AB1074 FATAL BUT PREVENTABLE - SINGLE CENTRE SERIES OF 6 CASES OF PNEUMOCYSTIS JIROVECII PNEUMONIA (PJP) IN PATIENTS WITH AUTO-IMMUNE INFLAMMATORY RHEUMATIC DISEASE (AIIRD) IN ONE YEAR

Background

Pneumocystis jirovecii pneumonia (PJP) is an uncommon but frequently fatal fungal infection, which can affect patients with rheumatic diseases treated with immunosuppressants or high doses of steroids. There are no clear guidelines on when to prescribe primary prophylaxis and available agreements differ depending on the disease or immunosuppressant.

Objectives

To raise awareness about this preventable infection and to highlight the urgent need to create a tailored probability scoring, before starting any immunosuppression so that the risk benefit of prophylaxis can be objectively assessed.

Methods

This is a retrospective case series of six patients who developed definite or probable PJP known to the Rheumatology Department at Oxford University Hospitals NHS FT since the beginning of 2021. These patients were identified through the microbiology and infectious disease teams, and notes were reviewed to collate data regarding the clinical characteristics. Of these, five were being treated for large vessels vasculitis (LVV) whilst the other one had seropositive rheumatoid arthritis (RA). The diagnosis of PJP was made on clinical picture, laboratory results, bronchoscopy and CT findings.

Results

In this series, the median age was 78 years (range 55-93) with equal gender distribution. In three LVV patients, the diagnosis was confirmed on ultrasound, one had a positive PET-CT whilst the other case had a high probability clinical diagnosis. Comorbidities included chronic kidney disease and hypertension in three patients, diabetes, or previous underlying malignancy in other two. Smoking history was present in four patients, while five patients had lymphopenia with counts <1x10^9/L. Four of the six cases were on combined therapy with disease modifying anti-rheumatic therapy drugs (DMARDs) and prednisolone, only one was exclusively on prednisolone and the patient with RA was on Methotrexate and Humira.

The chronology of the infection was variable, still most of the patients developed PJP infection during the first three months of starting either a biologic or corticosteroids. The median steroids dose by the time of PJP infection was 30 mg and unfortunately three of the patients died. None of the patients who developed PJP had been given antibiotic prophylaxis prior to infection.

Some proposed scoring systems for serious infection risk in patients with AIIRD exist, however they focused on RA or biologics use rather than patients with vasculitis or connective tissue disorders who might be on high dose corticosteroids. Additionally, PJP prophylaxis is not recommended in any of the current guidelines for LVV management (BSR, EULAR, ACR). Cochrane review suggests reduction of risk by 85% in patients given prophylaxis.

Conclusion

Pneumocystis Jirovecii pneumonia (PJP) prophylaxis is not current practice for patients with large vessel vasculitis. Consideration needs to be given to PJP prophylaxis for patients on high dose steroids for a prolonged period, particularly in the presence of other risk factors. More data will be needed to help establish guidelines on PJP primary prophylaxis.

References

[1]Park JW, Curtis JR, Moon J, Song YW, et al. Prophylactic effect of trimethoprim-sulfamethoxazole for pneumocystis pneumonia in patients with rheumatic diseases exposed to prolonged high-dose glucocorticoids. Ann Rheum Dis. 2018 May;77(5):644-649.

[2]Stern A, Green H, Paul M, Vidal L, Leibovici L. Prophylaxis for Pneumocystis pneumonia (PCP) in non-HIV immunocompromised patients. Cochrane Database Syst Rev. 2014 Oct 1;2014(10)

Table 1.

Baseline characteristics of the cases (*n)

Male gender3Age, year Median78Underlying disease  Large vessels vasculitis5Confirmed on imaging (n)4  Seropositive Rheumatoid arthritis1Smoking4Lymphopenia5Steroid dose ≥ 30 mg by the time of PJP infection4Concomitant DMARDs used4Numbers of deaths3

*n = numbers

Disclosure of Interests

None declared

POS0565 WORSE OUTCOMES LINKED TO ETHNICITY FOR EARLY INFLAMMATORY ARTHRITIS IN ENGLAND AND WALES: A NATIONAL COHORT STUDY

Background

Patients from ethnic minority backgrounds suffer considerable health inequality, with generally poorer health outcomes relative to the rest of the population.1 Further exploration of these differences is essential if we are to deliver the best care for all, and close the health gap for our patients.

Objectives

We used the National Early Inflammatory Arthritis Audit (NEIAA) to assess variability in care quality and treatment outcomes across ethnicities for patients diagnosed with early inflammatory arthritis (EIA) in England and Wales.

Methods

NEIAA is an observational cohort design. Data were from adult patients newly diagnosed with EIA, and seen by rheumatology in England and Wales between May 2018 and March 2020. Quality of care outcomes were assessed against six metrics contained within the National Institute for Health and Clinical Excellence (NICE) Quality Standard for Rheumatoid Arthritis.2 Clinical outcomes were measured using DAS28. Outcomes were compared between ethnic groups (White, Black, Asian, Mixed, Other), and adjusted for confounders (age, sex, smoking, comorbidity, seropositivity and disease severity at presentation) using Logistic regression models with multiple imputation for missing data.

Results

Data for 35,807 eligible patients were analysed, of whom 30,643 (85.6%) were White and 5,164 (14.6%) were from ethnic minority backgrounds: 1,035 (2.8%) Black; 2,617 (7.3%) Asian; 238 (0.6%) Mixed; 1,274 (3.5%) Other. A total of 12,955 patients had confirmed EIA. Of those, 11,315 were White and 1,640 were from ethnic minority backgrounds: 314 (2.4%) Black; 927 (7.1%) Asian; 70 (0.5%) Mixed; 329 (2.5%) Other.

Of 35,160 eligible patients who had data available, 14,803 (42.1%) were assessed by rheumatology within three weeks of referral. Of 9,900 EIA-eligible patients with data available, 5,642 (57.0%) started treatment within six weeks of referral. There were no significant differences in these outcomes by ethnicity. Ethnic minority patients did, however, have lower odds of disease remission at three months, relative to patients of White ethnicity (adjusted odds ratio 0.79; 95% CI: 0.65-0.96; p=0.02). This difference was due to lower odds of disease remission in Black and Asian patients, relative to White patients (Table 1). Ethnic minority patients were significantly less likely to receive initial treatment with methotrexate (0.68; 95% CI: 0.52-0.90; p=0.008) or with glucocorticoids (0.63, 95% CI: 0.49-0.80; p< 0.001).

Table 1.

Associations between ethnicity and disease remission at three months in EIA patients

ModelOdds ratio95% CIP-valueUnadjustedAll ethnic minority0.76(0.62,0.93)0.01backgroundsBlack0.48(0.34,0.67)<0.001Asian0.74(0.59,0.93)0.01Mixed0.61(0.28,1.35)0.22Other1.09(0.71,1.68)0.67Age and sex-adjustedAll ethnic minority0.78(0.63,0.96)0.01backgroundsBlack0.49(0.35,0.69)0.00Asian0.75(0.60,0.94)0.01Mixed0.63(0.28,1.39)0.25Other1.11(0.71,1.71)0.63Fully-adjustedAll ethnic minority0.79(0.65,0.96)0.02backgroundsBlack0.57(0.41,0.79)0.001Asian0.76(0.62,0.93)0.009Mixed0.63(0.27,1.46)0.29Other1.04(0.71,1.54)0.80

Conclusion

The results from this large cohort demonstrate that some minority ethnic groups are less likely to reach disease remission in the early months following an EIA diagnosis. Our results are not explained by delays in referral or treatment. Intitial treatment strategies varied across ethnic groups. These data highlight the need for investigation into the possible drivers of these inequitable outcomes and reappraisal of EIA management pathways.

References

[1]Greenberg JD, Spruill TM, Shan Y, Reed G, Kremer JM, Potter J, et al. Racial and ethnic disparities in disease activity in patients with rheumatoid arthritis. Am J Med. 2013;126(12):1089-98.

[2]NICE quality standard for rheumatoid arthritis in over 16s. Nice.org.uk. 2013 [cited 25 January 2022]. Available from: https://www.nice.org.uk/guidance/qs33/documents/previous-version-of-quality-standard.

Disclosure of Interests

Maryam Adas: None declared, Sathiyaa Balachandran: None declared, Sam Norton: None declared, Edward Alveyn: None declared, Mark Russell Speakers bureau: Has received speaker fees and educational grants from Janssen, Lilly, Menarini, Pfizer and UCB, Tom Esterine Speakers bureau: Patient review of P.I.S and consent form into lay language for KCL that was linked to Pharma company., Paul Amlani-Hatcher: None declared, Sarah Oyebanjo: None declared, Heidi Lempp: None declared, Jo Ledingham: None declared, Kanta Kumar Speakers bureau: Has received training form Pfizer and speaker fees 2021 from Janssen., Paid instructor for: Has received training form Pfizer, James Galloway Speakers bureau: Has received honoraria from AbbVie, Celgene, Chugai, Gilead, Janssen, Eli Lilly, Pfizer, Roche and UCB., Shirish Dubey: None declared.

Perception of Employees Regarding the Quality Management System Implemented at a Tertiary Care Eye Hospital in North India: A Mixed-Methods Study

Background:

Quality management in healthcare is critical for hospitals and everyone in the loop —from physicians to support staff—needs to be aware of and involved in this process.

Objectives:

To assess the perception of employees about the quality management system (QMS) implemented at a tertiary care eye hospital in north India and to use it to identify scope for further improvement.

Methods:

This cross-sectional mixed-method study involved both questionnaire-based survey and an in-depth interview by a third party. The questionnaire had 12 questions to assess the changes in culture, infrastructure, environment, system, operation theatre and outpatient department. Employees shared their opinion about improvements brought by the QMS in eight years. Respondents were divided into five groups based on their job description: (i) doctors, (ii) technical staff (nursing/operation theatre/laboratory), (iii) optometrists/opticians/audiologists, (iv) patient care executives and (v) human resources/administration/others.

Results:

Of the 73 employees interviewed, 94.5% perceived an improved treatment and care process and 91.8% perceived improved treatment results. According to 83.6% of the employees, they were encouraged to report patient safety concerns and 71.2% saw improved incidence and adverse event management. The QMS has increased patient satisfaction according to 83%, while 91.8% felt it improved the profile of the hospital. The employees stated no negative effects of the QMS except a long waiting time of the patients and the duplication of paperwork.

Conclusion:

QMS has brought many positive changes across the hospital. Still, there is scope to reduce the patient waiting time and paperwork duplication.

Corticosteroids reduce vascular ultrasound sensitivity in fast- track pathways (FTP): results from Coventry Multi-Disciplinary FTP for cranial Giant Cell Arteritis

OBJECTIVES

This study aims to assess the feasibility of the Coventry multidisciplinary fast-track cranial giant cell arteritis (FTGCA) pathway, which was set up in 2013 in collaboration with vascular physiology and ophthalmology to enable prompt multidisciplinary assessment, including ultrasound (US). This study also looks at the impact of prior corticosteroid (CS) use on the performance of US in real life.

METHOD

Data were collected retrospectively for patients who attended the Coventry FTGCA pathway between 1 January 2014 and 31 December 2017. Patients were identified from US lists and clinical details were obtained from electronic medical records.

RESULTS

In total, 620 eligible patients were included in this study. US had a sensitivity of 50%, which improved to nearly 56% in CS-naïve patients. The median duration of CS use prior to US was 2 days, and sensitivity was around 46% in this group. The specificity of US was > 96%, and CS use was avoided completely in 345 patients (56%). CSs negatively impacted on the utility of US, with US more likely to be false negative.

CONCLUSIONS

This novel multidisciplinary pathway demonstrates excellent feasibility and minimizes the use of CSs in patients without giant cell arteritis. US was performed promptly, was cost effective- and had reassuring real-life sensitivity and specificity in this cohort, with excellent patient feedback. CS-naïve patients showed higher sensitivity for US despite the short duration of CS use.

Measurement of Differential Branching Fractions of Inclusive B→X_{u}ℓ^{+}ν_{ℓ} Decays

The first measurements of differential branching fractions of inclusive semileptonic B→X_{u}ℓ^{+}ν_{ℓ} decays are performed using the full Belle data set of 711  fb^{-1} of integrated luminosity at the ϒ(4S) resonance and for ℓ=e, μ. With the availability of these measurements, new avenues for future shape-function model-independent determinations of the Cabibbo-Kobayashi-Maskawa matrix element |V_{ub}| can be pursued to gain new insights in the existing tension with respect to exclusive determinations. The differential branching fractions are reported as a function of the lepton energy, the four-momentum-transfer squared, light-cone momenta, the hadronic mass, and the hadronic mass squared. They are obtained by subtracting the backgrounds from semileptonic B→X_{c}ℓ^{+}ν_{ℓ} decays and other processes, and corrected for resolution and acceptance effects.

Precise Measurement of the D^{0} and D^{+} Lifetimes at Belle II

We report a measurement of the D^{0} and D^{+} lifetimes using D^{0}→K^{-}π^{+} and D^{+}→K^{-}π^{+}π^{+} decays reconstructed in e^{+}e^{-}→cc[over ¯] data recorded by the Belle II experiment at the SuperKEKB asymmetric-energy e^{+}e^{-} collider. The data, collected at center-of-mass energies at or near the ϒ(4S) resonance, correspond to an integrated luminosity of 72  fb^{-1}. The results, τ(D^{0})=410.5±1.1(stat)±0.8(syst)  fs and τ(D^{+})=1030.4±4.7(stat)±3.1(syst)  fs, are the most precise to date and are consistent with previous determinations.

Search for B^{+}→K^{+}νν[over ¯] Decays Using an Inclusive Tagging Method at Belle II

A search for the flavor-changing neutral-current decay B^{+}→K^{+}νν[over ¯] is performed at the Belle II experiment at the SuperKEKB asymmetric energy electron-positron collider. The data sample corresponds to an integrated luminosity of 63  fb^{-1} collected at the ϒ(4S) resonance and a sample of 9  fb^{-1} collected at an energy 60 MeV below the resonance. Because the measurable decay signature involves only a single charged kaon, a novel measurement approach is used that exploits not only the properties of the B^{+}→K^{+}νν[over ¯] decay, but also the inclusive properties of the other B meson in the ϒ(4S)→BB[over ¯] event, to suppress the background from other B meson decays and light-quark pair production. This inclusive tagging approach offers a higher signal efficiency compared to previous searches. No significant signal is observed. An upper limit on the branching fraction of B^{+}→K^{+}νν[over ¯] of 4.1×10^{-5} is set at the 90% confidence level.

OP0063 SINGLE CENTRE EXPERIENCE OF THE CLINICAL SPECTRUM, AETIOLOGIES AND MANAGEMENT OF NON-INFECTIOUS AORTITIS

Background:

Aortitis, a rare form of large vessel vasculitis, may occur in the context of a primary systemic vasculitis, as a part of systemic autoimmune disease or in isolation. The evidence and guidelines to diagnose, manage and monitor aortitis remain limited. However, PET CT and vascular MRI scans have facilitated our ability to make the diagnosis more readily. The optimal management strategy and complication rates remain uncertain.

Objectives:

Our aim was to explore the clinical, laboratory and radiological features of aortitis. We sought to review the management and complications of this illness by collecting detailed information on the outcomes and treatments used, including disease modifying agents (DMARDs) and biologics.

Methods:

Patients diagnosed with aortitis since 2006 that had been managed in a single tertiary centre were identified using the Rheumatology Assessment Database Innovation in Oxford (RHADIO). Their medical notes were retrospectively reviewed using a local electronic patient record system and the following information was obtained: demographics, underlying risk factors, imaging and laboratory results (including biopsy reports if available), management and outcome.

Results:

We identified 155 patients who met the inclusion criteria. There was a female preponderance of 57.4% (n=89). At the time of diagnosis, the average age was 69 (range 30-92) and the mean symptomatology length prior to diagnosis was 12 months (range 0-120). The majority of patients (60.4%, n=94) had aortitis secondary to giant cell arteritis (GCA), isolated aortitis was identified in 29.7% (n=46) and IgG4-related disease aortitis was uncommon (2.6%, n=4). Those with cranial GCA-like symptoms were diagnosed on average 3.9 months before those who presented differently (10.1 months versus 14.0 months).

Common presentations comprised: systemic inflammatory response syndrome (49.0%, n=76), cranial GCA-like symptoms (26.5%, n=41) and unexplained weight loss (24.5%, n=38). Importantly, 18.7% (n=29) of patients presented with ischaemic symptoms that included angina, TIAs/strokes and claudication. Aortic dissection was the primary presentation for 6.5% (n=10) of patients.

At presentation, the mean CRP was 84 mg/L (range 1-249) and the ESR was 72 mm/hr (range 2-164). Most (73.5%, n=114) had diagnostic PET CT changes. For those patients with GCA, diagnostic ultrasound changes were seen in 27.7% (n=26).

Nearly all were treated with prednisolone (92.3%, n=143) and all but 8 (5.1%) received a DMARD at some point. Methotrexate was the most commonly used DMARD (93.9%, n=138), followed by leflunomide (22.3%, n=35) and azathioprine (19.1%, n=28). Cyclophosphamide was used in 23.8% of patients (n=38) and 15 patients (9.7%) received tocilizumab.

Around a third (34.1% n=53/155) had received at least two DMARDs during their treatment course. On average, patients required 3.46 drugs to manage their aortitis. Those who relapsed (43.2%, n=67) were more likely to have GCA (65.7%, n=44).

Vascular sequelae were present in 37.4% (n=58). The most common complications were ischaemic in nature with stroke/TIA and claudication reported in 16.8% (n=26). Aortic aneurysms were recorded in 11.6% (n=18) of cases and 5.1% (n=8) developed dissections despite being on treatment for their aortitis. One patient developed renal infarcts and ischaemic bowel leading to intestinal failure because of florid vasculitis.

Conclusion:

Aortitis has a varied presentation with systemic inflammatory response syndrome being the most common. Delayed diagnosis remains a problem and especially for those with non-GCA related aortitis, which is likely to contribute to the risk of subsequent vascular complications. Vascular events including dissection are common, many of which could be preventable, emphasising the importance of early diagnosis and good disease control.

References:

[1]Koster M et al. Large-vessel giant cell arteritis: diagnosis, monitoring and management. Rheumatology [Internet]. 2018 Feb 1;57(suppl_2):ii32–42. Available from: https://doi.org/10.1093/rheumatology/kex424

Disclosure of Interests:

None declared

Test of Lepton-Flavor Universality in B→K^{*}ℓ^{+}ℓ^{-} Decays at Belle

We present a measurement of R_{K^{*}}, the branching fraction ratio B(B→K^{*}μ^{+}μ^{-})/B(B→K^{*}e^{+}e^{-}), for both charged and neutral B mesons. The ratio for the charged case R_{K^{*+}} is the first measurement ever performed. In addition, we report absolute branching fractions for the individual modes in bins of the squared dilepton invariant mass q^{2}. The analysis is based on a data sample of 711  fb^{-1}, containing 772×10^{6}  BB[over ¯] events, recorded at the ϒ(4S) resonance with the Belle detector at the KEKB asymmetric-energy e^{+}e^{-} collider. The obtained results are consistent with standard model expectations.

Using Circular Dichroism to Control Energy Transfer in Multiphoton Ionization

Chirality causes symmetry breaks in a large variety of natural phenomena ranging from particle physics to biochemistry. We investigate one of the simplest conceivable chiral systems, a laser-excited, oriented, effective one-electron Li target. Prepared in a polarized p state with |m|=1 in an optical trap, the atoms are exposed to co- and counterrotating circularly polarized femtosecond laser pulses. For a field frequency near the excitation energy of the oriented initial state, a strong circular dichroism is observed and the photoelectron energies are significantly affected by the helicity-dependent Autler-Townes splitting. Besides its fundamental relevance, this system is suited to create spin-polarized electron pulses with a reversible switch on a femtosecond timescale at an energy resolution of a few meV.

Using protease inhibitors to improve protein stability in the presence of skin: A case study on the stability of insulin like growth factor 1

Insulin-like growth factor 1 (IGF-1) is indicated for growth failure in pediatric patients with primary IGF-1 deficiency and for patients with neutralizing antibodies to growth hormone. IGF-1 was cloned, expressed and purified in-house. Preliminary stability studies prior to the transdermal delivery experiments showed that although stable in contact with stratum corneum, the solution concentration of IGF-1 decreased to 23.63 ± 2.48 and 21.58 ± 2.62% of the initial value upon exposure for 8 h to porcine dermis of 250 and 750 µm thickness. This led to an investigation into how it might be possible to improve the stability of IGF-1 in the presence of porcine/human skin. The stability of IGF-1 in the presence of dermis improved upon heating the skin samples at 60 °C for 2 min suggesting that IGF-1 was subject to enzymatic degradation. Although addition of the protease inhibitor, phenylmethanesulfonyl fluoride (PMSF) alone, did not improve stability, the use of a protease inhibitor cocktail completely blocked proteolytic degradation of IGF-1; the solution concentration after an 8 h exposure to porcine skin was equivalent to the initial level (103.87 ± 9.15%). The results obtained with porcine skin were confirmed with human skin (IGF-1 recovery was 99.31 ± 9.98%). These findings suggest that the inclusion of protease inhibitor cocktails may be useful in limiting the degradation of therapeutic proteins during iontophoresis and transdermal delivery in general - this could be of particular interest for local delivery of peptide/protein therapeutics for dermatological applications.

Low-dose ACTH test for evaluation of hypothalamus-pituitary-adrenal axis preoperatively and 3-month follow-up in non-functioning pituitary adenomas

BACKGROUND

Peri-operative glucocorticoids are routinely administered to patients undergoing trans-sphenoidal surgery for non-functional pituitary adenomas (NFPA) irrespective of hypothalamus-pituitary-adrenal (HPA) axis status.

PURPOSE

Evaluation of HPA axis before and 12 weeks after endoscopic trans-sphenoidal adenomectomy (E-TSA) utilizing low-dose (1 μg) ACTH stimulation test (LDACTH) to determine the need for glucocorticoid administration in patients with NFPA. We also determined the factors that can predict occurrence of hypocortisolism at 12 weeks after surgery.

METHODS

Sixty-three consecutive patients with NFPA requiring surgical excision were enrolled in this study. Glucocorticoids were administered to patients with demonstrable hypocortisolism [preoperative peak cortisol < 16 μg/dL during LDACTH test, postoperative day 3 (POD-3) 0800 hrs Cortisol < 8 μg/dL or stimulated cortisol (LDACTH) < 16 μg/dL at 12 weeks].

RESULTS

Hypocortisolism was present in 43 patients (68.2%) pre-operatively and persisted in 33 patients (52.4%) on POD-3. Thirty-three patients (52.4%) had hypocortisolism at 12 weeks after surgery. Eleven patients (17.4%) did not require glucocorticoids during the entire study period and 30 patients (47.6%) did not require glucocorticoids after 3 months. None of the patients developed adrenal crisis during the study. Hypocortisolism on the third post-operative day was the single significant predictor of hypocortisolism at 12 weeks after the surgery. There was a significant correlation between POD-3 0800 hrs cortisol ≥ 8μg/dL and stimulated cortisol (LDACTH) ≥16μg/dL at 12 weeks (r = 0.62, p < 0.0001). POD-3 0800 hrs cortisol ≥ 8 μg/dL had 73% sensitivity and 79% specificity in predicting eucortisolism at 12 weeks.

CONCLUSIONS

HPA function is preserved in significant proportion of NFPA patients undergoing E-TSA. Perioperative glucocorticoids should be given only in patients with demonstrable preoperative hypocortisolism on 1 μg ACTH test. Postoperative day 3 0800 hrs cortisol is a reasonable predictor of HPA axis status at 12 weeks after surgery.

Cytomegalovirus in Indian systemic lupus erythematosus patients: troublemaker or onlooker?

Introduction

cytomegalovirus (CMV) infection has been reported to be associated with onset/exacerbation of systemic lupus erythematosus (SLE). In an attempt to verify this, we studied CMV infection in SLE patients.

Methods

forty-two SLE patients were studied at 3-time points; disease onset/flare, at peak of immunosuppression (at 6 weeks) and at low doses of immunosuppression (at 6 months). We studied healthy blood donors as controls, only once. Clinical assessment and SLE Disease Activity Index scoring were done at each visit. RT-PCR and ELISA were performed to detect CMV viral-load and anti-CMV antibodies (Ab) respectively.

Results

nine of 106 patients had detectable viral-load (145-50,000 copies/ml). Of these nine, three patients had significant viral-load, 6 patients had low viral-loads of doubtful clinical significance. None of the patients developed CMV disease. Six of 42 cases were positive for IgM Abs. All controls were negative for CMV DNA as well as CMV IgM Abs. All samples from patients and controls were positive for CMV IgG Ab indicating widespread prevalence.

Conclusion

significantly, a higher seroprevalence of CMV IgM Abs against CMV observed in SLE patients when compared to controls, indicating possible reactivation due to immune modulation.

AB1151 COMPLIANCE/CONCORDANCE WITH MYCOPHENOLATE MOFETIL IN PATIENTS WITH CONNECTIVE TISSUE DISORDERS IN COVENTRY

Background:

Connective tissue disorders like Systemic lupus erythematosus (SLE) are multi-organ systemic conditions characterised by disordered immune function. Mycophenolate Mofetil (MMF) is commonly used for treatment of SLE1and other connective tissue disorders like Sjogren’s syndrome, myositis and Scleroderma. Compliance with drugs remains a significant issue in management of these conditions and varying reports from across the world2,3continue to show significant lack of concordance resulting in increased disease activity and damage.

Objectives:

The aim of this study was to investigate the compliance/concordance specifically with MMF treatment among patients attending clinics at University Hospitals Coventry and Warwickshire NHS Trust (UHCW)with SLE and other connective tissue disorders.

Methods:

Ethical approval was obtained through research and development department within the Trust. This is a retrospective study collating non-identifiable hospital pharmacy data in patients who requested the prescription for MMF drug between January 2015 and December2018. Since MMF was required to be prescribed from the hospital (i.e. General practitioners within the region were unable to prescribe it), we have records for all prescriptions for these patients. We extracted information on sample size, frequency of prescription requested and length of follow up. Clinical data were obtained from paper and electronic notes of the patients. Data were analysed using the data analysis tool pack for linear regression, on Microsoft Excel package version 16.29.1.

Results:

We recruited 144 patients into this study, (74%) of these are females. Age range for this group was 2-89 years, median age was 45 (±11.2) years with a mean (±SD) age of 35.6 (±11.2) years and a disease duration of 8.8 (±6.2) years. 73.1% were White British, the remaining included 8.3% Indian, 5.5% Pakistani, 2.7% Black British, 2% Caucasian, 2.1% Chinese, and 6.3% other. Overall, we had 54 patients with SLE and 90 Patients with other connective tissue disorders. Good compliance (81-100%) with MMF therapy was seen in 49 patients, (34%). Poor compliance (0-20%) was seen in 13 patients, (9%). We found a significant correlation between lack of compliance and risk of flares (r= 0.25,p< 0.002), displayed in Figure 1. We also found a significant difference in compliance patters depending on diagnosis and also on age. SLE patients were 34% less compliant with MMF in comparison to other connective tissue disorders. Demographics suggested the degree of compliance increased with age. Patients between 40-69 years of age were 65% more compliant in comparison to the age 20-39 years (p< 0.002).

Conclusion:

SLE and connective tissue disorder patients within Coventry continue to have issues relating to compliance/concordance with MMF treatment and this appears to be worse in patients with SLE and in the 20-39 years of age. These patients also appear to be getting flares hence, this remains a major problem in the management of these conditions.

References:

[1]Gordon C, Amissah-Arthur MB, Gayed M et al. The British Society for Rheumatology guideline for the management of systemic lupus erythematosus in adults. Rheumatol 2017; doi: 10.1093/rheumatology/kex286.

[2]Alsowaida N, Alrasheed M, Mayet A, Alsuwaida A and Omair M A. Medication adherence, depression and disease activity among patients with systemic lupus erythematosus. Lupus 2018,27(2), 327–332. doi:10.1177/0961203317725585.

[3]Chehab G, G M Sauer, J G Richter, R Brinks, R Willers, R Fischer-Betz, B Winkler-Rohlfing, and M Schneider. Medical Adherence in Patients with Systemic Lupus Erythematosus in Germany: Predictors and Reasons for Non-Adherence – a Cross-Sectional Analysis of the LuLa-Cohort.” Lupus (September 2018),1652–60. doi:10.1177/0961203318785245.

Disclosure of Interests:

None declared

OP0150 WHAT IS THE ROLE OF TEMPORAL ARTERY BIOPSY IN GIANT CELL ARTERITIS FAST-TRACK PATHWAYS WHEN TEMPORAL ARTERY ULTRASOUND IS NEGATIVE?

Background:

A number of centres are now running fast track pathways for diagnosis and management of Giant cell arteritis with ultrasound as the first port of call for diagnosis1. Temporal artery biopsies (TABs) have become the second line of investigation, and it is unclear how useful TAB is in this setting.

Objectives:

This study looked at accuracy of Temporal artery biopsy (TAB) in patients with suspected Giant Cell arteritis (GCA) with negative/inconclusive ultrasound (U/S) and how duration of treatment on steroids prior to these investigations and arterial specimen size affected it.

Methods:

Prospective study of all patients with suspected GCA referred for TAB when U/S was negative or inconclusive, as part of the local fast-track pathway (Coventry). Database included clinical findings, serological work up, U/S and TAB results and treatment. Sensitivity and specificity of U/S and TAB was calculated and compared based on duration of treatment with steroids.

Results:

One hundred and nine patients were referred for TAB via Coventry fast-track-pathway. The sensitivity of U/S in this cohort of patients was 9.08% and specificity was 93.33%. After 3 days of steroid this was 0% and 100% respectively. For TAB when done within 10 days of starting steroids, this was 65% and 87.5% respectively. After 20 days of steroids this was 0 % and 100%. The sensitivity and specificity was 20% and 85% when arterial specimen size was 11-15mm and 47% and 100% when specimen size was 16 mm or more. Sensitivity and specificity of U/S of 644 suspected GCA patients was 48% and 98%.

Conclusion:

Our study demonstrates that TAB plays a relevant role in GCA fast-track-pathways, when U/S is negative/inconclusive. TAB was more sensitive than U/S in this cohort of patients, but overall sensitivity of U/S was higher when calculated for all patients suspected with GCA. Both remain useful tests if performed early. TAB specimen size should ideally be 16mm or more and done within 10 days of starting steroids.

References:

[1]Jonathan Pinnell, Carl Tiivas, Kaushik Chaudhuri, Purnima Mehta, Shirish Dubey, O38 The diagnostic performance of ultrasound Doppler in a fast-track pathway for giant cell arteritis,Rheumatology, Volume 58, Issue Supplement_3, April 2019, kez105.036,https://doi.org/10.1093/rheumatology/kez105.036

Disclosure of Interests:

None declared

Search for an Invisibly Decaying Z^{'} Boson at Belle II in e^{+}e^{-}→μ^{+}μ^{-}(e^{±}μ^{∓}) Plus Missing Energy Final States

Theories beyond the standard model often predict the existence of an additional neutral boson, the Z^{'}. Using data collected by the Belle II experiment during 2018 at the SuperKEKB collider, we perform the first searches for the invisible decay of a Z^{'} in the process e^{+}e^{-}→μ^{+}μ^{-}Z^{'} and of a lepton-flavor-violating Z^{'} in e^{+}e^{-}→e^{±}μ^{∓}Z^{'}. We do not find any excess of events and set 90% credibility level upper limits on the cross sections of these processes. We translate the former, in the framework of an L_{μ}-L_{τ} theory, into upper limits on the Z^{'} coupling constant at the level of 5×10^{-2}-1 for M_{Z^{'}}≤6  GeV/c^{2}.

An assessment on crystallization phenomena of Si in Al/a-Si thin films via thermal annealing and ion irradiation

In the present study, crystallization of amorphous-Si (a-Si) in Al/a-Si bilayer thin films under thermal annealing and ion irradiation has been investigated for future solar energy materials applications. In particular, the effect of thickness ratio (e.g. in Al : a-Si, the ratio of the Al and a-Si layer thickness) and temperature during irradiation on crystallization of the Si films has been explored for the first time. Two sets of samples with thickness ratio 1 : 1 (set-A: 50 nm Al/50 nm a-Si) and thickness ratio 1 : 3 (set-B: 50 nm Al/150 nm a-Si) have been prepared on thermally oxidized Si-substrates. In one experiment, thermal annealing of the as-prepared sample (of both the sets) has been done at different temperatures of 100 °C, 200 °C, 300 °C, 400 °C, and 500 °C. Significant crystallization was found to initiate at 200 °C with the help of thermal annealing, which increased further by increasing the temperature. In another experiment, ion irradiation on both sets of samples has been carried out at 100 °C and 200 °C using 100 MeV Ni7+ ions with fluences of 1 × 1012 ions per cm2, 5 × 1012 ions per cm2, 1 × 1013 ions per cm2, and 5 × 1013 ions per cm2. Significant crystallization of Si was observed at a remarkably low temperature of 100 °C under ion irradiation. The samples irradiated at 100 °C show better crystallization than the samples irradiated at 200 °C. The maximum crystallization of a-Si has been observed at a fluence of 1 × 1012 ions per cm2, which was found to decrease with increasing ion fluence at both temperatures (i.e. 100 °C & 200 °C). The crystallization of a-Si is found to be better for set-B samples as compared to set-A samples at all the fluences and irradiation temperatures. The present work is aimed at developing the understanding of the crystallization process, which may have significant advantages for designing crystalline layers at lower temperature using appropriate masks for irradiation at the desired location. The detailed mechanisms behind all the above observations are discussed in this paper.

Crystallization of Ge in ion-irradiated amorphous-Ge/Au thin films

Herein, the structural, optical, and electrical properties of Au-induced crystallization in amorphous germanium (a-Ge) thin films are presented for future solar energy material applications.