Pandemic lockdowns: who feels coerced and why? - a study on perceived coercion, perceived pressures and procedural justice during the UK COVID-19 lockdowns

BACKGROUND

This study examined perceptions of coercion, pressures and procedural injustice and how such perceptions influenced psychological well-being in those who experienced a UK COVID-19 lockdown, with a view to preparing for the possibility of future lockdowns.

METHODS

40 individuals categorised as perceiving the lockdown(s) as either highly or lowly coercive took part in one of six asynchronous virtual focus groups (AVFGs).

RESULTS

Using thematic analysis, the following key themes were identified in participants' discussions: (1) Choice, control and freedom; (2) threats; (3) fairness; (4) circumstantial factors; and (5) psychological factors.

CONCLUSIONS

As the first qualitative study to investigate the psychological construct of perceived coercion in relation to COVID-19 lockdowns, its findings suggest that the extent to which individuals perceived pandemic-related lockdowns as coercive may have been linked to their acceptance of restrictions. Preparing for future pandemics should include consideration of perceptions of coercion and efforts to combat this, particularly in relation to differences in equity, in addition to clarity of public health messaging and public engagement.

Developing a Pipeline of African Global Surgery Scholars

Global surgery is developing as new discipline in many countries. Global surgery primarily aims to improve access to quality surgery in low-and-middle Income countries (LMICs). Thus, ensuring appropriate LMIC representation and leadership in global surgery research, projects, and innovations, is essential. There is a paucity of pathways for students and young clinicians in LMICs to attain training in and exposure to global surgery research and projects. If equity in global surgery leadership and scholarship is truly desired, steps need to be taken to ensure that more students and young clinicians in LMICs are exposed to global surgery as an academic discipline and are offered pathways to practice and leadership. This paper explores ways of ensuring this through increased exposure, increased training and increased funding.

First Experience With Postoperative Transcranial Ultrasound Through Sonolucent Burr Hole Covers in Adult Hydrocephalus Patients

BACKGROUND

Managing patients with hydrocephalus and cerebrospinal fluid (CSF) disorders requires repeated head imaging. In adults, it is typically computed tomography (CT) or less commonly magnetic resonance imaging (MRI). However, CT poses cumulative radiation risks and MRI is costly. Ultrasound is a radiation-free, relatively inexpensive, and optionally point-of-care alternative, but is prohibited by very limited windows through an intact skull.

OBJECTIVE

To describe our initial experience with transcutaneous transcranial ultrasound through sonolucent burr hole covers in postoperative hydrocephalus and CSF disorder patients.

METHODS

Using cohort study design, infection and revision rates were compared between patients who underwent sonolucent burr hole cover placement during new ventriculoperitoneal shunt placement and endoscopic third ventriculostomy over the 1-year study time period and controls from the period 1 year before. Postoperatively, trans-burr hole ultrasound was performed in the clinic, at bedside inpatient, and in the radiology suite to assess ventricular anatomy.

RESULTS

Thirty-seven patients with sonolucent burr hole cover were compared with 57 historical control patients. There was no statistically significant difference in infection rates between the sonolucent burr hole cover group (1/37, 2.7%) and the control group (0/57, P = .394). Revision rates were 13.5% vs 15.8% (P = 1.000), but no revisions were related to the burr hole or cranial hardware.

CONCLUSION

Trans-burr hole ultrasound is feasible for gross evaluation of ventricular caliber postoperatively in patients with sonolucent burr hole covers. There was no increase in infection rate or revision rate. This imaging technique may serve as an alternative to CT and MRI in the management of select patients with hydrocephalus and CSF disorders.

SURG-40. SINGLE-STAGE RECONSTRUCTION FOLLOWING ONCOLOGIC RESECTION OF BRAIN TUMORS WITH SKULL INVASION

BACKGROUND: Craniectomies requiring skull reconstruction are indicated following oncological resection of masses involving the underlying brain and/or skull. Immediate cranioplasties have previously been performed using suboptimal hand-bending or molding techniques using ‘‘off – the – shelf’’ products. Today with computer – aided design, customized craniofacial implants have become widely available for personalized reconstruction of resected bone and soft tissue. We present the largest series to date of single stage reconstruction using alloplastic biomaterials in consecutive patient series with oversized customized implants.In total, 56 patients underwent resection of skull neoplasms and subsequent cranioplasty reconstruction using customized implants. The most common neoplasms were meningiomas (39%). The most common complications seen among patients were dehiscence – (7%), and extrusion of implant – (3.5%). There was no significant difference in the incidence of postoperative complications between patients who had postoperative chemotherapy/radiotherapy versus those that did not (22.2% versus 13.1%, P 0.39). One-year follow-up revealed acceptable cranial contour and symmetry in all 56 cases.

Patterns and characteristics of TB among key risk groups in Canada, 1993–2018

BACKGROUND: Canada has a low incidence of TB, although certain groups are disproportionately affected.OBJECTIVE: To describe and compare the epidemiology, trends and characteristics of TB in Quebec, Canada, among all patients reported during 1993–2018.METHODS: Demographics and risk factors were compared for the three groups accounting for most TB diagnoses reported in Quebec (foreign-born, Canadian-born non-Indigenous and Inuit). Average annual incidence and incidence rate ratios (IRRs) were estimated and compared using Poisson regression.RESULTS: Of 6,941 persons with a first episode of TB, 4,077 (59%) were foreign-born, 2,314 (33%) were Canadian-born non-Indigenous and 389 (6%) were Inuit. The average annual incidence for foreign-born, Canadian-born non-Indigenous and Inuit was respectively 17.0, 1.4 and 137.1 per 100,000 population. Compared to Canadian-born non-Indigenous, the IRR for foreign-born and Inuit was respectively 12.3 (95% CI 11.6–12.9) and 98.7 (95% CI 88.6–109.9). There was evidence of community transmission among the Inuit, with more than 80% of patients having a TB contact (2012–2018 data) and 65% (251/389) of diagnoses in those aged <25 years.CONCLUSION: Although TB rates among the Canadian-born non-Indigenous are extremely low, there are persistent and distinct TB epidemics among the foreign-born and Inuit. Tailored approaches to TB prevention and care are needed to address TB among high-risk populations in low TB incidence settings.

P-147 Cumulus cell co-culture in media drops does not improve in vitro maturation of vitrified warmed immature oocytes

Study question

Does co-culture with vitrified warmed cumulus cells (CC) in media drops improve in vitro maturation (IVM) of previously vitrified immature oocytes?

Summary answer

CC co-culture in this simple two-dimensional system does not improve IVM of vitrified warmed immature oocytes.

What is known already

Previous studies have shown improved IVM of fresh immature oocytes when co-cultured with cumulus cells in a three-dimensional (3D) matrix. However, scheduling and workload of embryologists would benefit from a simpler IVM approach, particularly in the setting of time-sensitive oncofertility oocyte cryopreservation cases. Although yield of developmentally competent mature (metaphase II, MII) oocytes is increased if IVM is performed before cryopreservation, it is unknown whether maturation of previously vitrified immature oocytes is improved following co-culture with CCs in a simple system not involving a 3D matrix.

Study design, size, duration

A randomized controlled trial was performed where 320 immature oocytes (160 GV and 160 MI) and autologous CC clumps were vitrified from 7/2020 to 9/2021. Upon warming, the oocytes were randomized to culture in IVM media with cumulus cells (+CC) or without cumulus cells (-CC) and then assessed for nuclear maturation using confocal microscopy and for cytoplasmic maturation following parthenogenetic activation.

Participants/materials, setting, methods

GV and MI oocytes were cultured in 25µL (SAGE IVM medium) for 32 and 20-22 hours, respectively. Oocytes with a polar body (MII) were randomized to confocal microscopy for analysis of spindle integrity and chromosomal alignment or parthenogenetic activation to assess cytoplasmic maturity. Wilcoxon rank sum tests for continuous variables and chi square or Fisher’s Exact test for categorical variables assessed statistical significance. Relative risks (RR) and 95% confidence intervals (CI) were calculated.

Main results and the role of chance

Patient demographic characteristics were similar for both GV and MI groups after randomization to +CC vs -CC. No statistically significant differences were observed between +CC versus -CC groups regarding the % MII from either GV [42.5% (34/80) vs 52.5% (42/80); RR 0.81 95% CI: 0.57-1.15] or MI [76.3% (61/80;) vs 72.5% (58/80); RR 1.05 95% CI: 0.88-1.26] oocytes. There was more parthenogenetic activation of GV-matured MIIs in the +CC group [92.3% (12/13) vs 70.8% (17/24)], but the difference was not statistically significant (RR 0.77 95% CI: 0.57-1.03). There was no difference for MI-matured oocytes [74.3% (26/35) vs 75.0% (18/24), CC+ vs CC-; RR 1.01 95% CI: 0.76-1.35]. No significant differences were observed between +CC vs -CC groups for parthenotes from GV-matured oocytes for cleavage [91.7% (11/12) vs 82.4% (14/17)] or blastulation (0% for both); or for MI-matured oocytes [cleavage: 80.8% (21/26) vs 94.4% (17/18); blastulation: 0% (0/26) vs 16.7% (3/18)]. Further, no significant differences were observed between +CC vs -CC for GV-matured oocytes regarding incidence of bipolar spindles [38.9% (7/18) vs 33.3% (5/15)] or aligned chromosomes [22.2% (4/18) vs 0.0% (0/15)]; or for MI-matured oocytes [bipolar spindle: 38.9% (7/18) vs 42.9% (2/28); aligned chromosomes: 35.3% (6/17) vs 24.1% (7/29)].

Limitations, reasons for caution

One person performed the vitrification, thaw, co-culture and parthenogenetic activation experiments so scheduling capacity required the culture duration to be shorter than the optimum of at least 36 hours. Small sample sizes for the parthenogenetic activation and confocal analyses limit reliability of definitive conclusions.

Wider implications of the findings

Warmed CCs and immature oocytes co-cultured in medium drops may not result in improvements in nuclear and cytoplasmic maturity, at least by the markers assessed here. Further work is required to assess the efficacy of this system given its potential to provide flexibility in a busy IVF clinic.

Trial registration number

not applicable

P-765 Association between oocyte retrieval technique and number of oocytes retrieved

Study question

Is there an optimal oocyte retrieval (OR) technique to retrieve a maximum number of oocytes and mature oocytes (MII)?

Summary answer

While certain OR techniques were associated with higher egg to follicle ratios, this did not correlate with more MII oocytes.

What is known already

While there are multiple studies assessing embryo transfer technique and associated outcomes, as well as practice committee guidelines on performing embryo transfers, there are no data on optimal OR techniques and associated outcomes. Studies have compared laparoscopic, transabdominal, transvesicular and transvaginal OR techniques, and transvaginal OR has become the standard of care. However, there are no data on the preferred transvaginal OR technique for retrieving the most oocytes and MII oocytes per follicle cohort.

Study design, size, duration

This was a retrospective study where nine attending physicians completed a survey on OR techniques. Responses were confirmed by fellow trainees not involved in the study who had worked with each physician for at least one year. Number of oocytes/follicle cohort, MIIs/follicle cohort and MIIs/oocytes retrieved (%MII) were assessed for each attending’s technique. Data were stratified by number of follicles on ultrasound on day of trigger (&lt;6, 6-10, &gt;10).

Participants/materials, setting, methods

The parameters evaluated: spatial plane in which the probe was held, direction of retrieval, order of retrieval (by follicle size, or not), retrieval of both large and very small follicles, re-sticking follicles, reversing the probe to retrieve the opposite side, and curetting the follicles or not. The technique with the highest outcome ratio was the referent technique. Adjusted relative risks were calculated controlling for BMI and infertility diagnosis.

Main results and the role of chance

Physicians had different survey responses, resulting in nine techniques, despite eight physicians training at the same institution. Patient demographics were equivalent between techniques. For &lt;6 follicles, three techniques resulted in significantly fewer oocyte/follicle (0.97 +/- 0.48, 0.95 +/- 0.66, and 0.90 +/- 0.41) compared to the top-performing technique (TPT) (1.11 +/- 0.55). There were no significant differences in MII/follicle or %MII. For 6-10 follicles, two techniques resulted in significantly fewer oocyte/follicle (0.95 +/- 0.39 and 0.93 +/- 0.35) compared to the TPT (1.06 +/- 0.42). A different technique had significantly higher %MII (0.77 +/- 0.19) compared to two other techniques (0.74 +/- 0.21 and 0.72 +/- 0.22) within the 6-10 follicle group. For &gt;10 follicles, two techniques resulted in significantly fewer oocyte/follicle (1.01 +/- 0.42 and 1.07 +/- 0.40) compared to the TPT (1.15 +/- 0.41). These two techniques also resulted in fewer MII/follicle (0.75 +/- 0.33 and 0.81 +/- 0.34) compared to the same TPT (0.87 +/- 0.34). There were no significant differences in %MII for this group. There was no consistent TPT across follicle number groups or for all outcome variables. The parameters most associated with TPT were re-sticking and curetting follicles.

Limitations, reasons for caution

While statistically significant, some outcome ratios are similar with wide confidence intervals, limiting the clinical significance of these outcomes. We did not evaluate pregnancy and live birth rates so the results from our study cannot be directly correlated to IVF success.

Wider implications of the findings

There does not appear to be a clear TPT, even for patients with few follicles. Providers who perform OR in a similar fashion to physicians at our institution should feel confident that they obtain equivalent oocyte yields as others.

Trial registration number

Not Applicable

Experiences of Multidisciplinary Working: Perspectives from the Wessex Ghana Stroke Partnership

INTRODUCTION

Substantial gaps remain in our understanding of stroke in Africa as well as in stroke care, practice and policy on the continent. The effective organization of preventative, therapeutic and rehabilitative stroke services continue to be challenging in many African countries.

METHODOLOGY

In this article we define the nature, function and benefits of effective multidisciplinary team (MDT) working. The experiences and perspectives of members of the MDT were collated by focus group discussions as well as individual and country specific contributions.

RESULTS

The experiences and perspectives of multidisciplinary team members from the United Kingdom and Ghana implementing these practices at the first stroke unit in Korle Bu Teaching Hospital, Accra, with a transparent discussion of successes and challenges faced throughout development of the service, is presented. MDT working has improved outcomes for patients and families who use the services, including encouraging better shared treatment planning and compliance. More stroke rehabilitation services are provided than previously, including greater self-management education and better secondary prevention care.

CONCLUSION

It is hoped that this article will provide an inspirational model for others working to provide stroke care in low-resource settings in Africa and worldwide.

Abstract CT158: Use of 4-demethyl-4-cholesteryloxycarbonyl-penclomedine (DM-CHOC-PEN) as therapy for advanced non-small cell lung cancer (NSCLC) involving the CNS

Background: 4-Demethyl-4-cholesteryloxycarbonylpenclomedine (DM-CHOC-PEN) is a poly-chlorinated pyridine cholesteryl carbonate that was designed to penetrate the blood brain barrier and be useful as therapy for brain tumors (IND 68,876). A 3-stage mechanism is proposed for drug entry into the CNS and into cancer cells via reversible binding with sialic acid on the surface of RBC’s; and transported into cancer cells with L-glutamine. DM-CHOC-PEN has a MOA via bis-alkylation of DNA @ N7-guanine and N4-cytosine. DM-CHOC-PEN has completed clinical trials involving sixty-four (64) adults and nineteen (19) adolescent/young adult subjects with advanced cancers. Long term survival, good qualities of life and minimal toxicities [AACR #1185, 2013; AACR #CT 129, 2019; AACR #CT152, 2021] have been reported. This update provides affirmation that the drug, previously described as a treatment for non-small cell lung cancer (NSCLC) involving the CNS, is well tolerated with continued durations of responses, no new toxicities, good survival and good quality of life. Primary aims of the previously reported DM-CHOC-PEN clinical trials were to assess clinical response and monitor toxicities/safety and verify the maximum tolerated doses (MTD) for the drug administered IV to subjects with cancer. Here is an update on the long term responses, tolerance and quality of survival in subjects with NSCLC involving the CNS.

Subjects & Methods: DM-CHOC-PEN was administered to adults (&gt; 18 y/o) with NSCLC involving the CNS that lacked genetic rearrangements or tumor targets and/or had failed standard therapies as a 3-hr IV infusion once every 21 days employing a verified 2-tiered MTD schedule: 85.8 mg/m2 for subjects with liver involvement and 98.7 mg/m2 for subjects with normal livers.

Results: Sixteen (16) adult subjects with NSCLC have been treated to date, which 11 had NSCLC (adeno/large cell carcinomas) involving the CNS that lacked genetic rearrangements, had no tumor targets, and/or had failed standard therapies. Seven of the 11 subjects with NSCLC involving the CNS also possessed cerebellar metastases. The drug was well tolerated with no Gr-3 toxicities. The most common Gr-2 adverse effects were reversible fatigue (17%), reversible vasogenic edema (9%) and nausea (9%). No drug associated neuro/psychological, hematological, cardiac or renal toxicities have been observed, nor have there been any drug associated deaths reported. The pK modelling and properties for the drug have been previously reported [AACR #1185, 2013] and continue to be confirmed. Eight (8) subjects with NSCLC involving the CNS responded to DM-CHOC-PEN with documented CR/PR (RECIST 1.1) and improved OS/QOL/PFS (Kaplan-Meier) lasting 8 - 82+ mos. with survivals of 25% at 34 mos., 50% at 10 mos. and 8% at 84+ mos.

Conclusion: DM-CHOC-PEN is a bis-alkylator of DNA that is safe at the dose levels described and has produced long term objective responses with manageable toxicities and improved quality of life in subjects with NSCLC involving the CNS lacking genetic rearrangements or tumor targets and/or had failed standard therapies. Complete data on subject responses and observed toxicities will be presented. Supported by NCI/SBIR grants - R43/44CA132257 and NIH NIGMS 1 U54 GM104940 - the latter supports the Louisiana Clinical and Translational Science Center, New Orleans, LA

Citation Format: Lee Roy Morgan, Roy S. Weiner, T. Mahmood, C. Gordon, M. Bhandari, AH Rodgers, ML Ware, Marc Matrana, Thomas M. Cosgriff, Philip Friedlander, J-J Zou. Use of 4-demethyl-4-cholesteryloxycarbonyl-penclomedine (DM-CHOC-PEN) as therapy for advanced non-small cell lung cancer (NSCLC) involving the CNS [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr CT158.

POS0189 EFFECT OF ATACICEPT ON RENAL FUNCTION IN PATIENTS WITH SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)

Background

Atacicept is a fusion protein that blocks B-lymphocyte stimulator and a proliferation-inducing ligand, which are increased in patients with SLE. APRIL-SLE was a double-blind, placebo-controlled, Phase 2 study that randomized patients with moderate-to-severe systemic lupus erythematosus (SLE) to atacicept 75 mg, atacicept 150 mg, or placebo twice-weekly for 4 weeks, then weekly for 48 weeks.

Objectives

The primary results of the APRIL-SLE study – the effect of atacicept compared to placebo in preventing new flares in patients with moderate-to-severe SLE – have been reported (Isenberg et al., 2013). We performed a post hoc analysis to describe the effect of atacicept compared to placebo on measures of renal function in patients with SLE; this effect has not been reported previously.

Methods

The APRIL-SLE study excluded patients with moderate to severe glomerulonephritis, as defined by either of the following: urinary protein/creatinine ratio (UPCR)>1 mg/mg and/or hematuria or a significant renal impairment as defined by estimated glomerular filtration rate (eGFR)<50 mL/min/1.73 m2. Patients with proteinuria and mild to moderate chronic kidney disease, as assessed by KDIGO criteria were eligible. UPCR and eGFR were measured at baseline, week 2, and then every 4 weeks until week 52. The median change from baseline to each of these timepoints was calculated for eGFR and UPCR using the Safety Analysis Set, comprised of all randomized patients who received at least 1 dose of study medication. Enrollment in the atacicept 150 mg group was discontinued prematurely due to 2 deaths from pneumonias. When treatment was discontinued, 62 of 144 patients in this group had completed 52 weeks of treatment; 27 other patients had already been withdrawn for various reasons; and, in the remaining 55 patients, treatment was stopped early as a safety precaution. Patients in the other two groups completed the protocol.

Results

In total, 111 patients in the placebo group, 112 patients in the atacicept 75 mg group, and 62 patients in the atacicept 150 mg group completed 52 weeks of treatment. The eGFR time course was stable for the atacicept groups compared to a 4.4% decline in the placebo group from baseline at week 52 (Figure 1 and Table 1). UPCR from baseline at week 52 declined in the atacicept groups and increased in the placebo group.

Table 1.

Median Percent Change from Baseline of Estimated Glomerular Filtration Rate (eGFR) and Proteinuria at Week 52 – Safety Analysis Set

VariablePlaceboAtacicept 75 mgAtacicept 150 mgeGFR (mL/min)n=110n=111n=62 bmedian-4.35-1.490.57UPCR (mg/mg)n=108n=108n=63median6.29-6.27-12.72UPCR (mg/mg) an=12n=15n=8median26.11-54.42-12.15

eGFR=estimated glomerular filtration rate; UPCR=urinary protein/creatinine ratio.

aAmong patients with screening UPCR ≥0.2 mg/mg.

bEnrollment in the atacicept 150 mg arm was discontinued prematurely (described in Isenberg et al., 2015).

Figure 1.

Median Change from Baseline in eGFR.

eGFR= estimated glomerular filtration rate; IQR=interquartile range

Conclusion

Results from this double-blind, placebo-controlled, Phase 2 study suggest a potential for improved renal function with atacicept treatment of patients with moderate-to-severe SLE.

References

[1]Isenberg D, Gordon C, Licu D, Copt S, Rossi CP, Wofsy D. Efficacy and safety of atacicept for prevention of flares in patients with moderate-to-severe systemic lupus erythematosus (SLE): 52-week data (APRIL-SLE randomised trial). Ann Rheum Dis. 2015;74(11):2006-15. Erratum in: Ann Rheum Dis. 2016 May;75(5):946.

Disclosure of Interests

David Isenberg Consultant of: Professor Isenberg has consulted for Veratx, Servier, Astro-Zeneca, Idorsia, Merck Serono, and Amgen. His honoraria are passed onto a local arthritis charity., Celia J. F. Lin Shareholder of: Dr. Lin is an employee of Vera Therapeutics, Inc., Employee of: Dr. Lin is an employee of Vera Therapeutics, Inc., Amy Kao Shareholder of: Dr. Kao own stocks of Merck KGaA, Darmstadt, Germany, Employee of: Dr. Kao is an employee of EMD Serono Research & Development Institute, Inc (a business of Merck KGaA), Aida Arselan Aydemir Employee of: Ms. Aydemir is an employee of EMD Serono Research & Development Institute, Inc (a business of Merck KGaA), Caroline Gordon Speakers bureau: Dr. Gordon reports personal fees for speakers bureau from UCB, Consultant of: Dr. Gordon reports personal fees for honoraria from consultancy work from the Center for Disease Control and Prevention, Amgen, Astra-Zeneca, AbbVie, EMD Serono, MGP, Sanofi, and UCB, Grant/research support from: Dr. Gordon reports an educational grant from UCB to Sandwell and West Birmingham Hospitals NHS Trust that supported previous research work unrelated to any specific drug (last payment July 2019).

OP0237 DISTINCT IMMUNE NETWORKS STRATIFY ORGAN INVOLVEMENT AND RESPONSE TO B CELL TARGETED THERAPIES IN SYSTEMIC LUPUS ERYTHEMATOSUS

Background

The results from the double-blind BEAT-lupus trial comparing belimumab vs placebo, both after rituximab in systemic lupus erythematosus (SLE) have recently been reported (1). We sought to identify biomarkers of response to belimumab after rituximab to aid a personalised approach to therapy for SLE.

Objectives

To identify biomarkers of clinical response to belimumab after rituximab in the BEAT-lupus trial.

Methods

We constructed a model utilising a range of clinical, routine and exploratory laboratory data, from the BEAT-lupus trial to identify variables at baseline (screening) that could predict a major clinical response (MCR, defined as reduction to BILAG C in all domains, steroid dose of ≤7.5mg/day & SLEDAI≤2, without anti-dsDNA antibody component) at 52 weeks. Relevant serum autoantibodies and cytokines were assayed by ELISA/Simoa, and interferon signatures and BAFF expression measured by RT-PCR. A linear mixed model was applied to longitudinal data collected during the trial stratified by treatment and clinical response. An independent cross-sectional lupus cohort was recruited to validate biomarker association with organ involvement.

Results

A major clinical response (MCR) was achieved in 48% (10 responders, 11 non-responders) of patients who received belimumab after rituximab compared to 35% (8 responders, 15 non-responders) in the placebo group (i.e. rituximab alone), added to tapered standard of care, at 52 weeks. Baseline serum IgA2 anti-dsDNA antibody levels emerged as the only positive predictor of attaining MCR in belimumab treated patients (AUROC 0.8, 95% confidence interval [CI] 0.7-1.0), but negatively predicted MCR in the placebo arm (AUROC 0.2, CI 0.1-0.4). At baseline, 77% and 85% of patients were positive for serum IgA2 anti-dsDNA antibodies in belimumab and placebo arms respectively, which reduced to 30% at 52 weeks in the belimumab group but remained unchanged with placebo (Fisher exact test, p=0.007). In striking contrast, the percentage of patients who remained IgG anti-dsDNA antibody positive from baseline to 52 weeks were similar between the belimumab and placebo group, despite the serum levels significantly falling in the belimumab group (1). A significant reduction in serum IgA2 anti-dsDNA antibody levels at 24 and 52 weeks from baseline was only observed in belimumab responders (Figure 1).

Figure 1.

Percentage change in serum IgA2 anti-dsDNA antibody levels through to 52 weeks stratified by clinical response to belimumab (after rituximab) and placebo (after rituximab) at 52 weeks.

The number of circulating IgA2-secreting (but not total) plasmablasts (p=0.032) and T follicular helper cells (p=0.031) were significantly reduced at 52 weeks in the belimumab treated arm compared to placebo. Elevated serum IgA2 anti-dsDNA antibody levels were also associated with active renal disease irrespective of treatment arm (odds ratio, OR 3.2, CI 1.7-5.8, p<0.001). In contrast, serum IgA1 anti-dsDNA antibody (OR 1.3, CI 1.0-1.7, p=0.042) and interferon-alpha levels (OR 1.4, CI 1.0-2.0, p=0.041), and interferon transcriptional signature (OR 1.1, CI 1.0-1.3, p=0.027) showed a modest association with mucocutaneous disease activity; but did not predict response to B cell targeted therapy. Patients with a high baseline serum IL-6 were less likely to achieve an MCR irrespective of therapy (OR 0.4, CI 0.2-0.9, p=0.033). The associations between serum IgA2 and IgA1 anti-dsDNA antibody levels and active renal and mucocutaneous disease respectively were confirmed in an independent cross-sectional lupus cohort.

Conclusion

IgA2 anti-DNA autoantibodies is a biomarker of response to belimumab after rituximab, and of active renal disease, in systemic lupus erythematosus. Our study reveals distinct molecular networks associated with renal and mucocutaneous involvement, and response to B cell targeted therapies, which could guide precision targeting of current therapies for this heterogenous disease.

References

[1]Shipa M, et al. Annals of Internal Medicine. 2021;174:1647-57.

Acknowledgements

This research was supported by Versus Arthritis (grant number 20873) and the UCLH Biomedical Research Centre (BRC). GSK provided belimumab free of charge, as well as additional funding. GSK had no role in this research and did not have any role during its execution, analyses, interpretation of the data, or decision to submit results. Versus Arthritis and the UCLH BRC reviewed the relevant grant proposals and monitor progress of relevant aspects of the study but did not play any role in the analyses, interpretation of data, or decision to submit results.

Disclosure of Interests

Muhammad Shipa: None declared, Liliana Santos Ribeiro: None declared, Dao Nguyen: None declared, Andrew Embleton-Thirsk: None declared, Mariea Parvaz: None declared, David Isenberg Consultant of: Received consultancy fees from Astra Zeneca, Eli Lilly, Merck Serono, Servier and UCB., Caroline Gordon Speakers bureau: Speakers’ bureau for GSK and UCB, Consultant of: Consultancy work from the Center for Disease Control and Prevention, AbbVie, Amgen, Astra-Zeneca, EMD Serono, MGP, Sanofi and UCB, Grant/research support from: Educational grant from UCB to Sandwell and West Birmingham Hospitals NHS Trust, Michael Ehrenstein Speakers bureau: Speakers’ bureau for GSK, Consultant of: Consultancy work for GSK, Grant/research support from: Part of this research was supported by a grant from GSK to University College London

Radiotherapy Quality Assurance in the PORTEC-3 (TROG 08.04) Trial

AIMS

Quality assurance in radiotherapy (QART) is essential to ensure the scientific integrity of a clinical trial. This paper reports the findings of the retrospective QART assessment for all centres that participated in PORTEC-3; a randomised controlled trial that compared pelvic radiotherapy with concurrent chemoradiotherapy to the pelvis followed by adjuvant chemotherapy. The trial showed an overall survival benefit for the addition of the chemotherapy in the management of women with high-risk endometrial cancer.

MATERIALS AND METHODS

Clinicians were invited to upload a randomly selected case/s treated at each of the participating sites. Panel reviewers analysed the contours to certify that the target volumes and organ at risk structures were contoured according to guidelines. The results were categorised into acceptable, minor variation, major variation or unevaluable. The radiotherapy plans were dosimetrically evaluated using the well-established Trans-Tasman Radiation Oncology Group (TROG) protocol.

RESULTS

Between August 2010 and January 2018, data from 146 patients of 686 consecutively treated patients were retrospectively reviewed. All 16 Australia and New Zealand and 71 of 77 international centres uploaded data for evaluation. In total, 3514 dosimetric and contour variables were reviewed. Of these, 3136 variables were deemed acceptable (89.2%), with 335 minor (9.6%) and 43 major variations (1.2%). Major contour variations included the clinical target volume vaginal vault, clinical target volume parametria and differential planning target volume vault expansion.

CONCLUSION

The results of the QART assessment confirmed high uniformity and low rates of both minor and major deviations in contouring and dosimetry in all sites. This supports the safe introduction of the PORTEC-3 treatment protocol into routine clinical practice.

Meningitis following cerebrospinal fluid-cutaneous fistula secondary to combined spinal-epidural anaesthesia for elective caesarean delivery

Cerebrospinal fluid-cutaneous fistula is a rare complication associated with neuraxial procedures. Here, we describe a case of fistula formation related to combined spinal-epidural anaesthesia for elective caesarean delivery, where the epidural catheter was removed only two hours later. The clear fluid leaking persistently from the site of the skin puncture associated with the epidural insertion site was confirmed to be cerebrospinal fluid with an increased beta-trace protein, and the fistula was closed with skin sutures. Subsequently, the patient presented with neurological signs and symptoms consistent with meningitis and she was treated empirically with intravenous antibiotics. Cerebrospinal fluid-cutaneous fistula formation with secondary meningitis is an exceptionally rare event in obstetric anaesthesia.

695 Photo-otoscopy Audit: A Review of Change in Departmental Practice Due to COVID-19

Background

Photo-otoscopy is a new service set up during the COVID-19 pandemic, with the view to minimise unnecessary appointments, protect vulnerable patients, and optimise efficiency of ENT-outpatient appointments. The objectives are to assess rate of diagnostic photos and investigate how to improve this service.

Method

First cycle was performed between June and July and second cycle between October and December 2020. All patients attending Audiology who had a photo taken were included. Photos were analysed based on a number of variables to identify the proportion of diagnostic and non-diagnostic photos. First cycle highlighted a few changes to practice that were then instigated for second cycle.

Results

324 patients and 232 patients were included in first and second cycle respectively. 17 operators/audiologists were involved. There is slight improvement in percentage of diagnostic photos in second cycle compared to first (30.6% to 31.9% in right ear and 23.5% to 35.8% in left ear). Percentages of non-diagnostic photos with blurriness as sole reason have increased compared to first cycle. Percentages of non-diagnostic photos with all 3 variables present have reduced significantly. Mean percentage of acceptable photos per operator have also improved. 8 out of 10 ENT consultants/registrars found the service useful.

Conclusions

Rate of diagnostic photos remained low (<40%) despite implementation of changes to practice from first cycle. 38% of non-diagnostic photos were wax-related. There is significant variation in rate of diagnostic photos due to its operator-dependent nature. Given the expansion of telemedicine, there is definitely scope for future development for photo-otoscopy.

Novel radical pelvectomy technique to treat chondrosarcoma in a large-breed dog

Surgical management of chondrosarcoma with hemipelvectomy is well described, but there have been no reports on extensive excision involving bilateral pubis and unilateral ischium. This report describes a novel pelvectomy technique for the treatment of chondrosarcoma in a large-breed dog. A 12-year-old Labrador Retriever presented for tenesmus due to a large, intra-pelvic mass which was confirmed on computed tomography (CT). Surgery involved removal of the entire left ischium and both pubic bones with preservation of both hind limbs. Histopathology confirmed the diagnosis of a high-grade chondrosarcoma with tumour-free margins of less than 3 mm. The dog recovered well following surgery and regained ambulation within 9 days. Four months postoperatively, the dog had no ongoing pain or tenesmus and only a mild gait abnormality in the left hind limb. Pelvectomy involving the entire pubis and unilateral ischium was well tolerated in a large-breed dog. This technique may offer a novel surgical option to treat neoplasia previously considered too extensive for complete excision.

P–601 Anovulatory patients with PCOS have lower euploidy rates compared to those with hypothalamic amenorrhea and to normo-ovulatory patients

Study question

How do euploidy rates differ in anovulatory women with polycystic ovarian syndrome (PCOS) and hypothalamic hypogonadism (HH) compared to normo-ovulatory women undergoing IVF/ICSI?

Summary answer

Patients with PCOS have a significantly lower euploidy rate compared to patients with HH and patients with tubal factor infertility.

What is known already

Previous studies have demonstrated similar blastocyst conversion rates in women with PCOS and tubal factor infertility. Reported aneuploidy rates in preimplantation genetic testing cycles are similar in women with PCOS and tubal infertility. There are no data on blastocyst conversion or aneuploidy rates in women with HH. While PCOS and HH are different physiologic processes, patients with these disorders are reported together to SART and to the CDC National ART Surveillance System under the diagnosis of “ovulatory dysfunction”. Study design, size, duration: Retrospective cohort study of all autologous IVF and ICSI cycles for patients with oligo-anovulation (PCOS, n = 552 and HH, n = 48) and normo-ovulation (tubal factor infertility, n = 423) from 1/1/2012 to 6/30/2019. A total of 1023 cycles from 720 patients were analyzed.

Participants/materials, setting, methods

Cycle outcomes, including number of oocytes, mature oocytes, blastocysts and euploid blastocysts were assessed for each diagnosis. Adjusted relative risks (aRR) and 95% confidence intervals (CI) were calculated adjusting for age, BMI, AMH, and stimulation protocol. Poisson regression was used for counts and with an offset for ratios. Patients contributing multiple cycles were accounted for using general estimating equations.

Main results and the role of chance

PCOS patients were given a lower starting dose of gonadotropins and received less total gonadotropins compared to patients with tubal factor infertility or HH, but had similar stimulation durations as tubal-factor patients. Patients with HH received higher total doses of gonadotropins and had longer stimulation durations. PCOS patients had significantly more oocytes retrieved and a higher number of blastocysts than patients with tubal factor infertility (18.9 vs. 13.6 aRR 1.16 95% CI: 1.05–1.28 and 6.6 vs. 3.7 aRR 1.32 95% CI 1.10–1.57, respectively). Patients with HH had a similar number of oocytes retrieved and number of blastocysts compared to tubal factor patients. The blastocyst conversion rate was higher for PCOS than tubal (59.4% vs. 49.7%), but not significantly different (aRR 1.04 95% CI: 0.94–1.15). Blastocyst conversion and euploidy rates were similar for HH and tubal factor patients (51.9% vs. 49.7% and 39.1% vs. 44.9%, respectively, aRR 1.01 95% CI: 0.81–1.26 and aRR 1.05 95% CI: 0.85–1.31, respectively). In the adjusted model, patients with PCOS had a significantly lower euploidy rate than patients with tubal infertility (aRR 0.75 95% CI: 0.58–0.96). Patients with HH also had a significantly higher euploidy rate compared to women with PCOS (aRR 1.41 95% CI: 1.05–1.89).

Limitations, reasons for caution

This study is limited by its retrospective nature and the small sample size of women with hypothalamic hypogonadism. Additionally, these data represent outcomes from a single academic center, so generalizability of our findings may be limited.

Wider implications of the findings: Cycle outcomes differ for ovulatory dysfunction patients with PCOS as compared to those with HH. HH patients require higher total doses of gonadotropins and longer stimulations to achieve similar cycle outcomes as normo-ovulatory patients. While PCOS patients have more embryos, the percent of euploid blastocysts is lower.

Trial registration number

Not applicable

P–521 Association between maternal age and euploid blastocyst availability in cycles with less than four two-pronucleate zygotes

Study question

For patients with less than four two-pronucleate (2pn) zygotes, is there an age-cutoff above which preimplantation genetic diagnosis for aneuploidy (PGT-A) is futile?

Summary answer

Women over 40y with less than four 2pn zygotes should consider transfer of a day 3 embryo over culture to blastocyst with PGT-A.

What is known already

During a typical IVF cycle, there is unavoidable attrition from oocytes retrieved, to embryos obtained, to blastocysts formed such that some patients, particularly those with advanced age or poor ovarian response, may not have blastocysts available to biopsy. While randomized trials have shown improved pregnancy rates with the use of PGT-A in patients of advancing age, these trials primarily included patients with good ovarian reserve and multiple blastocysts available. The optimal age group within poor responders who would benefit most from PGT-A has yet to be determined.

Study design, size, duration

This was a retrospective cohort study of all fresh autologous IVF or IVF/ICSI cycles in which PGT-A was planned from 1/2012 to 3/2020. Only patients with less than four 2pn zygotes were included. A total of 85 cycles from 75 patients were analyzed.

Participants/materials, setting, methods

Number of cleavage-stage embryos, blastocysts, biopsy-quality blastocysts and euploid embryos were assessed, after stratification by age. Adjusted relative risks (aRR) and 95% confidence intervals (CI) were calculated adjusting for BMI, AMH, FSH, stimulation protocol, and ICSI. Poisson regression was used for counts. Generalized estimating equations were used to account for patients contributing multiple cycles.

Main results and the role of chance

There were no differences in number of 2pn zygotes (p = 0.98) or cleavage stage embryos (p = 0.94) across age groups. Patients aged 41–42y had a significantly lower number of blastocysts (1.18 vs. 2.00; aRR 0.59 95%CI: 0.37–0.95) and biopsy-quality blastocysts (0.73 vs. 1.53; aRR 0.50 95% CI: 0.26–0.98) compared to patients &lt;35y.These patients also had fewer euploid embryos available (0.09 vs 0.67), although the difference was not significant in the adjusted model (aRR 0.14 95% CI: 0.01–1.57). None of the patients &gt;42y had euploid blastocysts. When considering the mean and three standard deviations (0.09 [SD 0.3]), 99.7% of patients over 40y have no euploid embryo available for transfer.

Limitations, reasons for caution

This study was retrospective in nature and limited by small sample sizes when patients were stratified by age. A prospective randomized trial of patients with less than four 2pn zygotes to day 3 fresh embryo transfer vs PGT-A frozen embryo transfer is needed to confirm these findings.

Wider implications of the findings: Patients over 40y with less than four 2pn zygotes are at high risk of having no euploid blastocysts. While the literature demonstrates higher live birth rates with the use of PGT-A in women of advancing age, this is inconsequential if there is no embryo available to transfer.

Trial registration number

Not applicable

Objective and subjective reduction of cellulite volume using a localized vibrational massage device in a 24-week randomized intra-individual single-blind regression study

Cellulite occurs in females and is a common condition of altered connective tissue matrix and increased adipogenicity with visible dimples and orange‐peel appearance on the skins surface. Whilst advancements in methods continue to help our understanding, attempts to correct the appearance of cellulite topically have yielded limited success. Various kinds of non‐invasive body contouring methods such as whole body vibration have been reported with demonstrable visible improvements in the cellulite condition. The aim of this study was to evaluate volume reduction and improvement of the visible appearance of cellulite as judged both objectively (AEVA‐HE phase‐shift 3‐D fringe projection, macrophotography image grading) and subjectively (questionnaires) after application of a hand‐held localized vibrational device over 24‐weeks. The study was conducted on 40 healthy female volunteers who were instructed how to use the device on defined areas of cellulite of the outside and rear of the thighs (iliotibial band, and over biceps femoris region respectively). The initial 12 weeks of continuous massage application of the study were followed by a 12 week phase in which volunteers were split into 2 subgroups – one for assessment of regression effects and one for continuous application effects. AEVA (skin surface volume) measurements of cellulite‐related dimples correlated with questionnaires and visual image evaluation scoring, in that in the iliotibial region cellulite was significantly reduced at 12 weeks. In the regression subgroup cellulite returned to initial values soon after cessation of treatment, whereas in the continuous application subgroup, cellulite remained diminished. The effect of this device to reduce cellulite as observed in this study proves that continuous use of vibrational massage is beneficial to mitigate visible signs of cellulite.

Automated Implant Resizing for Single-Stage Cranioplasty

Patient-specific customized cranial implants (CCIs) are designed to fill the bony voids in the cranial and craniofacial skeleton. The current clinical approach during single-stage cranioplasty involves a surgeon modifying an oversized CCI to fit a patient's skull defect. The manual process, however, can be imprecise and time-consuming. This paper presents an automated surgical workflow with a robotic workstation for intraoperative CCI modification that provides higher resizing accuracy compared to the manual approach. We proposed a 2-scan method for intraoperative patient-to-CT registration using reattachable fiducial markers to address the registration issue caused by the clinical draping requirement. First, the draped defected skull was 3D scanned and registered to the CT space using our proposed 2-scan registration method. Next, our algorithm generates a robot cutting toolpath based on the 3D defect model. The robot then performs automatic 3D scanning to localize the implant and resizes the implant to match the cranial defect. We evaluated the implant resizing accuracy of the proposed paradigm against the resizing accuracy of the manual approach by an expert surgeon on two plastic skulls and two cadavers. The evaluation results showed that our system was able to decrease the bone gap distance by more than 60% and 30% on plastic skulls and cadavers respectively compared to the manual approach, indicating lower risk of post-surgical complication and better aesthetic restoration.

OP0289 LLDAS (LOW LUPUS DISEASE ACTIVITY STATE), LOW DISEASE ACTIVITY (LDA) AND REMISSION (ON- OR OFF-TREATMENT) PREVENT DAMAGE ACCRUAL IN SYSTEMIC LUPUS ERYTHEMATOSUS (SLE) PATIENTS IN A MULTINATIONAL MULTICENTER COHORT

Background:

Remission, LDA and LDAS have been proposed as treatment goals for SLE. However, the independent impact of these states on damage accrual has not been fully evaluated.

Objectives:

To determine the independent impact of remission (both off & on treatment), LDA, and LLDAS on damage accrual.

Methods:

We studied a long-term longitudinal multinational SLE cohort, including patients completing at least two annual assessments. Remission off-treatment was defined as a SLEDAI (excluding serology) =0, without prednisone and immunosuppressive (IS) drugs. Remission on-treatment was defined as a SLEDAI (excluding serology) =0, prednisone daily dose<=5 mg/d and maintenance IS drugs. LDA was defined as a SLEDAI (excluding serology) <=2, without prednisone or IS drugs. LLDAS was defined as a SLEDAI <=4 with no activity in major organ systems, with no new features of lupus disease activity compared to the previous assessment, prednisone daily dose<=7.5 mg/d and maintenance IS drugs. Antimalarials were allowed in all groups. Damage accrual was ascertained with the SLICC/ACR damage index (SDI). Univariable and multivariable generalized estimated equation (GEE) negative binomial regression models were used. To create mutually exclusive groups, disease activity was divided into five states: remission off-treatment, remission on-treatment (minus remission off treatment), LDA (minus remission), LLDAS (minus remission and LDA) and not-optimally controlled. The proportion of the time that patients were in the specific state at each visit since cohort entry was determined. Possible effect modifiers and confounders adjusted for included sex, age at diagnosis, race/ethnicity, education, baseline disease duration, follow-up time, the highest-ever glucocorticoid dose prior to cohort entry, antimalarials and SDI. Time-dependent covariates were determined at the same annual visit as disease activity state; the outcome was the increase in the SDI and it was assessed at the subsequent visit.

Results:

There were 1,652 patients, 1464 (88.6%) were female, mean age at diagnosis was 34.6 (SD 13.4) years and mean baseline disease duration was 5.5 (SD 4.1) months. Patients had a mean follow-up of 6.5 (SD 4.3) years, 11686 visits were included. 763 patients (46.2%) had an increase in SDI score ≥1 during follow-up. 2483 (21.2%) of the visits were classified as remission off-treatment, 2276 (19.5%) as remission on-treatment, 544 (4.7%) as LDA, 657 (5.6%) as LLDAS and 5726 (49.0%) as not-optimally controlled. Being in remission off-treatment, remission on-treatment, LDA and LLDAS were predictive of a lower probability of damage accrual [remission off-treatment IRR=0.403, 95% CI 0.301-0.541); remission on-treatment IRR=0.313 (95% CI 0.218-0.451) LDA: IRR=0.469 (CI 95% CI 0.272-0.809); LLDAS IRR=0.440 (95% CI 0.241-0.803)]. The multivariable model is summarized in Table 1.

Table 1.

Multivariable GEE model of the impact of disease activity states on damage accrual.

Incidence Rate Ratio95% CIDisease activity stateRemission off treatment0.4030.301-0.541Remission on treatment0.3130.218-0.451LDA0.4690.272-0.809LLDAS0.4400.241-0.803Gender, male1.2741.086-1.495Age at diagnosis1.0241.020-1.029EthnicityCaucasian USRef.Caucasian other1.0170.849-1.217African1.4671.211-1.776Asian0.8630.693-1.075Hispanic1.2661.034-1.550Other1.1210.759-1.656Educational level, years0.9770.957-0.996Disease duration at baseline0.9600.801-1.150Follow-up time0.9420.923-0.960Antimalarial use0.7860.681-0.908Highest prednisone dose before baseline1.0021.001-1.007SDI before1.1001.050-1.1152

LLDAS: Low lupus disease activity state LDA: Low disease activity SDI: SLICC/ACR Damage Index

Conclusion:

Remission on- and off-treatment, LDA and LLDAS were associated with less damage accrual, even adjusting for possible confounders and effect modifiers. This highlights the importance of treating to target in SLE.

Disclosure of Interests:

Manuel F. Ugarte-Gil Grant/research support from: Pfizer, Janssen, John Hanly: None declared, Murray B Urowitz: None declared, Caroline Gordon Speakers bureau: UCB, Consultant of: Center for Disease Control, Astra-Zeneca, MFP, Sanofi, UCB, Sang-Cheol Bae: None declared, Juanita Romero-Diaz: None declared, Jorge Sanchez-Guerrero: None declared, Sasha Bernatsky: None declared, Ann E Clarke Consultant of: AstraZeneca, BristolMyersSquibb, GlaxoSmithKline, and Exagen Diagnostics, Daniel J Wallace Grant/research support from: Exagen, David Isenberg: None declared, Anisur Rahman: None declared, Joan T Merrill: None declared, Paul Fortin: None declared, Dafna D Gladman Consultant of: Abbvie, Janssen, Pfizer, Novartis, Amgen, Grant/research support from: Abbvie, Janssen, Pfizer, Novartis, Amgen, Ian N. Bruce: None declared, Michelle A Petri: None declared, Ellen M Ginzler Grant/research support from: Aurinia pharmaceutical, M.A. Dooley: None declared, Rosalind Ramsey-Goldman: None declared, Susan Manzi: None declared, Andreas Jonsen: None declared, Ronald van Vollenhoven Speakers bureau: AbbVie, Galapagos, GSK, Janssen, Pfizer, UCB, Consultant of: Abbvie, AstraZeneca, Biogen, Biotest, Celgen, Galapagos, Gilead, Janssen, Pfizer, Sanofie, Servier, UCB, Vielabo, Grant/research support from: BMS, GSK, Lilly, UCB, Cynthia Aranow: None declared, Meggan Mackay: None declared, Guillermo Ruiz-Irastorza: None declared, S. Sam Lim: None declared, Murat Inanc: None declared, Kenneth C Kalunian Consultant of: Roche, Biogen, Janssen, AstraZeneca, Eli Lilly, Genetech, Gilead, ILTOO, Nektar, Viela, Equillium, Bristol-Meyers Squibb, Soren Jacobsen Grant/research support from: BMS, Christine Peschken: None declared, Diane L Kamen: None declared, Anca Askanase Consultant of: Abbvie, Grant/research support from: Glaxo Smith Kline, Astra Zeneca, Janssen, Eli Lilly and Company, Mallinckrodt, Pfizer, Bernardo Pons-Estel Consultant of: GSK, Janssen, Graciela S Alarcon: None declared.

OP0081 A CASE OF ATYPICAL MYCOBACTERIUM INFECTION COMPLICATING EXTRA-NODAL ROSAI-DORFMAN DISEASE IN A PATIENT WITH SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)

Background:

We present the case of a 28 year old Black-British female with severe SLE requiring treatment with rituximab in 2012 due to persistent low-grade activity and severe episodes of pleuro-pericardial effusions, pancytopaenia, fever and weight loss

Her other background includes beta-thalassaemia trait and excision of calcific fibrotic tissue on bilateral anterolateral orbits in 2015.

In 2018 she reported an 18-month history of non-tender, non-fluctuant, slow growing left thigh mass with USS revealing a well demarcated subcutaneous complex cystic lesion of ~2x4x7cm. There was no preceding trauma or skin infection. Histology from a needle biopsy revealed diffuse histiocytosis with positive immunohistochemistry (ICH) for S100, CD68 and CD31, it was negative for CD1a, consistent with Extra-nodal Rosai-Dorfman disease (RDD).

She developed constitutional symptoms after reporting months of gradual weight loss with gradual ESR, CRP rise and leucocytosis. Her SLE symptoms were stable and given lack of SLE-specific symptoms; PET-CT was used to identify systemic RDD; the thigh mass showed strong FDG avidity along with a small focus of uptake in the small bowel, thought to be RDD related with no other areas of uptake.

She had ongoing ooze from the enlarging thigh lesion (5 x 26 x 15 cm), this was sent for MCS and AAFB; which isolated Mycobacterium avium. She was treated with rifampicin, ethambutol and clarithromycin resulting in improved thigh lesion, constitutional symptoms and inflammatory markers.

Objectives:

[1]To describe a rare associated complication of severe SLE and to educate and inform clinicians regarding possible masquerades of disease

[2]To education and inform about the approach to diagnosis of mycobacterium infection.

Methods:

Case report and literature review.

Results:

Mycobacterium infections rarely complicate RDD; to date, only one case report is published involving an HIV infected patient with RDD confirmed on LN biopsy presenting with splenomegaly and treated with oral corticosteroids (OCS) complicated by Mycobacterium avium complex and Salmonella enterica confirmed on bone marrow biopsy/culture, similar to our patient, he presented with constitutional symptoms and weight loss(2).

Mycobacterium can also mimic RDD, a case report has described a 74 year old with tender lymphadenopathy diagnosed with RDD on LN biopsy. She was treated with IV and OCS, but was unresponsive. A repeat LN biopsy and CT imaging revealed the presence of mycobacterium kansasii; her biopsy was positive for CD68/S100 throughout. Of note, she had high levels of anti-interferon autoantibodies and was diagnosed with adult-onset immunodeficiency syndrome(3).

Conclusion:

This case illustrates the need for a MDT approach for multi-system diseases such as SLE and RDD, and the need to consider atypical infections when blood tests are incongruent with clinical state.

References:

[1]Bruce-Brand C, Schneider JW, Schubert P. Rosai-Dorfman disease: an overview. J Clin Pathol. 2020 Nov;73(11):697-705. doi: 10.1136/jclinpath-2020-206733.

[2]Olmedo-Reneaum A, Molina-Jaimes A, Conde-Vazquez E, Montero-Vazquez S. Rosai-Dorfman disease and superinfection due to Salmonella enterica and Mycobacterium avium complex in a patient living with HIV. IDCases. 2020 Jan 14;19:e00698.

[3]King YA, Hu CH, Lee YJ, Lin CF, Liu D, Wang KH. Disseminated cutaneous Mycobacterium kansasii infection presenting with Rosai-Dorfman disease-like histological features in a patient carrying anti-interferon-γ autoantibodies. J Dermatol. 2017 Dec;44(12):1396-1400.

Image 1.Table 1.SLE Clinical HistoryDiagnosed 2006 (‘97 ACR Classification Criteria)Clinical -Polyarthritis -Glandular (lacrimal swelling) -Pericardial effusion/Pleural Effusion -MyositisSerological -Anti-nuclear antibody (ANA) -Anti-dsDNA -Anti-U1-RNP -Anti- SS-A/Ro -Lupus AnticoagulantPrevious SLE Treatment -Hydroxychloroquine (HCQ) -Methotrexate (MTX) -Azathioprine (AZA) -Rituximab (RTX)

Disclosure of Interests:

None declared

POS0106 BILAG-2004 LDA AND BST LDA ARE VALID TREAT TO TARGET IN SLE

Background:

Low disease activity state has been defined using SLEDAI and used as treatment target in SLE. However, there has not been any such definition using BILAG-2004 index (BILAG-2004).

Objectives:

This study was to determine if low disease activity state according to BILAG-2004 is valid for use as treatment target in SLE. We also assessed disease activity longitudinally using BILAG-2004 systems tally (BST). BST is an alternative way of representing BILAG-2004 scores that combines the flexibility and simplification of numerical scoring of BILAG-2004 with the clinical intuitiveness of BILAG-2004 structure.

Methods:

This was a prospective multi-centre longitudinal study in the UK of an inception cohort of SLE patients (recruited within 12 months of achieving 1997 ACR revised criteria for SLE). Data were collected on disease activity (BILAG-2004 and BILAG2004-Pregnancy Index during pregnancy), SLICC/ACR DI (SDI), cumulative drug exposure and death at every visit. This study ran from 1st January 2005 to 31st December 2017. Four low disease activity states (LDA) were defined using BILAG-2004: 1) BILAG-2004 LDA when all 9 systems had scores of C, D or E on assessment (no Grade A or B), 2) BST LDA when there was persistent score of C, D or E in all 9 systems between 2 consecutive visits (equivalent to 2 consecutive visits with BILAG-2004 LDA), 3) BILAG-2004 Remission when all 9 systems had scores of D or E on assessment and 4) Persistent Remission when there was persistent score of D or E in all 9 systems between 2 consecutive visits. Longitudinal analysis using Poisson regression with random effects model was used with development of new damage as the outcome of interest. Gender, cardiovascular risk factors, antiphospholipid syndrome status and most drugs (except hydroxychloroquine, glucocorticoids, mycophenolate and cyclophosphamide) were excluded from the model as they were not associated with development of damage in univariate analysis.

Results:

273 patients were recruited (91.2% female, 59.3% Caucasian, 17.2% African/Caribbean, 17.2% South Asian) with mean age at recruitment of 38.5 years (SD 14.8). 97.8% had no damage at recruitment (2.2% had SDI score of 1). Median follow-up was 73.4 months (range: 1.8, 153.8) with total follow-up of 1767 patient-years. There were 13 deaths and 114 new damage items occurred during follow-up. There were 6674 assessments with disease activity score: 319 assessments with Grade A activity in 95 patients (84.6% had only 1 system with grade A, range: 1 - 4) and 1704 assessments with Grade A or B activity in 239 patients (78.7% had only 1 system with Grade A or B, range: 1 - 5).

BILAG-2004 LDA was achieved in 74.5% of assessments (from 271 patients). BILAG-2004 Remission occurred in 28.2% of assessments (from 234 patients).

6401 observations with BST were available (1 observation derived from change in activity between 2 consecutive assessments) and 63.7% were in BST LDA. There was no observation with Persistent Remission between consecutive visits.

Table 1 summarises multivariate analysis which showed BILAG-2004 LDA to be inversely associated with damage. Similar results were obtained with BILAG-2004 Remission (RR 0.60 with 95% CI 0.38, 0.96) and BST LDA (RR 0.65 with 95% CI 0.43, 0.99). Cumulative drug exposure since recruitment for mycophenolate was protective against new damage (RR 0.99 with 95% CI 0.99, 0.99).

Table 1.VariableRelative Risk (95% CI) for New DamageEthnicityAfro-Caribbean1.22 (0.68, 2.18)South Asian1.81 (0.97, 3.38)Others2.22 (0.63, 7.85)Age at diagnosis1.06 (1.04, 1.08)Prior SDI score0.68 (0.43, 1.06)BILAG-2004 LDA0.60 (0.39, 0.94)Hydroxychloroquine since last visit (per g)0.99 (0.98, 0.99)Steroids since last visit (per 100mg)1.02 (1.01, 1.03)Cyclophosphamide since last visit (per g)1.67 (1.15, 2.41)

Conclusion:

BILAG-2004 LDA and BST LDA are valid treatment targets in SLE. BILAG-2004 Remission and Persistent Remission are uncommon, which make them unrealistic as a treatment target.

References:

[1]Yee C. S., et al. The BILAG-2004 systems tally – a novel way of representing the BILAG-2004 index scores longitudinally. Rheumatology (Oxford) 2012; 51[11]: 2099-2105.

Acknowledgements :

Versus Arthritis, Vifor Pharma

Disclosure of Interests:

Chee-Seng Yee Consultant of: Bristol Myers Squibb, ImmuPharma, Grant/research support from: Vifor Pharma, Caroline Gordon Speakers bureau: UCB, Consultant of: Center for Disease Control, Astra-Zeneca, MGP, Sanofi and UCB, Mohammed Akil: None declared, Peter Lanyon: None declared, Christopher John Edwards Consultant of: Glaxo Smith Kline, Roche, Grant/research support from: Glaxo Smith Kline, Roche, David Isenberg: None declared, Anisur Rahman: None declared, Lee-Suan Teh: None declared, Sofia Tosounidou: None declared, Robert Stevens: None declared, Ahtiveer Prabu: None declared, Bridget Griffiths: None declared, Neil McHugh: None declared, Ian N. Bruce: None declared, Yasmeen Ahmad: None declared, Munther Khamashta: None declared, Vernon Farewell: None declared