Reducing salinity of treated waste water with large scale desalination

Agriculture, the largest global water consumer, accounts for ~70% of freshwater use thereby considerably influencing water availability. The use of treated wastewater [TWW] for agricultural irrigation has been suggested as a possible solution to help mitigate water scarcity without disrupting food production. However, despite the benefits of TWW irrigation, it is often characterized by high salinity that can reduce crop performance and damage soil structure. In Israel, over 50% of the water used for irrigation is TWW, and a third of the produced TWW undergoes soil aquifer treatment [SAT], i.e., infiltration and percolation to groundwater through the soil before utilization for irrigation. In parallel, seawater desalination provides about 80% of the urban and industrial sector water use. These developments in Israel's water economy during the last three decades, accompanied by extensive governmental monitoring, enabled us to harness high-resolution nation-wide datasets to study the effects of the large-scale introduction of desalination and SAT on TWW quality and salinity in particular. The analyses revealed that large-scale desalination considerably reduced the salinity of TWW to levels similar to freshwater (up to 70% and 60% for Cl and Na, respectively). However, sodium absorption ratio remained unchanged due to the concurrent reductions of Na, Ca and Mg. Mg was reduced to levels that can potentially harm both crops and human health, while B concentrations increased to levels of possible toxicity to crops, suggesting the need for stringent requirements in the post-treatment process. Salinity of groundwater was increased by SAT in the long-term, but was reduced after the introduction of desalination. The results, encompassing almost three decades of water monitoring, suggest that high-quality TWW with a significant portion of desalinated base-water can provide groundwater salinity remediation services.

Restoration of normal sinus rhythm in atrial fibrillation: impact of reverse remodelling of right chambers on tricuspid regurgitation severity

Background

The severity of tricuspid regurgitation (TR) in patients with restored normal sinus rhythm (SR) after atrial fibrillation (AF) has been poorly assessed.

Purpose

Our study aimed to assess (1) right chamber remodelling and (2) TR severity in patients with AF who have had their rhythms restored to normal sinus.

Methods

We prospectively evaluated 94 consecutive patients hospitalized for AF who received either ablation, direct current cardioversion, or pharmacological therapy. Patients were divided into two groups according to their cardiac rhythm at 6 months follow up (6M): restoration to SR (SR group, n=54), persistence of AF (AF group, n=40). TR vena contracta (VC), TR grade severity was divided into 4 grades using an integrated approach (0: none or trace; 1: mild; 2: moderate; 3: severe TR). Two dimensional (2D) end diastolic (ED) tricuspid annulus (TA) diameter in the apical 4 chambers view, three-dimensional (3D) indexed volumes (3D Vi) of the right atrium (RA) and right ventricle (RV) in end systole (ES) and ED were acquired using transthoracic echocardiography at admission and at 6M.

Results

At 6M, in the SR group a significant improvement in TR VC (Figure A) and TR grade (Figure B) were noted, whereas there was no differences in the AF group (0.41 vs. 0.42cm, p=0.24 for TR VC; 1.70 vs. 1.76, p=0.16 for mean TR grade). In the SR group a significant reduction in 3D ES RV Vi, 2D ED TA diameter, 3D ES and ED Vi of the RA (Table) were observed. Regression of TR VC was correlated with regression of right cavities parameters (ρ=0.47, p<0.001 for 2D ED TA diameter; ρ=0.34, p<0.005 for 3D ES RA Vi; ρ=0.33, p<0.005 for 3D ED RV Vi; ρ=0.29, p<0.005 for 3D ES RV Vi).

Conclusion

Restoration of normal SR in patients with AF results in beneficial remodelling of right cavities at 6M of follow-up which were associated with a significant decrease in TR severity. Strategies for normal SR restoration in patients with AF and TR should be vigorously attempted.

TR Evolution

Funding Acknowledgement

Type of funding source: None

Prognosis of acute kidney injury during acute heart failure: the role of diuretics

Background

Acute kidney injury (AKI) frequently occurs after diuretic treatment initiation during acute heart failure (AHF). Treatment-induced hemoconcentration seems associated with improved prognosis. Transient AKI, with or without hemoconcentration, is of unsettled prognosis.

Purpose

We aimed to determine the independent prognostic values of transient AKI, persistent AKI and hemoconcentration in the context of hospitalized AHF.

Methods

Data were obtained from our institution's Clinical Data Warehouse. Patients that visited our unit at least once were screened. All hospitalizations in our institution were examined (>30 hospitals). Inclusion criteria were: ≥1 hospitalization with ≥1 recorded furosemide administration and ≥1 AHF ICD-10 code. Only the first hospitalization fulfilling these criteria was considered. AKI during 1–13 days following first furosemide administration was defined based on Kidney Disease Improving Global Outcome guidelines. Hemoconcentration was defined as an increase in serum proteins ≥5 g/l during the same period. We performed multivariate logistic regression to determine which characteristics were predictive of AKI. We used Cox regression of 100-days all-cause mortality using several confounders to determine the prognostic values of transient AKI (lasting <14 days), persistent AKI (lasting ≥14 days) and hemoconcentration. To account for immortality bias, AKI and hemoconcentration were treated as time-dependent covariates.

Results

We included 579 patients in the study. Median follow-up was 114 days. AKI following furosemide initiation occurred in 234 patients (40.4%). Patients that experienced AKI more frequently suffered from chronic kidney disease (43.6% vs. 33%, p=0.01) or presented with right ventricular dilatation (12% vs. 6.7%, p=0.04). Independent predictors of AKI were arterial hypertension (adjusted OR: 1.86 [1.08–3.22]), elevated serum creatinine at baseline (adjusted OR: 1.07 [1.01–1.14] per 10 μmol/l increase) and initial intravenous furosemide (adjusted OR: 2.42 [1.39–4.29]). Death during follow-up occurred in 35% of patients in the AKI group compared to 21% in the non-AKI group (p<0.001). In Cox regression, persistent AKI was independently associated with increased mortality in a period of 100 days following furosemide initiation (adjusted HR: 2.31 [1.07–4.99]). Transient AKI was not significantly associated with mortality (adjusted HR: 0.64 [0.34–1.19]). Hemoconcentration was independently associated with decreased mortality (adjusted HR: 0.46 [0.27–0.79]).

Conclusion

In the context of hospitalized AHF, AKI that developed 1–13 days after furosemide initiation and that lasted ≥14 days was independently associated with decreased 100 days survival. Hemoconcentration, using a clinically relevant definition, was independently associated with improved survival. These findings show that serum creatinine and proteins, routinely used and with limited cost, accurately stratify mortality risk during AHF.

Kaplan-Meier curves

Funding Acknowledgement

Type of funding source: None

Impact of rhythm in non-valvular atrial fibrillation on four cardiac chamber deformation imaging

Background

Few studies have assessed the evolution of cardiac chambers deformation imaging in patients with atrial fibrillation (AF) according to cardiac rhythm outcome.

Purpose

To evaluate cardiac chamber deformation imaging in patients admitted for AF and the evolution at 6-month follow-up (M6).

Methods

In forty-one consecutive patients hospitalised for AF two-dimensional transthoracic echocardiography was performed at admission (M0) and after six months (M6) of follow up. In addition to the usual parameters of chamber size and function, chamber deformation imaging was obtained including global left atrium (LA) and right atrium (RA) reservoir strain, global left ventricular (LV) and right ventricular (RV) free wall longitudinal strain. Patients were divided into three groups according to their cardiac rhythm at M0 and M6: AF at M0 and sinus rhythm (SR) at M6 (AF-SR) (n=23), AF at M0 and AF at M6 (AF-AF) (n=11), SR at M0 (spontaneous conversion before the first echocardiography exam) and SR in M6 (SR-SR) (n=7)

Results

In comparison with SR patients (n=7), at M0, AF patients (n=34)) had lower global LA reservoir strain (+5.2 (+0.4 to 12.8) versus +33.2 (+27.0 to +51.5)%; p<0.001), lower global RA reservoir strain (+8.6 (−5.4 to 11.6) versus +24.3 (+12.3 to +44.9)%; p<0.001), lower global LV longitudinal strain (respectively −12.8 (−15.2 to −10.4) versus −19.1 (−21.8 to −18.3)%; p<0.001) and lower global RV longitudinal strain (respectively −14.2 (−17.3 to −10.7) versus −23.8 (−31.1 to −16.2)%; p=0.001). When compared with the AF-SR group at M0 the AF-AF group had no significant differences with regard to global LA and RA reservoir strain, global LV and RV longitudinal strain (Table). Between M0 and M6 there was a significant improvement in global longitudinal strain of the four chambers in the AF-SR group whereas no improvements were noted in the AF-AF and SR-SR group (Figure).

Conclusion

Initial atrial and ventricular deformations were not associated with rhythm outcome at six-month follow up in AF. The improvement in strain in all four chambers strain suggests global reverse remodelling all cardiac cavities with the restoration of sinus rhythm.

Evolution of strain between M0 and M6

Funding Acknowledgement

Type of funding source: None

Axitinib as a third or further line of treatment in renal cancer: a single institution experience

BACKGROUND

Kidney cancer is a lethal neoplasm that affects several thousands of people every year. Renal cell carcinoma (RCC) is the most common histologic type. Recent developments in the therapeutic approach include antiangiogenic targeted approaches and Immunotherapy. Thus, the therapeutic algorithm of RCC patients and the survival outcomes have changed dramatically.

METHODS

Herein we present a retrospective study of the patients treated in our Department with an antiangiogenic agent -Axitinib, a tyrosine kinase inhibitor- as a third or further line treatment. Statistical analysis was performed with SPSS, including the available clinicopathological data of the patients included.

RESULTS

Axitinib was found to be active in patients who received this treatment beyond second line. The toxicity profile of this regimen did not reveal any unknown adverse events.

CONCLUSIONS

Our real world data reflect that axitinib is a safe and effective option, even beyond the second line.

SAT0603 SYSTEMIC SCLEROSIS IS AN INDEPENDENT RISK FACTOR FOR ISCHEMIC HEART DISEASE WITH AN ADDITIONAL RISK IN THOSE POSITIVE FOR CERTAIN ANTI-PHOSPHOLIPID ANTIBODIES: A VERY LARGE CASE-CONTROL STUDY

Background:

A higher prevalence of ischemic heart disease (IHD) in patients with systemic sclerosis (SSc) was reported. However, contrasting findings were published concerning the role of SSc-related autoantibodies in IHD risk which remains controversial.

Objectives:

The current study explored the link between SSc and IHD, impact of putative links on SSc mortality and the role of SSc-related and antiphospholipid autoantibodies in disease associated IHD.

Methods:

A large cohort study utilising the Clalit-Health-Service (CHS) database was conducted on 2,431 SSc patients and 12,710 age- and sex matched controls. The proportion of IHD was compared between patients diagnosed with SSc and age- and gender-matched controls. The role of SSc-linked and antiphospholipid autoantibodies in disease associated IHD was assessed.

Results:

The rate of IHD was significantly higher in SSc than controls (20.4%vs15.0%, p<0.001). At the multivariate analysis, SSc was an independent predictor of IHD with an OR of 1.91 (95%CI 1.57-2.31, p<0.0001). SSc patients with IHD had a higher mortality rate with an HR of 2.67 (95%CI 2.03-3.53, p<0.0001) than those without IHD. SSc patients with positive anti-beta2GPI (IgM-isotype) or anti-cardiolipin (aCL) (IgA-isotype) exhibited a higher risk of IHD than SSc patients without these antibodies with an OR 1.89 (95% 1.04-3.45, p=0.0369) and OR of 3.72 (95% 1.25-11.11, p=0.0184), respectively.

Conclusion:

Patients with SSc are at higher risk for developing IHD with an additional risk for the latter in those positive for aCL or anti-beta2GPI. A high degree of suspicion is needed during routine patient follow-up and pre-emptive screening should be considered.

Disclosure of Interests:

Abdulla Watad: None declared, Dennis McGonagle Grant/research support from: Janssen Research & Development, LLC, Nicola Luigi Bragazzi: None declared, Doron Comanesther: None declared, Arnon Cohen: None declared, Merav Lidar: None declared, Howard Amital: None declared

AB0780 TREATMENT PERSISTENCE OF BIOLOGICS AMONG PATIENTS WITH PSORIATIC ARTHRITIS (PsA)

Background:

Persistence in biologic therapy in psoriatic arthritis is critical to optimize symptom remission, functional capacity and health care costs.

Objectives:

To estimate the persistence to biologic treatment prescribed to PsA patients in a real-life setting as well as factors associated with improved biologic drug survival in these patients.

Methods:

Patients with PsA from a large health care provider database with at least two consecutive dispensed prescriptions of a biologic agent indicated for PsA from January 1st, 2002 until December 31st, 2018 were identified and followed until medication stop date or the end of observation period. Patients were considered non-persistent whenever a new prescription was dispensed and a permissible gap of 6 months was exceeded prior to starting on this biologic agent from the prescription date. Treatment changes were based on physician decisions and patient preferences.

Demographic data including age, sex, BMI, ethnicity, smoking history and socioeconomic status as well as Charlson comorbidity index were retrieved. Data regarding use of steroids and non-biologic disease-modifying anti-rheumatic drugs were also extracted. Descriptive statistics, including means (standard deviations) for continuous variables and frequencies (%) for categorical variables, were used. Persistence estimates were derived using non-parametric survival analysis using Kaplan-Meier functions, with treatment discontinuations as failure events. Cox regression hazard ratio models were conducted to investigate factors associated with drug persistence.

Results:

2301 PsA patients with 2958 treatment periods were identified and included in the analyses. The mean age was 50.9±14 years of whom 54% were females, 70.4% of the study population had a BMI>25, and 36% were obese(BMI>30), 40% were current smokers, and 76% had a Charlson comorbidity index higher than 1. The most commonly prescribed drug was etanercept, followed by adalimumab, golimumab, secukinumab, ustekinumab and infliximab at 33%, 29%, 12%, 10%,8% and 8%, respectively. Only about 20% of patients remained on a particular biologic agent after 5 years, whereas about 40% persisted on therapy following 20 months of treatment. A Kaplan-Mayer survival analysis with pairwise comparisons of all treatment choices with respect to lines of therapy was conducted. When analyzing the data for all treatment periods and taking into account all lines of therapy, secukinumab had a higher persistency than adalimumab, infliximab and ustekinumab, with a Log Rank of 0.022, 0.047 and 0.001, respectively, as is shown in figure 1. Female sex and smoking were associated with lower drug persistence (HR=1.25, 95%CI 1.13-1.38 and HR=1.109, 95%CI 1.01-1.21, respectively). When analyzing the data regarding second-line biologic agents, secukinumab was found to be superior to adalimumab, etanercept, infliximab and ustekinumab but not to golimumab with a Log-Rank P value of 0.001, 0.004, 0.025 and 0.002, respectively (figure 2). On analyzing the data using only the first indicated biologic line, no superiority of any single anti-Tumor Necrosis Factor-alpha (anti-TNFα) agent was observed.

Conclusion:

In this large observational cohort, in the era of biologic therapy, a relatively low persistence was observed, with female sex and smoking having a negative impact on persistency. None of the anti-TNFα agents as first line therapy was found to be more persistent than others, while secukinumab was found to be superior to other biologics when indicated as second line of therapy.

References:

None

Figure 1.Figure 2.

Acknowledgments:

none

Disclosure of Interests:

None declared

OP0143 CANCER IN GIANT-CELL ARTERITIS PATIENTS: A LARGE NATIONWIDE STUDY

Background:

The association between giant-cell arteritis (GCA) and malignancy is controversial.

Objectives:

To asses malignancy rates and risk in GCA patients in a large-scale population-based study.

Methods:

We utilized the medical database of Clalit-Health-Services for this retrospective cohort study. Follow-up was from January 1,2002 and continued until death or end of follow-up on September 1,2018. Incident GCA patients were compared with age-and-sex-matched controls. Hazard-ratios for subtypes of malignancies were obtained by the Cox proportional-hazard model, adjusted for socio-demographic variables and cancer risk factors.

Results:

The study population included 7,213 GCA patients and 32,987 age- and sex-matched controls who were not diagnosed with the disease. The mean age of GCA diagnosis was 72.3±9.9 years (median 73.1 years) and 69.1% were women. At Kaplan–Meier survival analysis, assessing cumulative cancer-free survival in GCA patients and controls, GCA patients had worse curve than controls (chi-squared = 49.84; degrees of freedom = 1; p < 0.0001; Figure 1). At the cox-survival analysis adjusted for age, sex, SES and cancer risk factors GCA patients showed increased risk for overall cancer (HR 1.29 [95%CI 1.20-1.39]), kidney cancer (HR 1.60 [95%CI 1.15-2.23]), sarcoma (HR 2.14 [95%CI 1.41-3.24]), acute-leukemia (HR 1.81 [95%CI 1.06-3.07]), chronic-leukemia (HR 1.82 [95%CI 1.19-2.77]), Hodgkin’s lymphoma (HR 2.42 [95%CI 1.12-5.20]), non-Hodgkin’s lymphoma (HR 1.66 [95%CI 1.21-2.29]) and multiple myeloma (HR 2.40 [95%CI 1.63-3.53) (Table 1). The time (mean [months] ± SD) to the diagnosis of any malignancy was significantly shorter in GCA patients (48.6 ± 41.3) compared to controls (58.1 ± 43.6; p<0.001).

Table 1.

Cox survival analysis assessing crude and adjusted hazard for cancer in GCA patients compare to controls

Type of malignancyAdjusted HRHR95% CIAny malignancy1.291.20, 1.39Oropharyngeal cancer0.960.69, 1.35Thyroid cancer1.200.66, 2.16Breast cancer0.930.75, 1.14Lung cancer1.260.99, 1.59Esophagus cancer1.860.93, 3.75Stomach Cancer0.610.37, 0.98Colorectal Cancer1.120.93, 1.36Liver and bile ducts cancer1.060.69, 1.62Kidney cancer1.601.15, 2.23Bladder cancer1.150.88, 1.50Uterus cancer0.850.55, 1.30Cervical cancer of the uterus0.450.37, 1.46Ovary Cancer0.960.58, 1.59Prostate Cancer1.070.80, 1.43Sarcoma2.141.41, 3.24Melanoma1.110.80, 1.55Acute Leukemia1.811.06, 3.07Chronic Leukemia1.821.19, 2.77Myelodysplastic syndrome1.840.94, 3.60Hodgkin’s Lymphoma2.421.12, 5.20Non-Hodgkin’s Lymphoma1.661.21, 2.29Multiple Myeloma2.401.63, 3.53Figure 1.

Kaplan-Meier cancer-free survival curve

Conclusion:

GCA patients are at increased risk for sarcoma, kidney cancer, hematological malignancies and overall malignancies compared to age-and-sex matched controls from the general population.

References:

[1]Watad A, McGonagle D, Bragazzi NL, Tiosano S, Comaneshter D, Shoenfeld Y, et al. Autoantibody status in systemic sclerosis patients defines both cancer risk and survival with ANA negativity in cases with concomitant cancer having a worse survival. Oncoimmunology 2019;8:e1588084.

[2]Ben-Shabat N, Tiosano S, Shovman O, Comaneshter D, Shoenfeld Y, Cohen AD, et al. Mortality among patients with giant-cell arteritis: A large-scale population-based cohort study. J Rheumatol 2019;

Disclosure of Interests:

None declared

OP0253 AUTOANTIBODY STATUS IN DERMATOMYOSITIS AND POLYMYOSITIS PATIENTS DEFINES BOTH CANCER RISK AND SURVIVAL WITH ANA NEGATIVITY IN CASES WITH CONCOMITANT CANCER HAVING A WORSE SURVIVAL

Background:

We previously reported that ANA-negative cases with systemic sclerosis (SSc) and concomitant cancer had a worse survival than ANA-positive cases with associated cancer possibly suggesting that humoral mediated autoimmunity conferred a survival advantage (1). Dermatomyositis (DM) and polymyositis (PM) are two immune-mediated myopathies associated with numerous autoantibodies.

Objectives:

The present large-scale, population-based study tested the hypothesis that humoral autoimmunity associated with cancer in solid/haematological malignancies impacted on DM/PM patient survival.

Methods:

Over 2000 cases with either DM or PM were recruited from the Clalit Health Service (CHS) chronic diseases registry, one of the largest healthcare maintenance Israeli organization, serving approximately half of the entire country’s population. Over 10000 matched controls were recruited. The data collected range from 2000 to 2018.

Results:

Altogether 12,278 subjects were recruited (2,085 cases, and 10,193 controls, 5,042 males, 41.1%, and 7,236 females, 58.9%). Among cases, 1,475 individuals (70.7%) were diagnosed with DM, whereas 610 (29.3%) with PM. Mean age was 47.81±22.51 years. 1,379 cases of cancers (11.2%) were diagnosed. At the univariate analysis and as expected, the rate of malignancies was significantly (p<0.0001) higher in DM/PM (n=361, 17.3%) with respect to controls (n=1,018, 10.0%).

Concerning prognosis, ANA positivity in PM/DM was associated with a better prognosis for all cancers (OR 0.39 [95% 0.24-0.63], p=0.0001). For individual cancer types; thyroid cancer (OR 0.39 [95% 0.24-0.63], p=0.0001), gastric cancer (OR 0.40 [95% 0.25-0.64], p=0.0001), kidney cancer (OR 0.39 [95% 0.24-0. 62], p=0.0001), acute leukaemia (OR 0.40 [95% 0.25-0.65], p=0.0002), non-Hodgkin’s lymphoma (OR 0.39 [95% 0.25-0.63], p=0.0001), but not for myelodysplastic syndrome.

The main cancers linked to PM/DM were thyroid cancer (OR 3.17 [95%CI 2.27-4.43]), gastric cancer (OR 5.96 [95%CI 4.24-8.38]), kidney cancer (OR 3.83 [95%CI 1.02-14.31], p=0.0462), and myelodysplastic syndrome (OR 2.01 [95%CI 1.17-3.46], p=0.0111). Regarding gastric cancer, positivity for anti-RNP (OR 5.68 [95%CI 3.02 to 10.71], p<0.0001), anti-SSA (OR 21.99 [95%CI 11.21 to 43.14], p<0.0001), and anti-Jo1 (OR 12.23 [95%CI 7.12 to 21.01], p<0.0001) was associated with a higher risk of cancer development.

Conclusion:

ANA positivity is an independent predictor of favorable prognosis in PM/DM patients with cancer, possibly suggesting that cancer directed humoral autoimmunity may have some benefit. Therefore, humoral autoimmunity in SSc and PM/DM is a broad mechanism that confers a survival advantage and is relevant for disease understanding and elucidating optimal anti tumoural immunity in the current age of cancer immunotherapy.

References:

[1]Watad A, McGonagle D, Bragazzi NL, Tiosano S, Comaneshter D, Shoenfeld Y, Cohen AD, Amital H. Autoantibody status in systemic sclerosis patients defines both cancer risk and survival with ANA negativity in cases with concomitant cancer having a worse survival. Oncoimmunology. 2019 Mar 24;8(6):e1588084.

Disclosure of Interests:

Abdulla Watad: None declared, Dennis McGonagle Grant/research support from: Janssen Research & Development, LLC, Merav Lidar: None declared, Nicola Luigi Bragazzi: None declared, Doron Comanesther: None declared, Arnon Cohen: None declared, Howard Amital: None declared

Macrophages of diverse phenotypes drive vascularization of engineered tissues

Macrophages are key contributors to vascularization, but the mechanisms behind their actions are not understood. Here, we show that diverse macrophage phenotypes have distinct effects on endothelial cell behavior, with resulting effects on vascularization of engineered tissues. In Transwell coculture, proinflammatory M1 macrophages caused endothelial cells to up-regulate genes associated with sprouting angiogenesis, whereas prohealing (M2a), proremodeling (M2c), and anti-inflammatory (M2f) macrophages promoted up-regulation of genes associated with pericyte cell differentiation. In 3D tissue-engineered human blood vessel networks in vitro, short-term exposure (1 day) to M1 macrophages increased vessel formation, while long-term exposure (3 days) caused regression. When human tissue-engineered blood vessel networks were implanted into athymic mice, macrophages expressing markers of both M1 and M2 phenotypes wrapped around and bridged adjacent vessels and formed vessel-like structures themselves. Last, depletion of host macrophages inhibited remodeling of engineered vessels, infiltration of host vessels, and anastomosis with host vessels.

A229 USTEKINUMAB FOR THE TREATMENT OF REFRACTORY PEDIATRIC CROHN’S DISEASE: A SINGLE CENTRE EXPERIENCE

Background

Despite the well-established efficacy of Tumor Necrosis Factor (TNF) antagonists as treatment options for Crohn’s Disease, many pediatric patients need a change in therapy due to adverse events, as well as primary and secondary loss of response, highlighting the necessity for medications with a different mechanism of action. Ustekinumab, a monoclonal antibody targeting IL-12 and IL-23, has been approved to treat psoriatic arthritis, plaque psoriasis, and adults with Crohn’s disease. While utekinumab has been shown to be effective in inducing clinical remission in adults with Crohn’s disease refractory to anti-TNF agents, minimal data exists in the pediatric population.

Aims

We retrospectively describe 11 pediatric patients who received ustekinumab at the Montreal Children’s Hospital with the goal of assessing its efficacy in inducing clinical, biochemical, and endoscopic remission.

Methods

We abstracted baseline data, prior treatment and response, indications for starting ustekinumab, clinical response, endoscopic data, and laboratory parameters pre- and post- therapy. Clinical response was defined as decrease in abbrPCDAI (Pediatric Crohn’s Disease Activity Index) score.

Results

Patients ranged in age from 12–17 years old upon initiation of treatment with ustekinumab and had all previously failed either one (N=8) or both (N=3) anti-TNF therapies. Follow-up ranged from 6 to 22 months. We examined three indices of response to ustekinumab: symptomatic improvement, biomarker normalization, and endoscopic changes. Five of eleven patients demonstrated a clinical response – two maintained clinical remission across available follow-up data, while the remaining three experienced a secondary loss of response. The other six patients studied were primary non-responders. Two of these patients had normal abbrPCDAI scores upon initiation of ustekinumab and terminated therapy due to persistent stricturing disease. The other four non-responders either remained unwell or demonstrated clinical worsening, as measured by the abbrPCDAI. Of the clinical responders, 3/5 had elevated CRP values prior to initiating ustekinumab therapy, all of which normalized within one month of clinical improvement. Endoscopic data both pre- and post- ustekinumab was available in two responders and two non-responders, with endoscopic improvement seen in both of the responders and in one of the two non-responders.

Conclusions

These results demonstrate that ustekinumab has the potential ability to induce not only clinical and biochemical remission, but also endoscopic improvement, in the pediatric population. An area of concern is the fact that only one patient maintained remission for longer than one year. Future research should focus on maximizing and lengthening the effect of ustekinumab, as well as determining factors that influence response to therapy.

Funding Agencies

None

VIDAS Enzyme-Linked Fluorescent Immunoassay for Detection of Salmonella in Foods: Collaborative Study

The VIDAS SLM method for detection of Salmonella was compared with the Bacteriological Analytical Manual (BAM)/AOAC culture method in a collaborative study. Twenty laboratories participated in the evaluation. Each laboratory tested one or more of 6 test products: milk chocolate, nonfat dry milk, dried whole egg, soy flour, ground black pepper, and ground raw turkey. No significant differences (P&lt; 0.05) were observed between the 2 methods. The 2 methods were in agreement for 99% of 1544 samples analyzed. Of the 20 samples out of agreement, 8 were VIDAS SLM positive and BAM/AOAC negative, and 12 were VIDAS SLM negative and BAM/AOAC positive. The VIDAS SLM method for detection of Salmonella in foods has been adopted first action by AOAC INTERNATIONAL.

P350 Right atrial remodelling in atrial fibrillation using three dimensional transthoracic echocardiography and strain imaging

Background

Evaluation of right atrial cavities and right atrial (RA) remodelling in atrial fibrillation (AF) has been poorly studied.

Purpose

The aim of this study was to evaluate in AF, the role of three-dimensional (3D) transthoracic echocardiography (TTE) and strain to refine the evaluation of the RA according to evolution of cardiac rhythm ad mid-term follow-up.

Methods

A complete 2D and 3D TTE was performed in patient hospitalized for AF. In addition to the usual parameters, RA parameters were specifically assessed: 3D RA end-systolic (ES) and end-diastolic (ED) volume, RA ejection fraction (EF) and the global longitudinal strain (GLS) of the RA. A complete clinical evaluation and electrocardiogram were performed at admission (M0) and 6 months after inclusion (M6) to determine the cardiac rhythm at follow-up.

Results

34 consecutive patients hospitalized for AF were analysed. At M0, there was no significant difference between 2D RA ES volume and the 3D RA ES volume. Three groups of patients were individualized according to cardiac rhythm at M0 and M6: AF at M0 and AF at M6 (AF-AF), AF at M0 and sinus rhythm (SR) at M6 (AF-SR), SR at M0 (spontaneous reduction before the admission ECG) and SR at M6 (SR-SR). At M0 echocardiography, in the AF-AF group and AF-SR in comparison with SR-SR group were as follow: the 3D RA ED volume was significantly higher (respectively 21.6 (18.2-26.6) and 26.9 (19.4-36.8) versus 11.3 (6.9-16.6) mL/m2 ; p = 0.0025), the 3D RAEF was significantly lower (42.2 (35.1-44.7) and 34.5 (24.1-38.6) versus 57.6 (53.4-62.2)%; p = 0.0105) and the RA GLS was also significantly lower (7.6 (6.5-10.5) and 9.1 (5.8-11.2) versus 26.6 (22.0-35.0)%; p = 0.0001) (Figure 1).

Conclusion

3D ultrasound and strain could be useful tools for evaluating the anatomical and functional RA remodelling in AF, to be further validated in a larger ongoing study.

Abstract P350 Figure 1

Total serum cholesterol by isotope dilution/mass spectrometry: a candidate definitive method

We describe a highly accurate and precise method for determination of total cholesterol in serum by isotope dilution/mass spectrometry. The method was developed for a Study Group of the Committee on Standards of the American Association for Clinical Chemistry, for use in establishing the accuracy of a candidate reference method for total cholesterol, and fulfills their criteria for a definitive method. Cholesterol-d7 is added to serum, with the weight ratio of cholesterol-d7 to total serum cholesterol kept near to 1:1. The esters are hydrolyzed and the cholesterol is separated and converted into the trimethylsilyl ether derivative for measurement by combined gas chromatography/mass spectrometry. The intensity ratio of the molecular ions at m/z 465 and 458 is measured for each sample and for two calibration mixtures, according to a prescribed bracketing protocol. A weight ratio for the sample is obtained by linear interpolation of the ion-intensity ratios, and the total cholesterol is then calculated. The method was applied four times over several weeks to each of five serum pools. Statistical analysis involving consideration of both replication error and variability between weeks gave a coefficient of variation for a single measurement of 0.36%. The absence of interferences in the method was demonstrated by measurements at several other masses.

Enumeration of Total Coliforms and E. coli in Foods by the SimPlate® Coliform and E. coli Color Indicator Method and Conventional Culture Methods: Collaborative Study

The relative effectiveness of the SimPlate® Coliform and E. coli Color Indicator (CEc-CI) method was compared to the AOAC 3-tube Most Probable Number (MPN) methods for enumerating and confirming coliforms and Escherichia coli in foods (966.23 and 966.24). In this study, test portions were prepared and analyzed according to the conditions stated in both the AOAC methods and SimPlate directions for use. Six food types were artificially contaminated with coliform bacteria and E. coli: frozen burritos, frozen broccoli, fluid pasteurized milk, whole almond nut meats, cheese, and powdered cake mix. Method comparisons were conducted. Overall, the SimPlate method demonstrated &lt;0.3 log difference for total coliform and E. coli counts compared to the AOAC reference methods for the majority of food types and levels analyzed. In all cases, the repeatability and reproducibility of the SimPlate CEc-CI method were not different from those of the reference methods and in certain cases, were statistically better than those of the AOAC 3-tube MPN methods. These results indicate that the SimPlate CEc-CI method and the reference culture methods are comparable for enumeration of both total coliforms and E. coli in foods.

P5338Atherosclerotic cardiovascular events in people living with Human Immunodeficiency Virus

Background

People living with Human Immunodeficiency Virus (PLWHIV) under antiretrovirals have an increased risk of atherosclerotic cardiovascular disease (ASCVD) events. The risk factors associated with ASCVD events in this high risk population are various including traditional vascular risk factors and specific HIV-related factors. However their respective influence is questionable.

Purpose

Our aim was to determine the incidence of ASCVD events in a large cohort of PLWHIV and to identify the risk factors associated.

Methods

We conducted a longitudinal observational cohort study of asymptomatic PLWHIV at high risk of ASCVD addressed to our preventive cardiovascular unit for non-invasive cardiovascular evaluation. The first ASCVD event was censored and included CV death, acute coronary syndromes, coronary and peripheral revascularizations (PCI or CABG or endarterectomy or limb procedures) and ischemic strokes.

Results

From January 2003 to December 2014, 763 consecutive asymptomatic PLWHIV were enrolled (mean age of 51.3±8.3 years, 87% men, 90% were free of known coronary artery disease, mean Left ventricular ejection fraction 60%). At baseline, traditional CV risk factors were as follow: 54% had dyslipidemia, 43% hypertension, 35% were active smokers, 22% had family history of CAD and 11% were diabetics. Statins were prescribed in 38% of the cohort, aspirin in 14%, clopidogrel in 14% betablockers in 14%, RAS blockers in 32%, Calcium channel blockers in 8%. At baseline, median duration of HIV seropositivity was 19.8 years (14.0–23.6), 94% were under ARV predominantly protease inhibitors (68%). Median CD4 cell count was 545/mm3 (404–745) and 92% had undetectable HIV viral load. During a median follow up of 5.8 years (3.7–8.7), 58 (7.3%) subjects had a first ASCVD event (incidence of 12.70 [9.78–16.51] per 1000 persons-years) including 5 cardiovascular deaths, 14 ACS, 20 coronary revascularizations, 13 peripheral vascular procedures and 6 strokes) with a median time of occurrence of 3.1 years (1.5–5.1). CV death (first and second ASCVD events) occurred in 8 patients (22%) after CV death related to malignancies (33%) but before deaths related to unexplained causes (21%), infectious disease (13%), liver disease (8%) and suicides (3%). Coronary events including coronary death, MI, and coronary revascularization occurred in 39 patients (5.2%); Incidence of 8.28 [6.00–11.43] per 1000 persons-years. Conventional multivariate Cox model shows that age and tobacco were the independent risk factors associated with ACSVD events [Hazard ratio (HR) 1.04, 95% CI 0.99–1.09, p=0.05 and HR 2.17, 95% CI 1.07–4.38, p=0.03].

Conclusion

Traditional vascular risk factors (age and active smoking) are associated with the occurrence of ASCVD events predominantly coronary artery disease in our observational cohort of asymptomatic PLWIHV at high risk for ASCVD. Cardiovascular prevention including tobacco cease action is mandatory in the aging HIV population.

Modeling variation of clinical team processes with multiple sequence alignment

Our objective was to model process variation of Emergency Medical Service teams responding to simulated pediatric emergencies and determine if sequence alignment distinguishes performance quality. We performed a retrospective process analysis by watching and coding activities in videos from standardized simulations of 42 Emergency Medical Service teams. Teams were classified into high- or low-performing groups based on the Clinical Teamwork Scale™. Activities were coded according to resuscitation tasks, performer, and times. We used ClustalG to align task sequences within and between groups, and measured similarity. Teams within and between performance levels had an average sequence similarity of 52 ± 7% and 50 ± 7%. Teams performed clinically appropriate tasks that varied in prioritization, for example, performing compressions or connecting the EKG monitor early. There was no statistical difference in gross similarity between groups but specific differences in prioritization may have had clinically meaningful implications. Alignment could improve by accounting for task duration and concurrency.

Minimally invasive spinal decompression surgery in diabetic patients: perioperative risks, complications and clinical outcomes compared with non-diabetic patients' cohort

BACKGROUND

Prior studies have documented an increased complication rate in diabetic patients undergoing spinal surgery. However, the impact of diabetes on the risk of postoperative complications and clinical outcome following minimally invasive spinal (MIS) decompression is not well understood.

OBJECTIVES

To compare complication rates and outcomes of MIS decompression in diabetic patients with a cohort of non-diabetic patients undergoing similar procedures.

METHODS

Medical records of 48 patients with diabetes and 151 control patients that underwent minimally invasive lumbar decompression between April 2009 and July 2014 at our institute were reviewed and compared. Past medical history, the American Society of Anesthesiologists score, perioperative mortality, complication and revision surgeries rates were analyzed. Patient outcomes included: the visual analog scale and the EQ-5D scores.

RESULTS

The mean age was 68.58 ± 11 years in the diabetic group and 51.7 ± 17.7 years in the control group. No major postoperative complications were recorded in either group. Both groups were statistically equivalent in their postoperative length of stay, minor complications and revision rates. Both groups showed significant improvement in their outcome scores following surgery.

CONCLUSIONS

Our results indicate that minimally invasive decompressive surgery is a safe and effective treatment for diabetic patients and does not pose an increased risk of complications. Future prospective studies are necessary to validate the specific advantages of the minimally invasive techniques in the diabetic population. These slides can be retrieved under Electronic Supplementary Material.

Observational multi-centre, prospective study to characterize novel pathogen-and host-related factors in hospitalized patients with lower respiratory tract infections and/or sepsis - the "TAILORED-Treatment" study

Background

The emergence and spread of antibiotic resistant micro-organisms is a global concern, which is largely attributable to inaccurate prescribing of antibiotics to patients presenting with non-bacterial infections. The use of ‘omics’ technologies for discovery of novel infection related biomarkers combined with novel treatment algorithms offers possibilities for rapidly distinguishing between bacterial and viral infections. This distinction can be particularly important for patients suffering from lower respiratory tract infections (LRTI) and/or sepsis as they represent a significant burden to healthcare systems. Here we present the study details of the TAILORED-Treatment study, an observational, prospective, multi-centre study aiming to generate a multi-parametric model, combining host and pathogen data, for distinguishing between bacterial and viral aetiologies in children and adults with LRTI and/or sepsis.

Methods

A total number of 1200 paediatric and adult patients aged 1 month and older with LRTI and/or sepsis or a non-infectious disease are recruited from Emergency Departments and hospital wards of seven Dutch and Israeli medical centres. A panel of three experienced physicians adjudicate a reference standard diagnosis for all patients (i.e., bacterial or viral infection) using all available clinical and laboratory information, including a 28-day follow-up assessment. Nasal swabs and blood samples are collected for multi-omics investigations including host RNA and protein biomarkers, nasal microbiota profiling, host genomic profiling and bacterial proteomics. Simplified data is entered into a custom-built database in order to develop a multi-parametric model and diagnostic tools for differentiating between bacterial and viral infections. The predictions from the model will be compared with the consensus diagnosis in order to determine its accuracy.

Discussion

The TAILORED-Treatment study will provide new insights into the interplay between the host and micro-organisms. New host- or pathogen-related biomarkers will be used to generate a multi-parametric model for distinguishing between bacterial and viral infections. This model will be helpful to better guide antimicrobial therapy for patients with LRTI and sepsis. This study has the potential to improve patient care, reduce unnecessary antibiotic prescribing and will contribute positively to institutional, national and international healthcare economics.

Trial Registration

NCT02025699. Registration Date: January, 1, 2014.

Electronic supplementary material

The online version of this article (10.1186/s12879-018-3300-9) contains supplementary material, which is available to authorized users.