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.

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.

Withdrawing gluten-free food from prescriptions in England: a mixed-methods study to examine the impact of policy changes on quality of life

Background

Some local areas in England stopped have gluten‐free prescriptions for coeliac disease. An explanatory mixed‐methods study has investigated the impact of these changes.

Methods

A cross‐sectional survey with 1697 participants was followed by 24 qualitative interviews. The survey included questions on the use of prescriptions and healthcare services, as well as the Coeliac Disease Assessment Questionnaire (CDAQ) to assess quality of life. The survey data were analysed by descriptive statistics, analysis of variance and regression analysis, and the interviews were analysed by thematic analysis. Findings from the interviews guided the survey analysis.

Results

Dietary burden was significantly different between prescribing and nonprescribing areas, with little impact on other aspects of quality of life. Survey participants in nonprescribing areas who felt more impacted by the prescription changes reported a lower quality of life. Satisfaction with and use of services was lower in nonprescribing areas. Interviews indicated that, after initial frustrations, most people adapted to the changed prescription policy. However, there was a clear preference for gluten‐free prescriptions to be available, in particular for staple foods.

Conclusions

The main quality of life impact was on Dietary burden. It is encouraging that most participants in the present study maintained a good quality of life. However, issues of worse experiences of care, lower follow‐up opportunities and inequity arose, and these should be taken into consideration in decisions on gluten‐free food prescriptions. The new guidelines for the National Health Service in England have retained prescriptions for bread and flour mixes, which is more limited than the range of staple foods preferred in the present study.

Maturation of the Oral Microbiome in Caries-Free Toddlers: A Longitudinal Study

Understanding the development of the oral microbiota in healthy children is of great importance to oral and general health. However, limited data exist on a healthy maturation of the oral microbial ecosystem in children. Moreover, the data are biased by mislabeling “caries-free” populations. Therefore, we aimed to characterize the healthy salivary and dental plaque microbiome in young children. Caries-free (ICDAS [International Caries Detection and Assessment System] score 0) children (n = 119) and their primary caregivers were followed from 1 until 4 y of child age. Salivary and dental plaque samples were collected from the children at 3 time points (T1, ~1 y old; T2, ~2.5 y old; and T3, ~4 y old). Only saliva samples were collected from the caregivers. Bacterial V4 16S ribosomal DNA amplicons were sequenced using Illumina MiSeq. The reads were denoised and mapped to the zero-radius operational taxonomic units (zOTUs). Taxonomy was assigned using HOMD. The microbial profiles of children showed significant differences (P = 0.0001) over time. Various taxa increased, including Fusobacterium, Actinomyces, and Corynebacterium, while others showed significant decreases (e.g., Alloprevotella and Capnocytophaga) in their relative abundances over time. Microbial diversity and child-caregiver similarity increased most between 1 and 2.5 y of age while still not reaching the complexity of the caregivers at 4 y of age. The microbiome at 1 y of age differed the most from those at later time points. A single zOTU (Streptococcus) was present in all samples (n = 925) of the study. A large variation in the proportion of shared zOTUs was observed within an individual child over time (2% to 42% of zOTUs in saliva; 2.5% to 38% in dental plaque). These findings indicate that the oral ecosystem of caries-free toddlers is highly heterogeneous and dynamic with substantial changes in microbial composition over time and only few taxa persisting across the 3 y of the study. The salivary microbiome of 4-y-old children is still distinct from that of their caregivers.

Prospective Follow-Up of Cortical Interruptions, Bone Density, and Micro-structure Detected on HR-pQCT: A Study in Patients with Rheumatoid Arthritis and Healthy Subjects

OBJECTIVES

The purpose of the study was to prospectively investigate change (repair or progression) in the number, surface area and volume of cortical interruptions, bone density (vBMD) and micro-structural parameters assessed by high-resolution peripheral quantitative computed tomography (HR-pQCT) in finger joints of patients with rheumatoid arthritis (RA) treated with synthetic disease modifying anti-rheumatic drugs (sDMARDs) and/or biologic DMARDs (bDMARDs) over a 1-year follow-up period, and in comparison with healthy subjects (HS).

METHODS

Thirty-two patients with RA (221 joints, 53% on bDMARDs) and 32 HS (117 joints) were assessed at baseline and after 1 year using semi-automatic analysis of HR-pQCT images. Mean changes (group level) and the proportion of joints (joint level) with changes beyond the least significant change were calculated.

RESULTS

At baseline, 530 interruptions were identified in patients, and 136 in HS. The mean of the interruption parameters did not significantly change in either group Mean vBMD decreased more in patients than in HS (- 4.4 versus - 1.1 mgHA/cm³, respectively). In patients versus HS, proportionally more joints showed repair in interruption volume (6.6% versus 1.7%, respectively) and loss of vBMD (26.7% versus 12.9%, respectively). In patients on sDMARDs versus patients on bDMARDs, proportionally more joints showed progression in the number of interruptions and loss of vBMD (6.1% versus 1.8% and 31.3% versus 17.2%, respectively).

CONCLUSIONS

HR-pQCT is able to quantify bone repair and progression. Cortical interruption-, vBMD-, and micro-structure were impaired in RA, of which vBMD and micro-structure further deteriorated, particularly in patients on sDMARDs.

Aids to management of headache disorders in primary care (2nd edition) : on behalf of the European Headache Federation and Lifting The Burden: the Global Campaign against Headache

The Aids to Management are a product of the Global Campaign against Headache, a worldwide programme of action conducted in official relations with the World Health Organization. Developed in partnership with the European Headache Federation, they update the first edition published 11 years ago.The common headache disorders (migraine, tension-type headache and medication-overuse headache) are major causes of ill health. They should be managed in primary care, firstly because their management is generally not difficult, and secondly because they are so common. These Aids to Management, with the European principles of management of headache disorders in primary care as the core of their content, combine educational materials with practical management aids. They are supplemented by translation protocols, to ensure that translations are unchanged in meaning from the English-language originals.The Aids to Management may be individually downloaded and, as is the case for all products of the Global Campaign against Headache, are available without restriction for non-commercial use.