Laboratory Management for Cytopathology Fellows: Our Institution’s Curriculum

Introduction/Objective

The cytopathology laboratory is one of the most highly regulated clinical laboratories. The Accreditation Council for Graduate Medical Education (ACGME) milestones include competencies in laboratory management. Additionally, many cytology fellows will be involved in laboratory management after finishing training. Therefore, it is imperative to incorporate formal laboratory management training for cytology fellows. Our cytopathology department implemented a formal laboratory management curriculum this year, with emphasis placed on the milestones (1.0 and 2.0) provided by the ACGME.

Methods/Case Report

The curriculum is divided into seven modules extending throughout the fellowship year (August-April). The modules include hand-off communication, process improvement, laboratory accreditation (introduction, intermediate, advanced) and error management (introduction, intermediate). Each module has two components: self-study of assigned reading materials and online courses, followed by an interactive session with faculty and/or laboratory personnel. Several engaging, high-quality resources are used including Institute for Healthcare Improvement Open School, modules from professional organizations, PubMed articles, National Quality Forum, departmental committees and mock inspections. Each module is followed by an interactive session to review policies, procedures and/or checklists. The fellows also spend time in the cytology laboratory preparation area and participate in Quality Improvement meetings.

Results (if a Case Study enter NA)

The fellowship director discusses the educational expectations at the start of each module. Evidence of compliance is demonstrated by uploading all of the completed assignments to MedHub (a web- based training management system) at the end of the module. All of the modules include self-assessment questions that are reviewed by the fellowship director.

Conclusion

Our cytopathology laboratory introduced a structured laboratory management curriculum. This curriculum fulfills some of the laboratory management competencies put forth in the ACGME milestones. This curriculum will also help to prepare fellows to confidently participate in cytology laboratory management as they enter the workforce.

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

OP0134 NOVEL INTERFERON GENE EXPRESSION SCORES PREDICT REFRACTORY SEVERE CUTANEOUS DISEASE FOLLOWING RITUXIMAB THERAPY IN SLE

Background:

We developed and validated two continuous interferon-stimulated gene (ISG) expression scores (IFN-Score-A and IFN-Score-B) that predict clinical outcomes in SLE. IFN-Score-A includes ISGs typically present in a global interferon signature while IFN-Score-B includes additional ISGs potentially responsive to multiple IFN subtypes [1].

We have previously shown that these scores associate with treatment response following rituximab (RTX) therapy within the British Isles Lupus Assessment Group (BILAG) Biologics Register (BILAG-BR), a UK wide study of patients treated with RTX for active SLE following cyclophosphamide and/ or mycophenolate mofetil treatment failure. Specifically, multivariable analysis showed higher baseline IFN-Score-B independently predicted BILAG response at 6 months post treatment [2].

We also showed that response of cutaneous lupus to RTX can be poor even when other organs respond well, and that interferons are enriched in the skin of patients with SLE where dysregulated keratinocytes are a source of IFNк [3]. MASTERPLANS is a consortium aimed at identifying therapeutic biomarkers in SLE.

Objectives:

To investigate how IFN-Score-A and -B associated with skin disease and response to RTX.

Methods:

Pre-treatment whole blood samples were collected in TEMPUS tubes from subjects undergoing first RTX treatment within BILAG-BR. IFN-Scores were derived using a custom Taqman array as previously described [1]. Clinical response was defined as improvement in BILAG-2004 disease activity, with a maximum of one domain showing persistent BILAG-2004 grade B disease, and no new BILAG grade A or B disease flares at 6 months. The mucocutaneous domain of BILAG was then analysed separately.

Results:

147 patients were studied, of whom 90 had follow up data available. Baseline BILAG-2004 grade A/B disease activity predominantly affected the mucocutaneous domain in 74/147 (50.3%), musculoskeletal in 61 /147 (41.5%) and renal domain 66/147 (37.4%).

At 6 months 59/90 (65.6%) achieved an overall treatment response. Responders showed significantly higher mean IFN-Score-B compared with non-responders (-1.8 vs -2.4, p = 0.04). Among those with active grade A/B BILAG-2004 mucocutaneous disease at baseline, 38/50 (76%) showed improvement within this domain at 6 months. However, among overall non-responders, 7/31 (22.6%) had new or residual BILAG-A mucocutaneous disease at 6 months post RTX, indicating it to be a substantial component of overall treatment failure. In contrast, persistent grade A musculoskeletal disease was seen in 9.7% of non-responders. BILAG-A mucocutaneous disease is characterised by severe manifestations including extensive rashes covering > 18% of body surface area, severe bullous lupus or panniculitis and disabling deep mucosal ulceration. Neither IFN-Score-A nor IFN-Score-B were significantly associated with the severity of mucocutaneous disease at baseline. However, individuals with persistent or new BILAG-A mucocutaneous disease at six months following RTX displayed significantly lower baseline IFN-Score-B than those with improving or residual less severe disease (-3.0 vs -2.1, p = 0.04) after RTX.

Conclusion:

Low IFN score-B status identified an endotype of severe mucocutaneous SLE which was resistant to RTX therapy in the BILAG-BR cohort. We previously showed that high IFN-score-B independently predicts overall therapeutic response to rituximab. Further work will aim to refine IFN status as overall and organ specific biomarkers in SLE.

References:

[1] El-Sherbiny et al., Sci. Rep. 2018; 8: 5793.

[2] Alase et al., ARD 2019;78:763-764

[3] Psarras et al., Nat Commun. 2020; 11: 6149

Acknowledgements:

We would like to thank the Medical Research Council, National Institute of Health Research, UK for funding the MASTERPLANS project

Disclosure of Interests:

Lucy Marie Carter: None declared, Adewonuola Alase: None declared, Zoe Wigston: None declared, Antonios Psarras: None declared, Agata Burska: None declared, Md Yuzaiful Md Yusof: None declared, Elizabeth Hensor: None declared, John Reynolds: None declared, Miriam Wittmann Consultant of: Abbvie, Celgene, Janssen, L’Oreal, Novartis and Pfizer, Ian N. Bruce Speakers bureau: GlaxoSmithKline, UCB Pharma, Consultant of: AstraZeneca, Eli Lilly, GlaxoSmithKline, ILTOO Pharma, MedImmune, Merck Serono, Grant/research support from: Genzyme Sanofi, GlaxoSmithKline, Edward Vital Consultant of: Roche, GSK and AstraZeneca, Grant/research support from: Roche, GSK and AstraZeneca

Mortality from esophagectomy for esophageal cancer across low, middle, and high-income countries: An international cohort study

BACKGROUND

No evidence currently exists characterising global outcomes following major cancer surgery, including esophageal cancer. Therefore, this study aimed to characterise impact of high income countries (HIC) versus low and middle income countries (LMIC) on the outcomes following esophagectomy for esophageal cancer.

METHOD

This international multi-center prospective study across 137 hospitals in 41 countries included patients who underwent an esophagectomy for esophageal cancer, with 90-day follow-up. The main explanatory variable was country income, defined according to the World Bank Data classification. The primary outcome was 90-day postoperative mortality, and secondary outcomes were composite leaks (anastomotic leak or conduit necrosis) and major complications (Clavien-Dindo Grade III - V). Multivariable generalized estimating equation models were used to produce adjusted odds ratios (ORs) and 95% confidence intervals (CI95%).

RESULTS

Between April 2018 to December 2018, 2247 patients were included. Patients from HIC were more significantly older, with higher ASA grade, and more advanced tumors. Patients from LMIC had almost three-fold increase in 90-day mortality, compared to HIC (9.4% vs 3.7%, p < 0.001). On adjusted analysis, LMIC were independently associated with higher 90-day mortality (OR: 2.31, CI95%: 1.17-4.55, p = 0.015). However, LMIC were not independently associated with higher rates of anastomotic leaks (OR: 1.06, CI95%: 0.57-1.99, p = 0.9) or major complications (OR: 0.85, CI95%: 0.54-1.32, p = 0.5), compared to HIC.

CONCLUSION

Resections in LMIC were independently associated with higher 90-day postoperative mortality, likely reflecting a failure to rescue of these patients following esophagectomy, despite similar composite anastomotic leaks and major complication rates to HIC. These findings warrant further research, to identify potential issues and solutions to improve global outcomes following esophagectomy for cancer.

Exenatide extended release in patients with type 1 diabetes with and without residual insulin production

AIMS

To test whether a long-acting GLP-1 receptor agonist would improve glucose control in patients with type 1 diabetes (T1D) and to determine whether the presence of residual beta cell function would affect the response. In addition, we sought to determine whether the drug would affect beta cell function.

METHODS

We performed a randomized placebo-controlled trial of exenatide extended release (ER) in participants with T1D with and without detectable levels of C-peptide. Seventy-nine participants were randomized to exenatide ER 2 mcg weekly, or placebo, stratified by the presence or absence of detectable C-peptide levels. The primary outcome was the difference in glycated haemoglobin (HbA1c) levels at 24 weeks. Participants were followed for another 6 months off study drug.

RESULTS

At week 24, the time of the primary outcome, the least squares (LS) mean HbA1c level was 7.76% (95% confidence interval [CI] 7.42, 8.10) in the exenatide ER group versus 8.0% (95% CI 7.64, 8.35) in the placebo group (P = 0.08). At week 12 the LS mean HbA1c levels were 7.71% (95% CI 7.37, 8.05) in the exenatide ER group versus 8.05% (95% CI 7.7, 8.4) in the placebo group (P = 0.01). The improvement at week 12 was driven mainly by those with detectable levels of C-peptide. Those treated with exenatide ER lost weight at 12 and 24 weeks compared to those treated with placebo (P <0.001 and P = 0.007). The total insulin dose was lower, but not when corrected for body weight, and was not affected by residual insulin production. Adverse events were more frequent with exenatide ER, but hypoglycaemia was not increased.

CONCLUSION

Treatment with exenatide ER may have short-term benefits in some individuals with T1D who are overweight or who have detectable levels of C-peptide, but short-term improvements were not sustained.

Antimicrobial Stewardship Optimization in the Emergency Department: The Effect of Multiplex Respiratory Pathogen Testing and Targeted Educational Intervention

Background

Antibacterial agents are often prescribed for patients with suspected respiratory tract infections even though these are most often caused by viruses. In this study, we sought to evaluate the effect of Respiratory Pathogen Panel (RPP) PCR result availability and antimicrobial stewardship education on antibiotic prescription rates in the adult emergency department (ED).

Methods

We compared rates of antibacterial and oseltamivir prescriptions between 2 nonconsecutive influenza seasons among ED visits, wherein the latter season followed the implementation of a comprehensive educational stewardship campaign. In addition, we sought to elucidate the effect of RPP-PCR on antibiotic prescriptions, with focus on result availability prior to the conclusion of emergency department encounters.

Results

Antibiotic prescription rates globally decreased by 17.9% in the FS-17/18 cohort compared to FS-14/15 (P &lt; 0.001), while oseltamivir prescription rates stayed the same overall (P = 0.42). Multivariate regression across both cohorts revealed that patients were less likely to receive antibiotics if RPP-PCR results were available before the end of the ED visit or if the RPP-PCR result was positive for influenza. Patients in the educational intervention cohort were also less likely to receive an antibiotic prescription.

Conclusion

This study provides evidence that RPP-PCR results are most helpful if available prior to the end of the provider-patient interaction. Further, these data suggest that detection of influenza remains an influential result in the context of antimicrobial treatment decision making. In addition, these data contribute to the body of literature which supports comprehensive ASP interventions including leadership and patient engagement.

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

SAT0192 TRAJECTORIES OF LUPUS DISEASE ACTIVITY OVER TIME IN THE CLINICAL TRIAL SETTING REVEALED BY LATENT CLASS MIXED MODELS

Background:

There is considerable debate regarding the most appropriate outcome measures for clinical trials in systemic lupus erythematosus (SLE). We propose that studying changes in disease activity over time may yield important information above and beyond fixed endpoints at 12 months.

Objectives:

To compare outcomes and predictors of response using i) traditional response definitions at a fixed time point and ii) trajectories of disease activity over time in a clinical trial dataset.

Methods:

Data from the phase 3 clinical trial of Epratuzumab (EMBODY) in patients with active SLE were reanalysed. Response at 12 months was defined as: reduction to ≤1 BILAG B score, no increase in SLEDAI-2K score and no increase in prednisolone dose. Latent class mixed models (LCMM) were constructed using the numerical BILAG-2004 (nBILAG) score (where A=12, B=8, C=1, D/E=0) from the screening visit until trial end. Cumulative prednisolone and Epratuzumab exposure was determined by estimating the area under the dose-time or concentration-time curves (AUC) respectively.

Results:

1202 patients were included with a median disease duration of 5.6 [1.9, 12.7] years and baseline nBILAG score of 20 [16, 24]. At 12 months there were 564/1202 (46.9%) responders. There was no association between receiving Epratuzumab and response. Responders were older, with lower baseline nBILAG score and baseline steroid dose. Using a cubic spline LCMM in the whole cohort, 5 trajectories were identified: Non-responders (NR, 33.9%), rapid responders (RR, 36.7%), slow responders (SR, 20.7%), flare (F, 4.7%) and high disease activity (HDA, 3.9%) (figure). Of the 564 12-month responders, 113 (20.4%) were in the NR latent class whilst 417 (73.9%) were in RR or SR classes. Whilst there were no differences in study drop-out due to adverse events, withdrawal due to inefficacy was 20.6% in NR compared to 8.4% in RR and 7.6% in SR.

In multivariable logistic regression models adjusted for age, gender and study drop-out, being a responder (RR or SR) was significantly associated with activity in constitutional, musculoskeletal and cardiorespiratory BILAG domains, higher baseline and cumulative steroid exposure, and receiving active drug.

There was a trend towards higher baseline CD19+ counts in RR compared to NR or SR (p=0.108) but in a population-averaged multivariable linear model only baseline CD19+ count, Epratuzumab and steroid dose were associated with number of CD19+ cell over time (p<0.001 for each).

Conclusion:

Compared to a fixed end-point at 12 months, LCMM identified trajectories of disease activity and an association between clinical improvement and receiving active drug. Predictors of response vary significantly according to the response definition used.

Table.

Comparison of predictors of response between the 2 models

Response at 12 monthsResponse latent call (RR or SR)AgeYesNoBaseline gBILAG scoreYes (negative)Yes (positive)Baseline steroid doseYesYesActive diseaseConstitutionalNoYesMusculoskeletalNoYesCardiorespiratoryNoYesGastroenterologicalYesNoAnti-SmithYesNoLow C3YesNoEpratuzumabNoYes

Acknowledgments:

Presented on behalf of the MASTERPLANS Consortium

Disclosure of Interests:

John Reynolds: None declared, Jennifer Prattley: None declared, Mark Lunt: None declared, Nophar Geifman: None declared, Ian N. Bruce Grant/research support from: Genzyme Sanofi, GSK, and UCB, Consultant of: Eli Lilly, AstraZeneca, UCB, Iltoo, and Merck Serono, Speakers bureau: UCB

OP0094 EULAR-ACR 2019 CLASSIFICATION CRITERIA FOR SLE: CAN WE CLASSIFY USING LABORATORY TESTS ALONE?

Background:

The EULAR-ACR 2019 (EULAR19) classification criteria for systemic lupus erythematosus (SLE) were developed to improve the sensitivity and specificity of previous criteria. Notably, both the EULAR19 and existing SLICC-SLE 2012 (SLICC12) criteria can classify patients as having SLE by the presence of immunology and haematological abnormalities in the absence of any signs or symptoms.

Objectives:

To validate the EULAR19 criteria, with comparison to existing criteria, in a large cohort of patients with an established systemic autoimmune rheumatic disease (SARD).

Methods:

We recruited 227 adult patients who were ANA positive with ≥1 clinical feature suggestive of a SARD, from three hospitals in the North West of England. Clinician diagnosis was used as gold standard; we then applied the EULAR19, SLICC12 and the ACR-SLE 1997 (ACR97) criteria.

Results:

Of the 227 patients recruited, by clinician diagnosis, 89 patients (36%) had SLE, 43 (17%) primary Sjögren’s (pSS), 62 (25%) undifferentiated CTD (UCTD), 25 (10%) systemic sclerosis (SSc) and 8 (3%) an inflammatory myositis. The characteristics of these patients and the breakdown of the EULAR19 criteria are outlined in figure 1.

Figure 1.

Baseline characteristics and classification criteria compared across five SARD diagnoses.

The sensitivity and specificity of the EULAR19 is similar to ACR97 (sensitivity 84% (95% CI 75-91%) vs. 87% (95% CI 78-93%) and specificity 78% (95% CI 70-84%) vs. 76% (95% CI 68-83%) respectively). The SLICC12 criteria by contrast are more sensitive (94% (95% CI 87-98%)) and less specific (61% (95% CI 52-69%)) in this cohort.

Figure 2 illustrates patients with a clinician diagnosis of SLE or UCTD who meet each of the classification criteria. Of the 89 patients with a clinician diagnosis of SLE, 39 (44%) patients would have sufficient points to meet EULAR19 criteria on blood test results alone in the absence of clinical symptoms. Four pSS patients and 4 UCTD patients would also meet EULAR19 criteria from positive blood results alone.

Figure 2.

Venn diagrams illustrating patients with SLE and UCTD who meet the EULAR19, ACR97 and SLICC12 classification criteria. No criteria refers to the patients not meeting any of the three SLE classification criteria.

Conclusion:

These results suggest that the EULAR19 criteria perform comparably to the ACR97 criteria when applied to an established cohort of SARDs. Similar to SLICC12, it is possible to classify patients as having SLE using the EULAR19 criteria by haematological and other laboratory tests. To what extent haematological abnormalities can be potentially used as the sole ‘clinical criteria’ needs consideration.

SLE n=89pSS n=43UCTD n=62SSc n=25Myositis n=8Female N (%)82 (92)42 (98)53 (85)24 (96)8 (100)Age, mean (SD) /years44 (13)52 (12)47 (13)60 (9)53 (7)Disease duration, mean (SD) /years12 (10)6 (5)5 (7)9 (11)3 (3)SLE classification criteriaEULAR SLE 2019, N (%)75 (84)10 (23)20 (32)1 (4)0ACR SLE 1997, N (%)77 (87)9 (21)21 (34)2 (8)1 (13)SLICC SLE 2012, N (%)84 (94)15 (35)33 (53)4 (16)2 (25)EULAR-ACR 2019 criteriaConstitutional, N (%)10 (11)2 (5)1 (2)01 (13)Neuropsychiatric, N (%)3 (3)01 (2)1 (4)0Mucocutaneous, N (%)71 (80)13 (30)27 (44)2 (8)2 (25)Serosal, N (%)13 (15)1 (2)2 (3)00Musculoskeletal, N (%)52 (58)14 (33)22 (35)3 (12)3 (38)Renal, N (%)30 (34)001 (4)0Haematological, N (%)44 (49)12 (28)10 (16)3 (12)0Antiphospholipid antibodies, N (%)43 (48)7 (16)17 (27)4 (16)0Low complement, N (%)48 (54)10 (23)10 (16)3 (12)1 (13)Anti-Sm, N (%)19 (21)2 (5)4 (6)1 (4)0Anti-dsDNA, N (%)50 (56)8 (19)12 (19)01 (13)

Disclosure of Interests:

Sarah Dyball: None declared, John Reynolds: None declared, Eoghan McCarthy: None declared, Sahena Haque: None declared, Ariane Herrick: None declared, Hector Chinoy: None declared, Ellen Bruce: None declared, Ben Parker Grant/research support from: GSK and Sanofi Genzyme, Consultant of: GSK, AstraZenaca, UCV, Abbvie, Pfizer, BMS, Celltrion, Ian N. Bruce Grant/research support from: Genzyme Sanofi, GSK, and UCB, Consultant of: Eli Lilly, AstraZeneca, UCB, Iltoo, and Merck Serono, Speakers bureau: UCB

SAT0191 PLASMA PROTEOMICS IDENTIFIES A PROTEIN SIGNATURE ASSOCIATED WITH RESPONSE TO RITUXIMAB IN PATIENTS WITH SLE

Background:

Rituximab (RTX) is B cell-depleting biological therapy used in the treatment of systemic lupus erythematosus (SLE). Response rates are typically around 50% and there are currently no robust biomarkers to identify which patients are more likely to respond.

Objectives:

To determine whether proteomic analysis of baseline plasma samples could identify novel biomarkers of response to RTX in patients with active SLE.

Methods:

Patients with SLE (≥ 4 ACR criteria) receiving RTX for active disease (BILAG A or 2 BILAG B scores) from the UK-based BILAG-BR register were included. Improvement at 12 months was defined as a reduction to ≤ 1 BILAG B score with no increase in either SLEDAI score or steroid dose. Proteomic analysis was performed on baseline plasma samples using sequential window acquisition of all theoretical fragment ion spectra mass spectrometry (SWATH-MS). Data were aligned and normalised to give relative protein abundance. A Lasso penalised logistic regression, with an outcome of improvement at 12 months, was used to perform the variable selection procedure using the R package ‘glmnet’. The penalty metric was set at the value which minimised deviance in a 10-fold cross-validation procedure. Confounding variables of sex, age, ethnicity, oral steroid dose, and SLEDAI score had no penalty applied and were thus forcibly retained in the model. Protein-protein interaction networks were visualised using STRING v11.0.

Results:

70 patients of whom 63/70 (90%) were female with a median (IQR) age of 41 (32, 51) years and disease duration of 11 (6, 20) years at baseline were included. Patients had active disease with a median SLEDAI score of 10 (6, 16). All patients received RTX according to NHS England guidelines. Of 829 proteins, 815 were detected in at least 1 patient. We identified 9 proteins which were associated with clinical improvement at 12 months. A literature search identified that these proteins have relevance to T cell function, complement activation and lupus nephritis. Gender had the greatest weight in the model followed by Serpin Family A Member 10 (SERPINA10) and complement factor B (CFB). Protein interaction networks linked SERPINA10 to CFB by C3 complement (figure).

Conclusion:

Plasma proteome analysis has identified a protein signature associated with response to RTX in SLE. These findings will be validated in independent cohorts and may offer the ability to predict response to RTX in lupus patients.

Protein Interaction Network of the 9 proteins from the multivariable model (with one additional level added). Cyan/magenta lines shown known interactions. Other colours show predicted interactions.

Disclosure of Interests: :

John Reynolds: None declared, Jennifer Prattley: None declared, Mark Lunt: None declared, Ian N. Bruce Grant/research support from: Genzyme Sanofi, GSK, and UCB, Consultant of: Eli Lilly, AstraZeneca, UCB, Iltoo, and Merck Serono, Speakers bureau: UCB

"It's all interconnected… like a spider web": a qualitative study of the meanings of food and healthy eating in an Indigenous community

Canadian Indigenous populations are disproportionately affected by rising rates of diet-related chronic disease and have been experiencing rapid lifestyle changes affecting diet. In recognition of these issues, this study aimed to obtain greater understanding of attitudes and meanings around healthy eating in a semi-remote community in Eeyou Istchee. A qualitative study design used semi-structured interviews and observational field notes to explore local accounts of food and health. Two distinct versions of “healthy eating” were identified: one relating to traditional food and preparation methods; the other reflecting medicalised accounts of illness and diagnosed conditions. The latter links with “southern” modes of accessing and preparing food, demonstrating local capacity to adapt to the rapid changes in body, lifestyle and environment being experienced. New connections, associating non-native ways with traditional practices, are being formed where traditional ways of living on the land have been severed. These local accounts show how people are continually negotiating different constructs of “healthy eating.” These findings expand current understandings of the context of food and healthy eating in Eeyou Istchee, emphasising present-day and historical experiences of the land. Future research and diet-related health interventions must continue to acknowledge and incorporate local understandings of health to help address the broader socio-political factors that shape Indigenous lifestyles, environments and health.

Trekstock RENEW: evaluation of a 12-week exercise referral programme for young adult cancer survivors delivered by a cancer charity

Purpose

To evaluate the uptake and effect of RENEW, a 12-week exercise referral programme for young adult cancer survivors delivered by Trekstock, a UK-based cancer charity.

Methods

The RENEW programme provides one-to-one individually tailored support from a level-4 cancer-rehabilitation-qualified gym instructor, free gym membership and access to information resources online. Objective and self-report data on cardiorespiratory function, strength, body composition, fatigue, sleep quality and general health-related quality of life (HRQoL) was collected from participants before the programme (week 0), immediately after (week 12) and 1 month later (week 16).

Results

Forty-eight young adults (83% female; mean age, 29 years) with a history of cancer took part within the 12-week programme and completed the evaluation measures. Physical activity (PA) levels significantly increased following the programme and remained raised at follow-up. Improvements in physical function were significant: peak expiratory flow (mean change, 30.96, p = 0.003), sit-and-reach test (mean change, 6.55 ± 4.54, p < 0.0001), and 6-mine-walk test (mean change, 0.12 ± 0.04, p < 0.0001). No significant changes in BMI, weight or muscle mass were observed. Improvements in fatigue, sleep and HRQoL were observed across the programme and at follow-up (mean change, weeks 0–16; 8.04 ± 1.49 p < 0.01; 1.05 ± 0.49 p < 0.05; and − 0.9 ± 0.46 p = 0.051, respectively). Changes in self-efficacy to exercise and motivations to exercise were not observed at 12 weeks or at follow-up.

Conclusions

Results suggest that the RENEW exercise referral programme has a positive impact upon some domains of physical function and well-being among young adult cancer survivors.

Implication for cancer survivors

Exercise referral programmes delivered by charity organisations are one means by which PA behaviour change support may be widely disseminated to young adult cancer survivors. Health professionals and charitable bodies specialising in the care of young adults with cancer should look to address factors which prevent engagement and uptake of ‘real-world’ PA interventions such as the RENEW programme.

Quality and Publication of Emergency Medicine Trials Registered in ClinicalTrials.gov

Introduction

Promoting emergency medicine (EM) clinical trials research remains a priority. To characterize the status of clinical EM research, this study assessed trial quality, funding source, and publication of EM clinical trials and compared EM and non-EM trials on these key metrics. We also examined the volume of EM trials and their subspecialty areas.

Methods

We abstracted data from ClinicalTrials.gov (February 2000 – September 2013) and used individual study National Clinical Trial numbers to identify published trials (January 2007 – September 2016). We used descriptive statistics and chi-square tests to examine study characteristics by EM and non-EM status, and Kaplan-Meier curves and log-rank tests to compare time to publication of completed EM and non-EM studies.

Results

We found 638 interventional EM trials and 59,512 non-EM interventional trials conducted in the United States between February 2000 and September 2013, registered on ClinicalTrials.gov. EM studies were significantly less likely than non-EM studies to be National Institutes of Health-funded or to evaluate a drug or biologic. However, EM studies had significantly larger sample sizes, and were significantly more likely to use randomization and blinding. Overall, 34.3% of EM and 26.0% of non-EM studies were published in peer-reviewed journals. By subspecialty, more EM trials concerned medical/surgical and psychiatric/neurological conditions than trauma.

Conclusion

Although EM studies were less likely to have received federal or industry funding, and the EM portfolio consisted of only 638 trials over the 14-year study period, the quality of EM trials surpassed that of non-EM trials, based on indices such as randomization and blinding. This novel finding bodes well for the future of clinical EM research, as does the higher proportion of published EM than non-EM trials. Our study also revealed that trauma studies were under-represented among EM studies. Periodic assessment of EM trials with the metrics used here could provide an informative and valuable longitudinal view of progress in clinical EM research.

Crowdsourcing hypothesis tests: Making transparent how design choices shape research results

To what extent are research results influenced by subjective decisions that scientists make as they design studies? Fifteen research teams independently designed studies to answer five original research questions related to moral judgments, negotiations, and implicit cognition. Participants from 2 separate large samples (total N > 15,000) were then randomly assigned to complete 1 version of each study. Effect sizes varied dramatically across different sets of materials designed to test the same hypothesis: Materials from different teams rendered statistically significant effects in opposite directions for 4 of 5 hypotheses, with the narrowest range in estimates being d = -0.37 to + 0.26. Meta-analysis and a Bayesian perspective on the results revealed overall support for 2 hypotheses and a lack of support for 3 hypotheses. Overall, practically none of the variability in effect sizes was attributable to the skill of the research team in designing materials, whereas considerable variability was attributable to the hypothesis being tested. In a forecasting survey, predictions of other scientists were significantly correlated with study results, both across and within hypotheses. Crowdsourced testing of research hypotheses helps reveal the true consistency of empirical support for a scientific claim. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Visual Immunoprecipitate Assay Eight Hour Method for Detection of Enterohemorrhagic Escherichia coli O157:H7 in Raw and Cooked Beef (Modification of AOAC Official Method 996.09): Collaborative Study

AOAC Official Method 996.09, Visual Immunoprecipitate Assay (VIP®) for Escherichia coli O157:H7, was modified to incorporate a new enrichment protocol using BioControl EHEC8™ medium for testing raw and cooked beef. Foods were tested by VIP assay and the U.S. Department of Agriculture/Food Safety and Inspection Service (USDA/FSIS) enrichment procedure and the FDA Bacteriological Analytical Manual (BAM) isolation and confirmation techniques. A total of 15 collaborators participated. Raw and cooked ground beef were inoculated with E. coli O157:H7 at 2 different levels: a high level, where predominantly positive results were expect d, and a low level where fractional recovery was anticipated. Collaborators tested 396 test portions and controls by both methods, for a total of 792 test portions. Of the 396 paired test portions, 75 were positive and 230 were negative by both the VIP and culture methods. Eleven test portions were presumptively positive by VIP and could not be confirmed culturally; 32 were negative by VIP, but confirmed positive by culture; and 65 were negative by the culture method, but confirmed positive by the VIP method. There was no statistical difference between results obtained with the VIP for EHEC 8 h method and the culture method except for cooked beef, where the VIP had significantly higher recovery for one inoculation level.

Assurance® Enzyme Immunoassay Eight Hour Method for Detection of Enterohemorrhagic Escherichia coli O157:H7 in Raw and Cooked Beef (Modification of AOAC Official Method 996.10): Collaborative Study

AOAC Official Method 996.10, Assurance® Enzyme Immunoassay (EIA) for Escherichia coli O157:H7 (EHEC), was modified to incorporate a new enrichment protocol using BioControl EHEC8™ medium for testing raw and cooked beef. Foods were tested by EIA and the U.S. Department of Agriculture/Food Safety and Inspection Service (USDA/FSIS) enrichment conditions and the FDA Bacteriological Analytical Manual (BAM) isolation and confirmation techniques. A total of 14 collaborators participated. Raw and cooked ground beef were inoculated with E. coli O157:H7 at 2 different levels: a high level where predominantly positive results were expected, and a low level where fractional recovery was anticipated. Collaborators tested 378 test portions and controls by both the 8 h EIA and the USDA/FSIS enrichment methods, for a total of 756 test portions. Of the 378 paired test portions, 75 were positive and 212 were negative by both methods. Thirteen test portions were presumptively positive by EIA and could not be confirmed culturally; 30 were negative by EIA, but confirmed positive by culture; and 65 were negative by the culture method, but confirmed positive by the EIA method. There was no statistical difference between results obtained with the Assurance EIA for EHEC 8 h method and the culture method for raw ground beef. The Assurance EIA had a significantly higher recovery for cooked beef.

A single fast radio burst localized to a massive galaxy at cosmological distance

Fast radio bursts (FRBs) are brief radio emissions from distant astronomical sources. Some are known to repeat, but most are single bursts. Nonrepeating FRB observations have had insufficient positional accuracy to localize them to an individual host galaxy. We report the interferometric localization of the single-pulse FRB 180924 to a position 4 kiloparsecs from the center of a luminous galaxy at redshift 0.3214. The burst has not been observed to repeat. The properties of the burst and its host are markedly different from those of the only other accurately localized FRB source. The integrated electron column density along the line of sight closely matches models of the intergalactic medium, indicating that some FRBs are clean probes of the baryonic component of the cosmic web.

Does care at a cardiac arrest centre improve outcome after out-of-hospital cardiac arrest? - A systematic review

AIM

To perform a systematic review to answer 'In adults with attempted resuscitation after non-traumatic cardiac arrest does care at a specialised cardiac arrest centre (CAC) compared to care in a healthcare facility not designated as a specialised cardiac arrest centre improve patient outcomes?'

METHODS

The PRISMA guidelines were followed. We searched bibliographic databases (Embase, MEDLINE and the Cochrane Library (CENTRAL)) from inception to 1st August 2018. Randomised controlled trials (RCTs) and non-randomised studies were eligible for inclusion. Two reviewers independently scrutinized studies for relevance, extracted data and assessed quality of studies. Risk of bias of studies and quality of evidence were assessed using ROBINS-I tool and GRADEpro respectively. Primary outcomes were survival to 30 days with favourable neurological outcomes and survival to hospital discharge with favourable neurological outcomes. Secondary outcomes were survival to 30 days, survival to hospital discharge and return of spontaneous circulation (ROSC) post-hospital arrival for patients with ongoing resuscitation. This systematic review was registered in PROSPERO (CRD 42018093369) RESULTS: We included data from 17 observational studies on out-of-hospital cardiac arrest (OHCA) patients in meta-analyses. Overall, the certainty of evidence was very low. Pooling data from only adjusted analyses, care at CAC was not associated with increased likelihood of survival to 30 days with favourable neurological outcome (OR 2.92, 95% CI 0.68-12.48) and survival to 30 days (OR 2.14, 95% CI 0.73-6.29) compared to care at other hospitals. Whereas patients cared for at CACs had improved survival to hospital discharge with favourable neurological outcomes (OR 2.22, 95% CI 1.74-2.84) and survival to hospital discharge (OR 1.85, 95% CI 1.46-2.34).

CONCLUSIONS

Very low certainty of evidence suggests that post-cardiac arrest care at CACs is associated with improved outcomes at hospital discharge. There remains a need for high quality data to fully elucidate the impact of CACs.