypes in large datasets. Algorithms were previously designed to identify a broad spectrum of patients with axSpA, including patients not identifiable with diagnosis codes. The study objective was to estimate the performance of axSpA identification methods in the general Veterans Affairs (VA) population. Methods A patient sample with known axSpA status (n = 300) was established with chart review. For feasibility, this sample was enriched with veterans with axSpA risk factors. Algorithm performance outcomes included sensitivities, positive predictive values (PPV), and F1 scores (an overall performance metric combining sensitivity and PPV). Performance was estimated with unweighted outcomes for the axSpA-enriched sample and inverse probability weighted (IPW) outcomes for the general VA population. These outcomes were also assessed for traditional identification methods using diagnosis codes for the ankylosing spondylitis (AS) subtype of axSpA. Results The mean age was 54.7 and 92% were male. Unweighted F1 scores (0.59–0.74) were higher than IPW F1 scores (0.48–0.65). The full algorithm had the best overall performance (F1IPW 0.65). The Early Algorithm was the most inclusive (sensitivityIPW 0.90, PPVIPW 0.38). The traditional method using ≥ 2 AS diagnosis codes from rheumatology had the highest PPV (PPVIPW 0.84, sensitivityIPW 0.34). Conclusion The axSpA identification methods demonstrated a range of performance attributes in the general VA population that may be appropriate for various types of studies. The novel identification algorithms may expand the scope of research by enabling identification of more diverse axSpA populations.

Objective. Observational axial spondyloarthritis (axSpA) research in large datasets has been limited by a lack of adequate methods for identifying patients with axSpA, because there are no billing codes in the United States for most subtypes of axSpA. The objective of this study was to develop methods to accurately identify patients with axSpA in a large dataset. Methods. The study population included 600 chart-reviewed veterans, with and without axSpA, in the Veterans Health Administration between January 1, 2005, and June 30, 2015. AxSpA identification algorithms were developed with variables anticipated by clinical experts to be predictive of an axSpA diagnosis [demographics, billing codes, healthcare use, medications, laboratory results, and natural language processing (NLP) for key SpA features]. Random Forest and 5-fold cross validation were used for algorithm development and testing in the training subset (n = 451). The algorithms were additionally tested in an independent testing subset (n = 149). Results. Three algorithms were developed: Full algorithm, High Feasibility algorithm, and Spond NLP algorithm. In the testing subset, the areas under the curve with the receiver-operating characteristic analysis were 0.96, 0.94, and 0.86, for the Full algorithm, High Feasibility algorithm, and Spond NLP algorithm, respectively. Algorithm sensitivities ranged from 85.0% to 95.0%, specificities from 78.0% to 93.6%, and accuracies from 82.6% to 91.3%. Conclusion. Novel axSpA identification algorithms performed well in classifying patients with axSpA. These algorithms offer a range of performance and feasibility attributes that may be appropriate for a broad array of axSpA studies. Additional research is required to validate the algorithms in other cohorts.

BACKGROUND: Delays in treatment for inflammatory arthritis (IA) are associated with unfavorable outcomes, including impaired quality of life, irreversible joint damage, and disability. OBJECTIVE: To characterize treatment initiation patterns in veterans with newly diagnosed rheumatoid arthritis (RA), psoriatic arthritis (PsA), or ankylosing spondylitis (AS). METHODS: ICD-9/10-CM codes and natural language processing were used to identify incident cases of RA, PsA, or AS between January 1, 2007, and December 31, 2015, in patients enrolled in the Veterans Health Administration. Patterns of treatment initiation and nontreatment with disease-modifying antirheumatic drugs (DMARDs) were assessed in the 12-month follow-up period after the incident diagnosis. Outcomes included the percentage of veterans treated with a DMARD, the mean time to the initial DMARD after diagnosis, and the percentage of veterans who accessed rheumatology care before DMARD initiation. To assess outcomes over time, veterans were grouped by year of initial IA diagnosis. Additionally, outcomes were compared between nonbiologic and biologic DMARDs and among IA subtypes (RA, PsA, and AS). Groups were statistically compared with 95% confidence intervals. RESULTS: The population consisted of 12,118 IA veterans (9,711 RA, 1,472 PsA, and 935 AS), with 91.3% males and a mean age of 63.7 years. The percentage of veterans treated with ≥ 1 DMARD (nonbiologic or biologic) during the 12-month follow-up period increased from 48.8% in 2007 to 66.4% in 2015. In veterans diagnosed with IA in 2015, DMARD treatment was more common for PsA patients (72.9%) and RA patients (68.6%) than for AS patients (28.9%). In the subset treated with a DMARD within 12 months after diagnosis, the mean time to the initial DMARD after diagnosis did not change throughout the observation period (35.5 days for RA, 43.9 days for PsA, and 59.5 days for AS). Rheumatology specialty care was accessed by 87.4% of veterans treated with a nonbiologic DMARD and 92.2% of veterans treated with a biologic DMARD, in patients diagnosed in 2015. CONCLUSIONS: DMARD treatment rates during the initial 12 months after diagnosis increased between 2007 and 2015, but nontreatment remained common, particularly in veterans with AS. The time to treatment after diagnosis was stable over time; it was shortest for RA, intermediate for PsA, and longest for AS. DMARD treatment was uncommon in veterans who did not access rheumatology specialty care. DISCLOSURES: AbbVie Pharmaceuticals and Marriott Daughters Foundation funded this study via investigator-initiated grants. Data analyses were completed by investigators independent of AbbVie and Marriott Daughters Foundation. Walker, Clewell, and Douglas are employed by, and stockholders in, Abbvie. Halwani reports grants from BMS, Kyowa Hakko Kirin, Seattle Genetics, Roche-Genentech, Miragen, Immunedesign, Takeda, Amgen, Pharmacyclics, and Abbvie. The other authors have nothing to disclose.

Introduction/Objectives: Gender is an important patient characteristic that may be used to predict clinical presentation, disease progression, and therapeutic response. In recent studies, women with psoriatic arthritis (PsA) have reported less favorable function, increased fatigue, and decreased quality of life, compared to men. Less is known about gender differences with other patient-reported outcomes (PROs) such as pain and work limitations. Our purpose was to characterize gender differences in PROs in participants of the Utah Psoriasis Initiative (UPI) Arthritis Registry. Methods: In this cross-sectional study, PROs assessing pain, fatigue, quality of life, and function were compared between men and women enrolled in the UPI Arthritis Registry between January 2010 and November 2014. Work limitations were assessed in the subset of participants working for pay at the time of enrollment. Results: Participants included 115 men and 138 women. Women had less favorable PROs for pain, fatigue, patient-reported joint count, physical demands at work, work output, and function, as measured by both Health Assessment Questionnaire and the Psoriatic Arthritis Screening and Evaluation function subscale. Conclusions: Women experienced PsA differently than men, with higher fatigue, pain, work disability, and functional limitations. The etiology of the gender differences in PsA are unclear, and further research is indicated to better understand the role of hormones, gene expression, and other potential pathophysiologic differences between men and women.

Background: The product of Physician Global Assessment and Body Surface Area (PGA x BSA) is a new outcome measure for psoriasis severity and response to therapy. The objective of this study was to evaluate PGA x BSA as an alternative to Psoriasis Area and Severity Index (PASI) for psoriasis assessments. Methods: The relationship between PASI and PGA x BSA was assessed in a post hoc analysis of pooled data from the PRISTINE (NCT00663052) and PRESTA (NCT00245960) trials in patients with moderate-to-severe psoriasis who received etanercept 50 mg/week. Data were analyzed using Spearman and intra-class correlation coefficients, effect sizes, scatterplots, Bland-Altman plots, and Kappa statistics. Results: Spearman correlations at baseline, week 12, and week 24 were strong for PGA x BSA versus PASI (r=0.78, 0.87, and 0.90, respectively; all P<0.0001) as were intra-class correlations (0.76 [95% confidence interval 0.73-0.80], 0.80 [0.76-0.83], and 0.85 [0.82-0.87], respectively). The effect size was -1.53 for PASI and -0.94 for PGA x BSA (baseline to week 24). Scatterplots and Bland-Altman plots detected a trend across the range of measurement. Kappa statistics (at 12 and 24 weeks) between PASI50/75/90 and 50/75/90% improvement in PGA x BSA showed good agreement (0.58-0.69 at week 12 and 0.63-0.67, respectively; all P<0.0001). At baseline, the Spearman correlation coefficients were 0.96, 0.51, 0.19, and 0.17 for PGA x BSA versus BSA, PGA, Patient Global Assessment, and Dermatology Life Quality Index, respectively (all P<0.001). Conclusion: PGA x BSA has advantages over PASI for measuring moderate-to-severe psoriasis; it is intuitive, sensitive, and easy to use.

Background Big data research is important for studying uncommon diseases in real-world settings. Most big data studies in axial spondyloarthritis (axSpA) have been limited to populations identified with billing codes for ankylosing spondylitis (AS). axSpA is a more inclusive concept, and reliance on AS codes does not produce a comprehensive axSpA study population. The first objective was to describe our process for establishing an appropriate sample of patients with and without axSpA for developing accurate axSpA identification methods. The second objective was to determine the classification performance of AS billing codes against the chart-reviewed axSpA reference standard. Methods Veteran Health Affairs clinical and administrative data, between January 2005 and June 2015, were used to randomly select patients with clinical phenotypes that represented high, moderate, and low likelihoods of an axSpA diagnosis. With chart review, the sampled patients were classified as Yes axSpA, No axSpA or Uncertain axSpA, and these classification assignments were used as the reference standard for determining the positive predictive value (PPV) and sensitivity of AS ICD-9 codes for axSpA. Results Six hundred patients were classified as Yes axSpA (26.8%), No axSpA (68.3%), or Uncertain axSpA (4.8%). The PPV and sensitivity of an AS ICD-9 code for axSpA were 83.3% and 57.3%, respectively. Conclusions Standard methods of identifying axSpA patients in a large dataset lacked sensitivity. An appropriate sample of patients with and without axSpA was established and characterized for developing novel axSpA identification methods that are anticipated to enable previously impractical big data research.

To the Editor In a recent survey, 97.6% of responding anesthesia providers reported a shortage of ≥1 anesthetic drug.1 Drug shortages have increased >5-fold between 2005 and 2011.2 Nickerson and Chikumba3 point out that access to anesthetic medicines affects access to safe anesthetic care, in the United States and other high-income countries as well as in low- and middle-income countries. At the local level, the University of Utah Pharmacy and Anesthesia Departments have been working on ways to mitigate these shortages to minimize impact on patient care. One way to confront this shortage is to use high-concentration single-dose vials multiple times, which is allowable if the product is prepared within a sterile International Organization of Standardization 5 environment.4 An intravenous bolus of remifentanil provides profound but short-duration analgesia to facilitate brief, painful procedures, such as placement of retrobulbar blocks. The remifentanil package insert states that the reconstituted drug is stable for 24 hours at room temperature. From vials of remifentanil, the University of Utah Pharmacy prepares syringes of remifentanil 100 μg/mL for use by anesthesia providers. The unused syringes are disposed of daily. As a way to reduce demand on the pharmacist and reduce drug waste, thereby decreasing drug shortages, pharmacy personnel proposed evaluating the stability of reconstituted remifentanil when stored at room temperature, refrigerated, or frozen. Remifentanil (1 mg/mL lyophilized) was reconstituted with 0.9% sodium chloride to a concentration of 100 μg/mL in an International Organization of Standardization 5 environment. Aliquots were drawn into syringes and stored light protected at room temperature (22°C), refrigerated (4°C), or frozen (−18°C). Samples were analyzed by high-performance liquid chromatography on days 0, 1, 3, 9, 30, and 45. Inter- and intraassay precision and accuracy were adequately tested, with standard curves and quality control samples assayed on each testing day. Changes in drug concentration over time were mathematically computed for percentage change. Reconstituted remifentanil syringes stored at room temperature were stable for 45 days, with variation in drug concentration fluctuating from −1.5% to 3.5% over all testing days. The absolute concentrations were 99.8–104.9 μg/mL. Remifentanil syringes refrigerated displayed a drug concentration fluctuation from −0.2% to 4.9%, with absolute concentrations of 101.1–106.4 μg/mL. Remifentanil syringes stored frozen showed a drug concentration fluctuation of −0.8% to 2.9%, with absolute concentrations of 100.5–104.3 μg/mL (Table).Table.: Change in Drug Concentration Over Time as a Percentage of Day 0Regardless of storage condition, drug concentrations did not vary >5% for ≤45 days of storage. These data suggest that if prepared according to United States Pharmacopeia guidelines and stored refrigerated for short-term use or frozen for longer-term use, the drug concentration will remain within appropriate limits. This would decrease the usage cost for remifentanil, decrease demand on pharmacists for the daily preparation of syringes, and help alleviate shortage issues. Because of frequent drug shortages, it may be time to take a closer look at ways to prevent or combat these shortages, such as utilization of various storage methods. This also may translate into cost savings for the hospital and ultimately for the patient. Tatjana S. Bevans-Warren, PhD, CRNADepartment of AnesthesiologyUniversity of UtahSalt Lake City, Utah[email protected] Daniel O. Clegg Jr, PharmDDepartment of PharmacyUniversity of UtahSalt Lake City, Utah Derek J. Sakata, MDDepartment of AnesthesiologyUniversity of UtahSalt Lake City, Utah Christopher A. Reilly, PhDDepartment of Pharmacology/ToxicologyUniversity of UtahSalt Lake City, Utah

OBJECTIVE:Large database research in axial spondyloarthritis (SpA) is limited by a lack of methods for identifying most types of axial SpA. Our objective was to develop methods for identifying axial SpA concepts in the free text of documents from electronic medical records. METHODS:Veterans with documents in the national Veterans Health Administration Corporate Data Warehouse between January 1, 2005 and June 30, 2015 were included. Methods were developed for exploring, selecting, and extracting meaningful terms that were likely to represent axial SpA concepts. With annotation, clinical experts reviewed sections of text containing the meaningful terms (snippets) and classified the snippets according to whether or not they represented the intended axial SpA concept. With natural language processing (NLP) tools, computers were trained to replicate the clinical experts' snippet classifications. RESULTS:Three axial SpA concepts were selected by clinical experts, including sacroiliitis, terms including the prefix spond*, and HLA-B27 positivity (HLA-B27+). With supervised machine learning on annotated snippets, NLP models were developed with accuracies of 91.1% for sacroiliitis, 93.5% for spond*, and 97.2% for HLA-B27+. With independent validation, the accuracies were 92.0% for sacroiliitis, 91.0% for spond*, and 99.0% for HLA-B27+. CONCLUSION:We developed feasible and accurate methods for identifying axial SpA concepts in the free text of clinical notes. Additional research is required to determine combinations of concepts that will accurately identify axial SpA phenotypes. These novel methods will facilitate previously impractical observational research in axial SpA and may be applied to research with other diseases.

Objective. To evaluate the effect of access to and distance from rheumatology care on the use of disease-modifying antirheumatic drugs (DMARD) in US veterans with inflammatory arthritis (IA). Methods. Provider encounters and DMARD dispensations for IA (rheumatoid arthritis, psoriatic arthritis, and ankylosing spondylitis) were evaluated in national Veterans Affairs (VA) datasets between January 1, 2015, and December 31, 2015. Results. Among 12,589 veterans with IA, 23.5% saw a rheumatology provider. In the general IA population, 25.3% and 13.6% of veterans were exposed to a synthetic DMARD (sDMARD) and biologic DMARD (bDMARD), respectively. DMARD exposure was 2.6- to 3.4-fold higher in the subpopulation using rheumatology providers, compared to the general IA population. The distance between veterans’ homes and the closest VA rheumatology site was < 40 miles (Near) for 55.9%, 40–99 miles (Intermediate) for 31.7%, and ≥ 100 miles (Far) for 12.4%. Veterans in the Intermediate and Far groups were less likely to see a rheumatology provider than veterans in the Near group (RR = 0.72 and RR = 0.49, respectively). Exposure to bDMARD was 34% less frequent in the Far group than the Near group. In the subpopulation who used rheumatology care, the bDMARD exposure discrepancy did not persist between distance groups. Conclusion. Use of rheumatology care and DMARD was low for veterans with IA. DMARD exposure was strongly associated with rheumatology care use. Veterans in the general IA population living far from rheumatology sites accessed rheumatology care and bDMARD less frequently than veterans living close to rheumatology sites.

This study determined the degree of adherence to medications for glaucoma among patients refilling prescriptions in community pharmacies. Methods: Data abstracted from the dispensing records for 3615 adult patients (18 years or older, predominantly over 45) receiving glaucoma medications from two retail pharmacy chains (64 stores in total) were analyzed. From a 24-month historic data capture period, the 12-month levels of adherence were determined using standard metrics, the proportion of days covered (PDC) and the medication possession ratio (MPR). The overall 12-month mean PDC was only 57%, and the mean MPR was 71%. Using a criterion by which 80% coverage was considered satisfactory adherence, only 30% had satisfactory overall 12-month PDC coverage, and only 37% had satisfactory overall 12-month MPR coverage. Refill adherence increased with age and was highest in the 65-and-older age group (p < 0.001). Differential adherence was found across medication classes, with the highest satisfactory coverage seen for those taking alpha2-adrenergic agonists (PDC = 36.0%; MPR = 47.6%) down to those taking direct cholinergic agonists (PDC = 25.0%; MPR = 31.2%) and combination products (PDC = 22.7%; MPR = 31.0%). Adherence to glaucoma medications in the community setting, as measured by pharmacy refill data, is very poor and represents a critical target for intervention. Community pharmacists are well positioned to monitor and reinforce adherence in this population.

Foodstuffs have long been thought to affect health beyond just their supply of calories. Some have been used as a ‘dietary supplement’ to health and thereby aid patients with osteoarthritis. The evidence demonstrating the effectiveness of using dietary supplements to improve pain or protect the structure of the joint is not complete, but some preliminary conclusions are possible. This chapter is an inclusive review of the current published evidence for selected commonly recommended dietary supplements for the treatment of osteoarthritis. Among the dietary supplements, the most credible evidence continues to be for glucosamine, chondroitin sulphate, and their combination with additional evidence suggesting potential benefit for avocado soybean unsaponifiables, ginger, rose hip powder, and strontium. For most agents, systematic reviews are the best evidence thus far as large well-designed trials are uncommon. Some dietary supplements, especially combined glucosamine and chondroitin sulphate, may be helpful to reducing the pain of patients with osteoarthritis. Others may slow joint space narrowing of osteoarthritis particularly strontium and the combination of glucosamine and chondroitin sulphate although further evidence will be required to inform best practice.

p>Background: Fatigue is common in inflammatory arthritis (IA). Obstructive sleep apnea (OSA) causes fatigue and is common in IA. OSA and IA are associated with systemic inflammation, including elevated levels of tumor necrosis factor alpha (TNFα). Tumor necrosis factor inhibitors (TNFi) reduce musculoskeletal symptoms and fatigue in IA. The effects of TNFi on OSA are unknown. Our goal was to explore the relationships between TNFi, fatigue, and OSA in IA. Methods: Consecutive patients starting TNFi for IA and high risk for OSA were enrolled. OSA was assessed with the Apnea Hypopnea Index (AHI) and percent time below 90% oxygen saturation (%time < 90%). Fatigue was assessed with the Functional Severity Scale (FSS). Sleep was assessed with the Functional Outcome of Sleep Questionnaire (FOSQ). IA was assessed with the patient global assessment of arthritis (PGA). Parameters were compared before and after TNFi. Changes in OSA, sleep, and fatigue outcomes were adjusted for changes in the PGA. Findings: Eighteen participants completed the study between September 2011 and February of 2014. The mean age was 54 years. 72% were male. Before and after TNFi: mean AHIs were 12.5 and 13.1, respectively (p=0.97); mean %times < 90% were 29.5 and 35.4, respectively (p=0.18); and mean FSS scores were 43.1 and 41.3, respectively (p=0.08); mean FOSQ scores were 11.4 and 11.8, respectively (p=0.09). Conclusions: OSA parameters did not improve with TNFi, but there were statistically non-significant trends toward improvement in fatigue and sleepiness with TNFi.

Background Stewardship of antimicrobial agents is an essential function of hospital pharmacies. The ideal pharmacist staffing model for antimicrobial stewardship programs is not known. Objective To inform staffing decisions for antimicrobial stewardship teams, we aimed to compare an antimicrobial stewardship program with a dedicated Infectious Diseases (ID) pharmacist (Dedicated ID Pharmacist Hospital) to a program relying on ward pharmacists for stewardship activities (Geographic Model Hospital). Methods We reviewed a randomly selected sample of 290 cases of inpatient parenteral antibiotic use. The electronic medical record was reviewed for compliance with indicators of appropriate antimicrobial stewardship. Results At the hospital staffed by a dedicated ID pharmacist, 96.8% of patients received initial antimicrobial therapy that adhered to local treatment guidelines compared to 87% of patients at the hospital that assigned antimicrobial stewardship duties to ward pharmacists (P < .002). Therapy was modified within 24 hours of availability of laboratory data in 86.7% of cases at the Dedicated ID Pharmacist Hospital versus 72.6% of cases at the Geographic Model Hospital (P < .03). When a patient's illness was determined not to be caused by a bacterial infection, antibiotics were discontinued in 78.0% of cases at the Dedicated ID Pharmacist Hospital and in 33.3% of cases at the Geographic Model Hospital (P < .0002). Conclusion An antimicrobial stewardship program with a dedicated ID pharmacist was associated with greater adherence to recommended antimicrobial therapy practices when compared to a stewardship program that relied on ward pharmacists.