MR compatibility, safety and accuracy of the redesigned UMC Utrecht single needle implant device

Purpose. The Utrecht single needle implant device (SNID) was redesigned to increase needle insertion velocity. The purpose of this study is to evaluate the magnetic resonance compatibility, safety and accuracy of the implant device preparing its application in a patient study to investigate the feasibility of inserting a brachytherapy needle into the prostate to a defined tumor target point.Methods. Several experiments were performed to evaluate the mechanical and radiofrequency safety of the needle system, the magnetic field perturbation, the calibration of the implant device in the MR coordinate system, functioning of the implant device during imaging and accuracy of needle insertion.Results. Endurance experiments showed the mechanical safety of the needle system. Magnetic field perturbation was acceptable with induced image distortions smaller than 0.5 mm for clinical MR sequences. Calibration of the implant device in the MR coordinate system was reproducible with average error (mean±standard deviation) of 0.2 ± 0.4 mm, 0.1 ± 0.3 mm and 0.6 ± 0.6 mm in thex,y- andz- direction, respectively. The RF safety measurement showed for clinical MR imaging sequences maximum temperature rises of 0.2 °C at the entry and tip points of the needle. Simultaneous functioning of the implant device and imaging is possible albeit with some intensity band artifacts in the fast field echo images. Finally, phantom measurements showed deviations amounting 2.5-3.6 mm measured as target-to-needle distance at a depth of 12 cm.Conclusions. This preclinical evaluation showed that the MR compatibility, safety and accuracy of the redesigned UMC Utrecht SNID allow its application in a patient study on the feasibility of inserting a brachytherapy needle into the prostate to a defined tumor target point.

POS0615 TOCILIZUMAB IS SAFE AND EFFECTIVE IN ELDERLY PATIENTS WITH RHEUMATOID ARTHRITIS

Background:

Average life spans of patients with rheumatoid arthritis (RA) are approaching those of the general population. This results in a large proportion of RA patients being elderly at some point and underlines effective RA treatments needed for this population. Pivotal clinical trials have demonstrated the efficacy of tocilizumab (TCZ) for the treatment of RA. However, real-world studies that explore the effectiveness of TCZ especially in the elderly are lacking. ICHIBAN was a large, observational study that followed patients with RA treated with TCZ under real-world conditions in Germany for up to 2 years.

Objectives:

In this analysis of ICHIBAN, we examined the safety and effectiveness of long-term TCZ treatment according to patient baseline (BL) age (<50, 50–65, >65 years).

Methods:

ICHIBAN (NCT01194401) was a prospective, non-interventional study that observed adult patients with active moderate to severe RA in German rheumatology clinics and practices. Patients were treated with TCZ according to the local label. The safety analyses set (SAF) included all patients who received at least one dose of TCZ. The effectiveness set (EFF) included all patients from the SAF who had no prior TCZ therapy. Patient-reported outcomes (PROs) were assessed using the visual analogue scale. Last observation carried forward was used to substitute for missing values.

Results:

At baseline (BL), 3,164 patients were included in the SAF: 29.2% <50 years, 47.3% 50–65 years, and 23.5% >65 years old (1.2% ≥80 years). Patients >65 years old were not only the most likely to have comorbidities such as hypertension, anaemia, renal insufficiency, osteoporosis, diabetes, and coronary heart disease, but also had the highest BL disease activity according to Disease Activity Score-28 erythrocyte sedimentation rate (DAS28-ESR) and Clinical Disease Activity Index (CDAI) (Table 1).

Proportions of patients with adverse events (AEs) considered related to treatment were similar in patients <50 (22.3%), 50–65 (21.9%) and >65 years (22.2%). More patients >65 years (20.2%) and 50–65 years (14.4%) experienced serious AEs (SAEs) than patients <50 years (11.5%). Slightly more patients >65 years old experienced infectious SAEs (4.8%) than younger patients (<50 years, 3.2% and 50–65 years, 3.1%). Yet, similar proportions of patients across all age groups discontinued TCZ due to AE (7.0% <50 years; 9.6% 50–65 years; 7.8% >65 years).

2,902 patients were included in the EFF. Patients <50 years experienced DAS28-ESR remission at least once during the treatment period (65.4%) more often than patients aged 50–65 years (59.8%) or >65 years (59.5%). However, patients >65 years had numerically greater improvements in DAS28-ESR (Table 1). Patients <50 years had the best physical functioning at BL and the greatest reduction in Health Assessment Questionnaire Disease Index (HAQ-DI) score (Figure 1A). All age groups had similar improvements in PROs such as fatigue, strength of pain, and sleep disturbances (Figure 1B).

Table 1.

Model summary for prediction of DAS28CRP using time and etanercept originator (relative to biosimilar)

<50 years50–65 years>65 yearsDAS28-ESR, mean ± SDn*7771237617BL4.9 ± 1.45.3 ± 1.35.4 ± 1.3Last visit2.8 ± 1.73.1 ± 1.73.2 ± 1.7Change from BL-2.0 ± 1.7-2.2 ± 1.7-2.2 ± 1.8CDAI, mean ± SDn*7681217590BL25.7 ± 12.828.4 ± 13.328.8 ± 12.8Last visit13.3 ± 12.814.6 ± 13.214.5 ± 12.8Change from BL-12.5 ± 13.6-13.8 ± 14.0-14.3 ± 13.8

*271 patients with missing data at BL

**327 patients with missing data at BL

Conclusion:

Although elderly patients experienced a higher rate of infections, the proportion of patients withdrawing due to AE was not higher than in the other age groups. Starting with higher baseline disease activity, patients >65 years had similar benefits to disease activity and PROs when compared with younger patients. Overall, these results indicate that long-term TCZ treatment of elderly patients is effective and has an acceptable safety profile.

Disclosure of Interests:

Christof Specker Speakers bureau: AbbVie, Celgene, Chugai, Janssen-Cilag, Lilly, MSD, Novartis, Pfizer, Roche, and UCB, Consultant of: AbbVie, Boehringer Ingelheim, Chugai, Lilly, Novartis, Sobi, and UCB, Grant/research support from: Boehringer, Chugai, GSK, and Roche, Martin Aringer Speakers bureau: Roche and Chugai, Consultant of: Roche and Chugai, Grant/research support from: Roche, Gerd Rüdiger Burmester Consultant of: Lilly, Pfizer, Sanofi, and Roche, Grant/research support from: Roche, Marvin Peters Employee of: Roche Pharma AG, Michael W. Hofmann Employee of: Chugai Pharma Germany GmbH, Herbert Kellner Consultant of: Roche, Grant/research support from: Roche, Frank Moosig Grant/research support from: Roche, Hans-Peter Tony Speakers bureau: Roche, Abbvie, BMS, Chugai, Janssen, Novartis, Sanofi, and Lilly, Consultant of: Roche, Abbvie, BMS, Chugai, Janssen, Novartis, Sanofi, and Lilly, Grant/research support from: Roche, Gerhard Fliedner Grant/research support from: Roche, Chugai, Abbvie, and Lilly

Diabetes care and pregnancy outcomes for women with pregestational diabetes in Ireland

AIMS

Pre-gestational diabetes mellitus (PGDM) is associated with adverse outcomes. We aimed to examine pregnancies affected by PGDM; report on these pregnancy outcomes and compare outcomes for patients with type 1 versus type 2 diabetes mellitus; compare our findings to published Irish and United Kingdom (UK) data and identify potential areas for improvement.

METHODS

Between 2016 and 2018 information on 679 pregnancies from 415 women with type 1 Diabetes Mellitus and 244 women with type 2 diabetes was analysed. Data was collected on maternal characteristics; pregnancy preparation; glycaemic control; pregnancy related complications; foetal and maternal outcomes; unscheduled hospitalisations; congenital anomalies and perinatal deaths.

RESULTS

Only 15.9% of women were adequately prepared for pregnancy. Significant deficits were identified in availability and attendance at pre-pregnancy clinic, use of folic acid, attaining appropriate glycaemic targets and appropriate retinal screening. The majority of pregnancies (n = 567, 83.5%) resulted in a live birth but the large number of infants born large for gestational age (LGA) (n = 280, 49.4%), born prematurely <37 weeks and requiring neonatal intensive care unit (NICU) admission continue to be significant issues.

CONCLUSIONS

This retrospective cohort study identifies multiple targets for improvements in the provision of care to women with pre-gestational DM which are likely to translate into better pregnancy outcomes.

Major differences in clinical presentation, diagnosis and management of men and women with autosomal inherited bleeding disorders

BACKGROUND

In recent years, more awareness is raised about sex-specific dilemmas in inherited bleeding disorders. However, no large studies have been performed to assess differences in diagnosis, bleeding phenotype and management of men and women with bleeding disorders. Therefore, we investigated sex differences in a large cohort of well-defined patients with autosomal inherited bleeding disorders (von Willebrand disease (VWD), rare bleeding disorders (RBDs) and congenital platelet defects (CPDs)).

METHODS

We included patients from three nationwide cross-sectional studies on VWD, RBDs and CPDs in the Netherlands, respectively the WiN, RBiN and TiN study. In all studies a bleeding score (BS) was obtained, and patients filled in an extensive questionnaire on the management and burden of their disorder.

FINDINGS

We included 1092 patients (834 VWD; 196 RBD; 62 CPD), of whom 665 (60.9%) were women. Women were more often referred because of a bleeding diathesis than men (47.9% vs 36.6%, p = 0.002). Age of first bleeding was similar between men and women, respectively 8.9 ± 13.6 (mean ±sd) years and 10.6 ± 11.3 years (p = 0.075). However, the diagnostic delay, which was defined as time from first bleeding to diagnosis, was longer in women (11.6 ± 16.4 years) than men (7.7 ± 16.6 years, p = 0.002). Similar results were found when patients referred for bleeding were analyzed separately. Of women aging 12 years or older, 469 (77.1%) had received treatment because of sex-specific bleeding.

INTERPRETATION

Women with autosomal inherited bleeding disorders are more often referred for bleeding, have a longer diagnostic delay, and often require treatment because of sex-specific bleeding.

FUNDING

The WiN study was supported (in part) by research funding from the Dutch Hemophilia Foundation (Stichting Haemophilia), Shire (Takeda), and CSL Behring (unrestricted grant).

Intraprostatic Cancer Recurrence following Radical Radiotherapy on Transperineal Template Mapping Biopsy: Implications for Focal Ablative Salvage Therapy

PURPOSE

Men in whom external beam radiotherapy fails are usually placed on delayed hormone therapy. Some of these men have localized recurrence that might be suitable for further local therapy. We describe patterns of recurrence and suitability for focal ablative therapy in those undergoing transperineal template prostate mapping biopsies.

MATERIALS AND METHODS

The study included 145 consecutive patients (December 2007 to May 2014) referred with suspicion of recurrence due to rising prostate specific antigen after external beam radiotherapy or brachytherapy who underwent transperineal template prostate mapping biopsies. Suitability for focal ablative therapy required the cancer to be unifocal or unilateral, or bilateral/multifocal with 1 dominant index lesion and secondary lesions with Gleason score 3+3=6 with no more than 3 mm cancer core involvement.

RESULTS

Mean patient age was 70.7 (SD 5.8) years. Median prostate specific antigen at time of transperineal template prostate mapping biopsy was 4.5 ng/ml (IQR 2.5-7.7). Overall 75.9% (110) were suitable for a form of focal salvage treatment, 40.7% (59) were suitable for quadrant ablation, 14.5% (21) hemiablation, 14.5% (21) bilateral focal ablation and 6.2% (9) for index lesion ablation.

CONCLUSIONS

Three-quarters of patients who have localized radiorecurrent prostate cancer may be suitable for focal ablative therapy to the prostate based on transperineal template prostate mapping biopsies.

Bleeding severity in patients with rare bleeding disorders: real-life data from the RBiN study

Patients with hereditary rare bleeding disorders (RBDs) present with diverse hemorrhagic symptoms. Correlation between factor activity levels and clinical bleeding severity is poor for most RBDs. Threshold factor activity levels have been previously described in relation to bleeding severity but have not yet been validated. The Rare Bleeding Disorders in the Netherlands (RBiN) study is a nationwide cross-sectional study of patients registered in all 6 Dutch Haemophilia Treatment Centers with a known RBD and who are age 1 to 99 years. Bleeding scores were determined, and laboratory and clinical data were extracted from patient files. In all, 263 patients were included, of whom 202 (77%) attended the scheduled study visit. The median International Society of Thrombosis and Haemostasis (ISTH) bleeding assessment tool (BAT) score was 9. Correlations between baseline factor activity levels and ISTH BAT scores were strong for deficiencies in factor II (FII) (r = -0.792) and FX (r = -0.838) and were moderate for deficiencies of fibrinogen (r = -0.683), FV (r = -0.623), FVII (r = -0.516), FXIII (r = -0.516), and α2-antiplasmin (r = -0.594). There was no correlation for FXI deficiency (r = -0.218). The RBD BAT identified more women (94% vs 83%) and children (100% vs 71%) with an RBD than the ISTH BAT did. Importantly, 48% of patients had more severe bleeding than predicted for their baseline factor activity level. In addition, 34% of patients were predicted to be asymptomatic, but they actually had grade 2 (31%) or 3 (3%) bleeding. Bleeding severity in patients with RBDs is more pronounced than previously anticipated. The previously determined threshold factor activity levels to ensure no (spontaneous) bleeding in patients with an RBD are inaccurate. This trial was registered at www.clinicaltrials.gov as #NCT03347591.

Illness cognitions associated with health-related quality of life in young adult men with haemophilia

INTRODUCTION AND AIM

Knowledge on patterns of beliefs about the illness (illness cognitions) can provide insight into individual differences in adjustment to haemophilia. The current study aimed to identify (a) which sociodemographic and disease characteristics were associated with illness cognitions and (b) which illness cognitions were associated with health-related quality of life (HRQOL) in young adult men with haemophilia, besides sociodemographic and disease characteristics.

METHODS

Young adult men (18-30 years) with haemophilia in the Netherlands participated in an online multicentre cross-sectional study. Participants completed the Pediatric Quality of Life Inventory Young Adult version (PedsQL_YA). Potential sociodemographic determinants were assessed with the Course of Life Questionnaire (CoLQ) and illness cognitions with the Illness Cognition Questionnaire (ICQ). Multiple linear regression analyses were performed to assess potential determinants of illness cognitions and HRQOL.

RESULTS

Seventy young adult men with haemophilia (mean age 24.7 years, SD 3.5) participated. Born outside the Netherlands (β -0.24) and >1 bleed past 6 months (β -0.32) were associated with less acceptance of the disease. More acceptance was associated with better HRQOL in all domains: β 0.23-0.39. More helplessness was associated with worse total (β -0.30) and physical (β -0.42) HRQOL. Disease benefits, sociodemographic and disease characteristics were not associated with HRQOL.

CONCLUSION

Illness cognitions are associated with HRQOL in young adult men with haemophilia. Early recognition and identification of illness cognitions are important to facilitate support and psychosocial treatment to optimize young adults' well-being. Extra attention is needed for young adult men with frequent bleeds because they are at risk of lowered levels of acceptance of the disease.

Healthcare experiences and quality of life of adults with coeliac disease: a cross-sectional study

BACKGROUND

Coeliac disease affects many aspects of quality of life and treatment can be burdensome. Access to healthcare services is necessary for the diagnosis and management of coeliac disease. The present study aimed to investigate the healthcare experiences of adults with coeliac disease and explore the relationship between experiences and quality of life.

METHODS

A cross-sectional postal survey was sent to 800 members of Coeliac UK and contained questions about diagnosis, dietary advice, follow-up appointments, prescriptions, knowledge and information provision, and quality of life [Coeliac Disease Assessment Questionnaire (CDAQ)]. Descriptive statistics were calculated. A total problem score summarised the number of problems experienced with healthcare services. Multiple linear regression analyses were conducted to investigate experiential and demographic factors associated with quality of life.

RESULTS

An average of 5.5 problems with healthcare services was reported, with females reporting significantly more problems than males (6.5 versus 5.0, P = 0.003). The total problem score was significantly related to the CDAQ overall index score and all CDAQ dimension scores (stigma, dietary burden, symptoms, social isolation, and worries and concerns) (P < 0.001). The analyses highlighted four key areas of healthcare experiences that were significantly related to quality of life: information provision, general practioners' knowledge, communication with health professionals and access to prescriptions.

CONCLUSIONS

Poorer experiences of healthcare services in coeliac disease are related to worse quality of life. Improving services in the four key areas identified may help adults with coeliac disease to achieve a better quality of life.

Central nervous signs, blindness and cerebral vermicosis in free-ranging peregrine falcons (Falco peregrinus) associated with aberrant larval migrations

Four free-ranging peregrine falcons (Falco peregrinus) were submitted with a history of unilateral or bilateral blindness and central nervous signs to a veterinary clinic in Germany. There were no indications of trauma or ocular disease. Likewise, other differential diagnoses for CNS signs were ruled out within the diagnostic process. The clinical diagnostic panel in live falcons included general examination, radiography, endoscopy, hematology, ophthalmoscopy and parasitological examination of the feces, blood gas analysis and blood chemistry as well as computed tomography, and magnetic resonance imaging (MRI). A complete pathological and histopathological examination was performed post-mortem. The only common finding in all birds was an infection with the nematode parasite Serratospiculum tendo. The parasite was confirmed morphologically and via PCR. In two falcons intracerebral vermicoses was suspected in MRI and confirmed in subsequent histopathology, but molecular biological identification of the parasite species failed from brain tissue. Until today, S. tendo had been reported to affect the respiratory system, the liver and different parts of the gastrointestinal tract and to cause cachexia, inappetence, regurgitation, dyspnea and general signs of illness such as lethargy, poor plumage, and reduced reproduction. Our findings indicate that aberrant migration should be considered as cause for CNS signs in falcons. As S. tendo might be a possible cause for this, CNS signs might be included in the list of clinical signs of serratospiculiasis in falcons.