Contemporary predictors of readmission outcomes in patients with infective endocarditis: analysis from a national readmission database

Background/Introduction

Infective endocarditis (IE) remains a serious illness that is associated with remarkable morbidity and mortality in the United States (US). There are limited studies that investigated predictors of 30-day readmission risk in this population.

Purpose

We aimed to perform a contemporary analysis to investigate predictors of 30-day readmission in IE patients in the US.

Methods

We used the 2017 national readmission database to identify index admissions among adults (age ≥18) with the diagnosis of IE. Appropriate International Statistical Classification (ICD-10) codes were used to identify patients with IE. Primary outcome of interest was 30-day readmission, and hospital cost was the secondary outcome.

Results

Out of 49,692 admissions for IE, 5,743 (11.6%) patients were readmitted within 30 days. Patients who had 30-day readmission were younger (55±20 vs 61±19 years, P<0.001), 44.8% were females (P=0.08), 27.9% had diabetes mellitus (DM), 56.8% had hypertension, 37.9% had heart failure (HF), 31.3% had chronic kidney disease (CKD), 12.2% had end stage renal disease, and 47.8% had Medicare insurance. Patients who had readmissions within 30 days were more likely to have non-elective index admission (96.9% vs 93.4%, P<0.001), more likely to have hepatitis C (19.5% vs 12.2%, P<0.001), human immunodeficiency virus (HIV) (1.7% vs 1.2%, P<0.001), substance abuse (8.6% vs 5.4%, P<0.001), opioid abuse (24% vs 14.7%, P<0.001), and cocaine use (7.4% vs 4.3%, P<0.001). Overall, 5,393 (10.9%) patients died during index admission. Median cost for readmissions within 30 days was $83,217 [$41,457-$165,487], compared to the index admission cost of $90,257 [$41,945- $208,851] (P<0.001). After adjusting for age, DM, HF, and CKD, substance abuse (odds ratio (OR): 1.19 [1.07–1.33]; P 0.001), opioid abuse (OR: 1.37, [1.26- 1.48]; P<0.001), cocaine use (OR: 1.33 [1.18- 1.48]; P<0.001), HIV (OR: 1.25 [1.01–1.56]; P=0.04), and hepatitis C (OR: 1.34 [1.24–1.45]; P<0.001) correlated with higher odds of readmissions within 30 days (Figure 1).

Conclusion

Approximately 1 in 4 patients admitted for IE in the US had a history of opioid abuse and almost one fifth had hepatitis C. The 30-day readmission rate remains significant in IE with high financial burden on the health system. Both opioid abuse and hepatitis C were among the highest predictors of readmission within 30 days. Identifying modifiable predictors of readmission in this population may reduce readmission risk and healthcare cost.

Figure 1

Funding Acknowledgement

Type of funding source: None

Long-term natural history of transient constrictive pericarditis

Background

In recent years, there has been increasing recognition of a potentially-reversible, transient/ subacute form of constrictive pericarditis (CP). To date, studies have been small with lack of long-term longitudinal follow-up.

Purpose

We aimed to elucidate the causes and natural history of subacute CP.

Methods

Patients were included if (1) they had a diagnosis of CP, (2) had cardiac magnetic resonance (CMR) within 12 months of symptom onset with evidence of pericardial delayed enhancement/ inflammation (Figure) (3) received anti-inflammatory medications.

Results

A total of 78 individuals were included, comprising 61 men (78%) with a mean age of 59±14 years. Causes of subacute CP included idiopathic/ viral pericarditis (58%), post-pericardiotomy (29%), autoimmune (6%), radiation therapy (3%) and others (4%). After median follow-up of 4.4 years, 31 (40%) required pericardiectomy. There were no deaths.

Patients who underwent pericardiectomy had longer duration of symptoms at presentation [6 (4–9) vs. 3 (2–5) months, P<0.01], were more likely to be on diuretic therapy (87 vs. 45%, P<0.001), had lower ultra-sensitive C-reactive protein [4.4 (2.6–13.1) vs. 11.95 (1.8–61.55) mg/dl, P<0.001] and lower erythrocyte sedimentation rate [5 (2–10) vs. 25 (6–43 mm/hr), P=0.031] compared to those who were managed medically. There were no other significant differences in clinical characteristics or baseline anti-inflammatory therapy. The presence of elevated inflammatory markers (HR: 0.18; 95% CI: 0.06–0.58, P<0.01) was an independent predictor of freedom from pericardiectomy after adjustment for relevant clinical and imaging parameters.

Conclusions

We present the original observations of the largest cohort of patients with transient CP to date and demonstrate that increased inflammatory markers were independently associated with long-term freedom from pericardiectomy. Our results suggest that a trial of anti-inflammatory therapy in the setting of elevated inflammatory markers may be appropriate prior to referral for surgery given the possible reversibility.

Pericardial delayed enhancement

Funding Acknowledgement

Type of funding source: None

Correction to: A role for mast cells and mast cell tryptase in driving neutrophil recruitment in LPS-induced lung inflammation via protease-activated receptor 2 in mice

The original article can be found online.

A role for mast cells and mast cell tryptase in driving neutrophil recruitment in LPS-induced lung inflammation via protease-activated receptor 2 in mice

OBJECTIVE

This study aims to investigate the role of protease-activated receptor (PAR) 2 and mast cell (MC) tryptase in LPS-induced lung inflammation and neutrophil recruitment in the lungs of C57BL/6 mice.

METHODS

C57BL/6 mice were pretreated with the PAR2 antagonist ENMD-1068, compound 48/80 or aprotinin prior to intranasal instillation of MC tryptase or LPS. Blood leukocytes, C-X-C motif chemokine ligand (CXCL) 1 production leukocytes recovered from bronchoalveolar lavage fluid (BALF), and histopathological analysis of the lung were evaluated 4 h later. Furthermore, we performed experiments to determine intracellular calcium signaling in RAW 264.7 cells stimulated with LPS in the presence or absence of a protease inhibitor cocktail or ENMD-1068 and evaluated PAR2 expression in the lungs of LPS-treated mice.

RESULTS

Pharmacological blockade of PAR2 or inhibition of proteases reduced neutrophils recovered in BALF and LPS-induced calcium signaling. PAR2 blockade impaired LPS-induced lung inflammation, PAR2 expression in the lung and CXCL1 release in BALF, and increased circulating blood neutrophils. Intranasal instillation of MC tryptase increased the number of neutrophils recovered in BALF, and MC depletion with compound 48/80 impaired LPS-induced neutrophil migration.

CONCLUSION

Our study provides, for the first time, evidence of a pivotal role for MCs and MC tryptase in neutrophil migration, lung inflammation and macrophage activation triggered by LPS, by a mechanism dependent on PAR2 activation.

[The first COVID-19 hotspot in a retirement home in Hamburg]

Background

Coronavirus disease 2019 (COVID-19), a disease caused by the new coronavirus (SARS-CoV-2), is a particular threat to old people. At the end of March 2020, the first and so far largest outbreak of the disease occurred in a retirement home in Hamburg.

Methods

Analysis of procedures in dealing with a residential unit affected by SARS-CoV‑2, accommodating a risk group of 60 seniors with dementia is presented as well as a detailed presentation of post-mortem examination results of all 8 deceased tested positive for SARS-CoV‑2.

Results

Out of 60 residents, 39 were infected by SARS-CoV‑2. Due to preventive procedures it was possible to stop further spreading of the infection to other residential areas. In all 8 fatal cases, the autopsy diagnosis was death due to COVID-19. Autopsies revealed all COVID-19 patients to have a fatal (broncho)pneumonia and signs of relevant pre-existing cardiac, renal and pulmonary conditions in all cases. In 75% (n = 6) of the cases a fresh venous thrombosis was found. In 66.7% (n = 4) of the cases thrombotic events were combined with peripheral pulmonary artery thromboembolisms.

Conclusion

The cohort of SARS-CoV‑2 infected residents of a nursing home is characteristic for clinical and epidemiological features of the new coronavirus disease. Due to a centralized evaluation of all fatalities at the Institute of Legal Medicine in Hamburg, a detailed examination of all deceased positive for SARS-CoV‑2 was possible. Thereby, increased case fatality rates of approximately 20% could in all cases be assigned to a relevant number of pre-existing comorbidities of multiple organ systems, which was consistent with the clinical data available.

Anti-inflammatory and immune properties of the peltatoside, isolated from the leaves of Annona crassiflora Mart., in a new experimental model zebrafish

Establishing new animal models for the study of inflammation is very important in the process of discovering new drugs, since the inflammatory event is the basis of many pathological processes. Whereas rodent models have been the primary focus of inflammation research, we defend the zebrafish (Danio rerio) test as a feasible alternative for preclinical studies. Moreover, despite all the technological development already achieved by humanity, nature can still be considered a relevant source of new medicines. In this context, the aim of this work was to evaluate the anti-inflammatory effect of a substance isolated from the medicinal plant Annona crassilfora Mart, the peltatoside, in an inflammatory model of zebrafish. It was determined: (i) total leukocyte count in the coelomate exudate; (ii) N-acetyl-β-d-glucuronidase (NAG); (iii) myeloperoxidase (MPO); (iv) and the histology of liver, intestine and mesentery. Peltotoside (25, 50 and 100 μg) and dexamethasone (25 μg) were administered intracelomatically (i.c.) 30 min before carrageenan (i.c.). Pretreatment with peltatoside at three doses significantly inhibited leukocyte recruitment in the coelomic cavity, and inhibited NAG and MPO activity against the action of Cg, in a similar manner as dexamethasone. However, some microlesions in the evaluated organs were detected. The dose of 25 μg showed an anti-inflammatory effect with lower undesirable effects in the tissues. Our results suggest that the zebrafish test was satisfactory in performing our analyzes and that the peltotoside has a modulatory action in reducing leukocyte migration.

SAT0502 LONG-TERM OBSERVATIONAL SAFETY SURVEILLANCE OF GOLIMUMAB TREATMENT FOR POLYARTICULAR JUVENILE IDIOPATHIC ARTHIRTIS—AN INTERIM ANALYSIS

Background:

Golimumab (GOL) is approved for treatment of polyarticular juvenile idiopathic arthritis (pJIA) in patients 2 years and older. Data on long-term safety in this indication are limited.

Objectives:

Prospective monitoring of long-term safety and effectiveness of GOL in routine care using the German BIKER registry.

Methods:

In this non-interventional study baseline and safety parameters were compared between patients initiating GOL and contemporary matched control cohorts starting either an alternative TNF inhibitor (TNFi) or methotrexate (MTX) without exposure to a biologic. Efficacy outcomes were JADAS10, JIA ACR scores, joint counts and Childhood Health Assessment Questionnaire disability-index (CHAQ-DI). Safety assessments were based on adverse event (AE) reports.

Results:

From 2016 to 2019, 55 patients initiating GOL have been recruited and matched to 110 patients starting alternative TNFi and 47 biologic-naïve patients. Patients starting GOL had a longer disease duration (6.8y vs. 4.1 y and 1.0y; p<0.0001) and use of GOL was significantly more often second-line (85% vs 31% and 0%, p<0.0001). Disease activity was lower at baseline compared to MTX patients as indicated by active joint counts, JADAS10 and concomitant steroid use. Otherwise they were comparable with patients treated with other TNFi (Table 1).

Table 1

Comparison of GOL cohort with (1) other TNFi cohort and (2) MTX cohort.

GOLN=55Other TNFiN=110MTXN=47p-value #GOL vs TNFi/MTXGender female, n (%)44 (80)86 (78)34 (72)0.8/0.5Age at baseline, mean (SD), years13.6 (2.8)13.6 (3.0)13.1 (3.4)1.0/0.4Disease duration, mean (SD), years6.8 (4.5)4.1 (3.8)1.0 (1.6)<0.0001RF neg. polyarthritis, n (%)28 (51)53 (48)29 (62)0.7/0.3RF pos. polyarthritis, n (%)6 (11)18 (16.4)11 (23.4)0.5/0.1Extended oligoarthritis, n (%)20 (36.4)37 (33.6)6 (12.8)0.7/0.007Psoriatic arthritis1 (1.8)2 (1.8)1 (2.1)1.0/1.0Pretreatment bDMARD n(%)47 (85.5)34 (30.9)0<0.0001Concomitant steroids, n (%)9 (16.4)26 (23.6)25 (53.2)0.3/0.0001Active joint count, mean (SD)4.6 (4.0)5.4 (6.1)9.7 (6.5)0.4/<0.0001CHAQ DI, mean (SD)0.4 (0.4)0.5 (0.6)0.6 (0.7)0.3/0.07ESR, mm/h, mean (SD)20.4 (27.6)15.4 (18.6)21.4 (18.6)0.2/0.8JADAS10, mean (SD)11.3 (6.0)12.4 (5.8)16.9 (5.4)0.3/<0.0001AE, n (rate/100PY; 95%CI)45 (96; 72-128)106 (114; 94-138)39 (107; 78-146)0.3/0.6SAE, n (rate/100PY; 95%CI)2 (4.2; 1.1-17)5 (5.4; 2-13)1 (2.7; 0.4-19)0.8/0.7Infectious AE, n (rate/100PY; 95%CI)6 (12.8; 5.7-28)11 (11.8; 6.5-21)9 (24.5; 13-47)0.9/0.2Serious infections, n (rate/100PY; 95%CI)02 (2.2; 0.5-8.6)0n.a.Uveitis new manifestation1 (2.1; 0.3-15)2 (2.2; 0.5-8.6)01.0/n.a.

In GOL treated patients a marked clinical response was noted at 6 months and beyond demonstrated by a significant decrease of the mean JADAS 10 from 11.3 to 6.4 (p=0.0008), as well as JIA ACR 30/50/70/90 response rates of 56/56/35/21%. JADAS remission and minimal disease activity was observed in 18% and 47% after 6 months and in 29% and 43% of patients after 12 months.

Rates of AE, SAE and infectious AE were comparable between the GOL cohort (96, 4.2 and 12.8/100PY), the alternative TNFi cohort (114, 5.4 and 11.8/100PY) and the MTX cohort (107, 2.7 and 24.5/100PY). SAE reported in the GOL cohort were uveitis and JIA flare (each 1). Two serious infections, both influenza, were reported in the alternative TNFi cohort, none in the GOL cohort. No case of pregnancy, malignancy or death was reported.

Conclusion:

Interim results from this ongoing safety surveillance study indicate acceptable safety and tolerability of GOL in pJIA that is comparable to treatment with alternative TNFi or MTX. The long-term effectiveness data reinforce the established efficacy of GOL in pJIA treatment.

Disclosure of Interests:

Gerd Horneff Grant/research support from: AbbVie, Chugai, Merck Sharp & Dohme, Novartis, Pfizer, Roche, Speakers bureau: AbbVie, Bayer, Chugai, Merck Sharp & Dohme, Novartis, Pfizer, Roche, Angela Zimmer: None declared, Kirsten Minden Consultant of: GlaxoSmithKline, Sanofi, Speakers bureau: Roche, Toni Hospach: None declared, Frank Weller-Heinemann: None declared, Sandra Hansmann Consultant of: Advisory board Novartis Pharma, Jasmin Kuemmerle-Deschner Grant/research support from: Novartis, Sobi, Consultant of: Novartis, Sobi, Speakers bureau: Novartis, Sobi, Maria Fasshauer Consultant of: Shire, CSL Behring, Nadja Hofmann: None declared, Hans Koessel: None declared, Ivan Foeldvari Consultant of: Novartis, Sonja Mrusek: None declared, Daniel Windschall Speakers bureau: Abbvie, Nils Onken: None declared, Markus Hufnagel: None declared, Dirk Foell Grant/research support from: Novartis, Sobi, Pfizer, Speakers bureau: Novartis, Sobi, Normi Brueck: None declared, Prasad Oommen Consultant of: Novartis, Frank Dressler: None declared, Astrid Helling-Bakki: None declared, Ariane Klein Consultant of: Celgene

SAT0490 MATCHED CONTROLLED SURVEILLANCE OF TOCILIZUMAB TREATMENT FOR POLYARTICULAR JUVENILE IDIOPATHIC ARTHRITIS–AN INTERIM ANALYSIS

Background:

Tocilizumab (TOC) is approved for treatment of polyarticular juvenile idiopathic arthritis (pJIA). Data out of clinical practice are limited.

Objectives:

Long-term surveillance of patients initiating TOC treatment compared to a cohort of patients initiating a comparator biologic using the BIKER-registry.

Methods:

Baseline parameters, efficacy and safety parameters were compared. Efficacy outcomes were JADAS10 and joint counts. Functional status was determined with the Childhood Health Assessment Questionnaire disability-index (CHAQ-DI). Safety was assessed by adverse events (AE) reports.

Results:

Until January 2020, 152 patients have been recruited to each cohort. Patients starting on TOC were older at treatment start (12.1 vs. 10.1 years (y); p<0.0001) and had a longer disease duration (5.4y vs. 3.0y; p<0.0001). TOC was significantly more often a second-line biologic (84% vs 13%, p< 0.0001). Otherwise patients were comparable (Table 1).

Table 1.

Comparison of TOC patients and matched controls.

TocilizumabN=152Matched controlsN=152pGender female, n (%)128 (84)124 (81)0.65Disease duration, mean (SD), years5.4 (4.1)3.0 (2.9)<0.0001RF neg. polyarthritis, n (%)104 (68.4)92 (60.5)0.19RF pos. polyarthritis, n (%)14 (9.2)19 (12.5)0.46Extended oligoarthritis, n (%)34 (22.4)41 (27)0.42Pretreatment with biologics, n(%)127 (83.5)20 (13.2)<0.0001Active joint count, mean (SD)6.7 (7.1)6.1 (5.1)0.4CHAQ DI, mean (SD)0.63 (0.63)0.65 (0.64)0.8ESR, mm/h, mean (SD)17.5 (14.9)20.9 (20.6)0.1JADAS10, mean (SD)16.8 (9.8)15.1 (5.8)0.067Efficacy Month 12N=87N=105JADAS MDA, n (%)50 (57.5)63 (60.0)0.77JADAS REM, n (%)32 (36.8)39 (37.1)1.0JIA ACR 30/50/70/90, %80/75/61/5386/84/70/560.34/0.15/0.17/0.66Adverse eventsN (rate/100PY; 95%CI)248,65 PY290.4 PYRR (95%CI); pAE145 (58.3; 50-69)157 (54.1; 46-63)1.1 (0.9-1.4); 0.5SAE12 (4.8; 2.7-8.5)4 (1.4; 0.5-3.7)3.5 (1.1-10.9); 0.03Medically important infection2 (0.8; 0.2-3.2)12 (4.1; 2.3-7.3)0.2 (0.04-0.9); 0.03Uveitis event2 (0.8; 0.2-3.2)12 (4.1; 2.3-7.3)0.2 (0.04-0.9); 0.03

Upon TOC a substantial response to treatment with a significant reduction in JADAS 10 from 16.8 to 3.4 (p<0.0001) after 12 months was observed. There were no significant differences between patients from the TOC cohort and their matched controls regarding JIA ACR 30/50/70/90 criteria and active joint counts. JADAS 10, JADAS remission (REM) and minimal disease activity (MDA) was reached by comparable numbers in the TOC (37% and 58%) and the control cohort (37% and 60%).

While the total number of AE was comparable between the TOC cohort (58/100PY) and in the control cohort (54/100PY; RR 1.1; 95%CI 0.9-1.4), more serious AE (SAE) were reported with TOC (4.8/100PY compared to 1.4/100PY; RR 3.5; 95% CI 1-10.9). Medically important infections and uveitis events were documented at significantly lower frequency in the TOC- (0.8/100PY) than in the control cohort (4.1/100PY; RR 0.2; 95% CI 0.04-0.9). SAE with TOC were suicidal intent (n=3), depression (n=2), exacerbation of JIA, abscess, gastrointestinal infection, abdominal pain, colitis, bone surgery and fracture (n=1). SAE in the control cohort were depression, osteomyelitis, gastrointestinal infection and superinfected eczema (n=1). No significant differences regarding cytopenia and elevated transaminases were observed. No gastrointestinal perforation, no vascular event, no malignancy and no death occurred.

Conclusion:

The efficacy of tocilizumab is comparable to that of alternative biologics. Tolerability was acceptable. As Tocilizumab was given as a second-line biologic in the vast majority of patients, comparisons between the cohorts have to be interpreted carefully. Observation in the registry is ongoing.

Disclosure of Interests:

Ariane Klein Consultant of: Celgene, Toni Hospach: None declared, Frank Weller-Heinemann: None declared, Sandra Hansmann Consultant of: Advisory board Novartis Pharma, Jasmin Kuemmerle-Deschner Grant/research support from: Novartis, Sobi, Consultant of: Novartis, Sobi, Speakers bureau: Novartis, Sobi, Maria Fasshauer Consultant of: Shire, CSL Behring, Kirsten Minden Consultant of: GlaxoSmithKline, Sanofi, Speakers bureau: Roche, Ivan Foeldvari Consultant of: Novartis, Christoph Rietschel Consultant of: Pfizer, Abbvie, Novartis, Chugai, and Sobi, Tobias Schwarz: None declared, Ralf Trauzeddel: None declared, Markus Hufnagel: None declared, Dirk Foell Grant/research support from: Novartis, Sobi, Pfizer, Speakers bureau: Novartis, Sobi, Rainer Berendes: None declared, Gundula Boeschow: None declared, Prasad Oommen Consultant of: Novartis, Frank Dressler: None declared, Astrid Helling-Bakki: None declared, Gerd Horneff Grant/research support from: AbbVie, Chugai, Merck Sharp & Dohme, Novartis, Pfizer, Roche, Speakers bureau: AbbVie, Bayer, Chugai, Merck Sharp & Dohme, Novartis, Pfizer, Roche

SAT0491 PSORIASIS ASSOCIATED WITH MONOCLONAL-ANTIBODY-TNF-Α INHIBITORS VS. FUSION PROTEIN ETANERCEPT IN JUVENILE IDIOPATHIC ARTHRITIS PATIENTS - ANALYSIS OF THE BIKER REGISTRY

Background:

Although efficacy of Tumor necrosis factor inhibitors (TNFi) for treatment of psoriasis is well established, patients may develop psoriasis for the first time while on TNFi as a paradoxical effect. Few data are available in patients with juvenile idiopathic arthritis (JIA).

Objectives:

To analyze the incidence of psoriasis in TNFi – treated JIA patients and to identify associated factors.

Methods:

Safety data from patients registered in the German Biologics registry (BIKeR) were analyzed. Cohorts of patients were grouped by treatment: any or multiple TNFi, single TNFi, biologics other than TNFi and no biologics (control group on methotrexate (MTX) only). TNFi-associated psoriasis was defined as incident diagnosis of psoriasis after starting a TNFi. Patients with personal history of psoriasis prior to TNFi therapy were excluded. Rates and events per 100 patient-years (PY) of exposure were calculated using AEs reported after first dose under therapy and under the age of 18 years. Rates were compared by X2-test, event rates by Wald test.

Results:

A total of 4149 treatment episodes with TNFi (Etanercept, Adalimumab, Golimumab, Infliximab), with a total exposure time of 8437 PY, were identified. There were 676 treatments with a non-TNFi- biologic (Tocilizumab, Abatacept, Anakinra, Canakinumab) with a total exposure time of 1112 PY. MTX monotherapy was conducted in 1692 patients with a total exposure time of 3971 PY. In total, 31 patients were diagnosed with incident psoriasis on JIA-treatment (Table 1). The mean duration of therapy until incident psoriasis was 2.2 (± 1.8) years. Multiple psoriatic skin manifestations were observed.

Psoriasis events were significantly more frequent in any or multiple TNFi compared to MTX-monotherapy, and specifically in the subgroup of TNF-antibody treatment (all) or Adalimumab compared to MTX or Etanercept (Table 2). Interestingly, psoriasis events were also observed with non-TNFi at high frequency. At occurrence of the event, patients exposed to biologics received MTX or steroids less frequently compared to the total patient cohort and had a higher JADAS10.

Table 1.N/PYTotalCohort*4792/13519All TNFi4149/8437ADA1105/1859ETA2824/6307GOL144/145INF76/126Non-TNFi676/1112MTX only1692/3971Psoriasis events/rate(%)31/0.623/0.613/1.27/0.22/1.41/1.37/0.61/0.1Pso**/100 PY (95%CI)0.2(0.2-0.3)0.3(0.2-0.4)0.7(0.4-1.2)0.1(0.1-0.2)1.4(0.3-5.5)0.8(0.1-5.6)1.0(0.5-2.1)0.03(0.004-0.2)Age at eventMean ± SD13.9(±3.1)13.9(± 3.2)14.0(±3.0)13.0(±4.0)15.1(±3.4)16.413.4(±3.1)17.3Female24(77%)18(78%)10(77%)5(71%)2(100%)1(100%)5(71%)1(100%)ANA positive22(71%)16(70%)10(77%)4(57%)1(50%)1(100%)5(71)1(100%)Treatment duration until event (years) Mean ±SD2.2±1.82.4±2.32.2±1.42.8±2.20.6±0.53.81.4±2.05.6ConcomitantMTX11(36%)6(26%)3(23%)2(29%)1(50%)04(57%)1(100%)ConcomitantSteroids4(13%)2(9%)01(14%)01(100%)2(29%)0JADAS10 Median [IQR]***2.5(0.6-8.8)4.2(1.0-11.0)2.0(0.6-10.1)5.8(1.5-11.4)18.06.61.3(0.8-3.4)1.7

*individual therapy numbers add to a sum > the total cohort number, because some patients switched between multiple drugs; ** Pso= Psoriasis event; *** at time of event

Table 2.ReferencePsoriasis eventn/100 PYComparatorPsoriasis eventn/100 PYRisk ratioP-valueNon-TNFi0.63TNFi0.270.4 (0.2 -1.0)0.052MTX0.03TNFi0.2710.8 (1.5-80.1)0.019MTX0.03ETA0.114.4 (0.5-35.8)0.165MTX0.03TNF-antibodies0.7542.9 (5.8-317)0.0002ETA0.11TNF-antibodies0.756.8 (2.8-16.5)0.00002MTX0.03ADA0.6927.4 (3.6-2209)0.001Non-TNFi0.63ADA0.691.1 (0.4-2.7)0.847Non-TNFi0.63ETA0.110.2(0.1-0.5)0.0012ETA0.11ADA0.696.2 (0.5-15.6)0.0001

Conclusion:

Our findings demonstrate a higher incidence of psoriasis in monoclonal-antibody-TNFi-treated JIA-patients, whereas in Etanercept-treated JIA patients no significant increase was detected. On average, psoriasis-manifestation occurred more than two years after treatment-initiation. Teenage females with ANA-positivity were most often affected.

Disclosure of Interests:

Angela Zimmer: None declared, Ariane Klein Consultant of: Celgene, Gerd Horneff Grant/research support from: AbbVie, Chugai, Merck Sharp & Dohme, Novartis, Pfizer, Roche, Speakers bureau: AbbVie, Bayer, Chugai, Merck Sharp & Dohme, Novartis, Pfizer, Roche

THU0515 SYSTEMIC LUPUS ERYTHEMATOSUS IN CHILDHOOD AND ADOLESCENCE - UPDATE FROM THE NATIONAL PEDIATRIC RHEUMATOLOGY DATABASE

Background:

Systemic lupus erythematosus (SLE) is a clinically heterogeneous disease, which begins in childhood and adolescence in 15 - 20% of cases. Since 2004, data on SLE have been collected by means of a disease-specific questionnaire as part of the National pediatric rheumatology database (NPRD) in Germany. Since 2014, kidney biopsy results have been recorded to further specify kidney involvement.

Objectives:

Evaluation of clinical signs and symptoms, outcome and laboratory data of patients with juvenile systemic lupus erythematosus from a large database in Germany.

Methods:

Data from patients with SLE recorded in the NPRD in 2017 were considered for the analysis. In addition to age, sex, onset of disease, the criteria that led to the diagnosis, various laboratory parameters, organ involvement (current, ever) and therapy (current, last 12 months), current disease activity (numerical rating scale 0-10, NRS) and ECLAM (score 0-10) were recorded. Patient-reported outcomes included global assessments of overall-wellbeing and fatigue (NRS 0-10) and functional ability (CHAQ).

Results:

196 patients (86% female) with a median age of 16 years were documented. Criteria most frequently met at diagnosis included “antinuclear antibodies” (88%), followed by “anti-ds-DNA-Ab” (66%), “butterfly erythema” (42%) and “arthritis” (41%). A positive family history was found in 10% of patients.

At documentation, 85% of patients received disease-modifying anti-rheumatic drugs, most frequently hydroxychloroquine (73%), followed by mycophenolate mofetil (32%) and azathioprine (17%). Systemic glucocorticoids obtained 52% of patients, 12% ≥ 0.2 mg/kg/day. Biologics (rituximab 2%) and cyclophosphamide i.v. (3%) were rarely administered during the last 12 months. Disease activity was reported as 1.0 (NRS, median, IQR 0 - 9), ECLAM as 1.0 (median, range 0 - 10). In the laboratory, leukopenia < 3500/µl was found in 9% of patients, lymphopenia < 1500/µl in 47% and erythrocyte sedimentation rate (ESR) > 25 mm in 15% of patients. Mean CHAQ was 0.24, and 86% of patients had a CHAQ score < 0.5. Mean patient`s global assessment of overall-wellbeing was 1.5, while the mean fatigue score was 2.86 (18% NRS score 7-10).

The following organ involvement was ever present: general symptoms 84%, skin/mucosa 72%, joints 73%, thyroid 15%, muscle 25%, lungs 17% and CNS 30%. In 45/190 (24%) patients, a kidney involvement was stated. In 34 patients (75%) a kidney biopsy was performed and histology yielded the following results: Class 1: 6.7%, Class 2: 16.7%, Class 3: 40.0%, Class 4: 23.3%, Class 5: 13.3%.

Conclusion:

The most common clinical symptoms documented in juvenile SLE patients were skin and joint involvement. In the course of the disease, a quarter of the patients developed kidney involvement, mostly proliferative nephritis. Apparently, azathioprine is increasingly being replaced by mycophenolate mofetil, biologicals have hardly been used so far. Although functional outcome and overall-wellbeing of jSLE patients was good, fatigue was a concern for some patients.

Disclosure of Interests:

Claudia Sengler: None declared, Martina Niewerth: None declared, Nils Geisemeyer: None declared, Hermann Girschick: None declared, Ariane Klein Consultant of: Celgene, Annette Friederike Jansson: None declared, Markus Hufnagel: None declared, Kirsten Minden Consultant of: GlaxoSmithKline, Sanofi, Speakers bureau: Roche

The effect of bleaching agents on the DNA analysis of bloodstains on different floor coverings

Blood at crime scenes is one of the most significant traces of evidence in investigation proceedings. Cleaning up these traces with household cleaning products, often containing bleaching agents, inhibits or complicates the detection of DNA. In this study, human blood was applied onto different floor coverings (carpet, laminate, parquet, PVC, tile) and subsequently cleaned with water and bleaching agents (hydrogen peroxide, sodium hypochlorite, DanKlorix®, Vanish Oxi Action®) at different times. Samples have been collected afterwards from the floors. The samples underwent a quantitative and qualitative DNA analysis. Cleaning smooth surfaces with water is usually sufficed to prohibit retrieving a DNA profile in most of the cases. Cleaning carpets was more difficult due to their absorbent surface whereas the use of bleaching agents caused an additional reduction of verifiable DNA concentrations. Retrieving partial or complete profiles after the use of bleaching agents was only possible when cleaning with low concentrations of 3% hydrogen peroxide.

P3349RHAPSODY: a pivotal phase 3 trial to assess efficacy and safety of rilonacept, an interleukin 1 alpha and beta blocker, in patients with recurrent pericarditis

Background

Recurrent pericarditis (RP) is managed with nonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroids (CS), and colchicine; up to 15% of pericarditis patients experience multiple recurrences. Interleukin 1 (IL-1) is an important cytokine in the pathophysiology of RP. Rilonacept (KPL-914) is a recombinant fusion protein which binds IL-1α and IL-1β. An ongoing Phase 2 study of rilonacept demonstrated improvements in RP symptoms and inflammation.

Purpose

To evaluate the efficacy and safety of subcutaneous (SC) rilonacept in patients with RP in a Phase 3, randomized, placebo-controlled trial.

Methods

RHAPSODY is a double-blind, placebo-controlled, randomized-withdrawal trial; ∼50 patients will be enrolled (Figure). Patients (≥12 y) must present with at least a third pericarditis episode (all etiologies except infectious and malignant) characterized by a pain score ≥4 on the 11-point Numeric Rating Scale (NRS) and C-reactive protein (CRP) ≥1 mg/dL at screening. Patients may be receiving stable doses of analgesics, NSAIDs, colchicine, and/or CS. After a loading dose (320 mg SC in adults and 4.4 mg/kg SC in children), all patients will receive weekly rilonacept (160 mg SC in adults and 2.2 mg/kg SC in children) during the run-in period. Patients able to taper and discontinue concomitant pericarditis medications and achieve clinical response (mean daily NRS score ≤2.0 during the 7 days before randomization and CRP level ≤0.5 mg/dL) will be randomized 1:1 in a blinded fashion to continued rilonacept or matching placebo weekly SC injections. Investigators may choose different treatments for pericarditis recurrences based on patient clinical status, including bailout rilonacept, while maintaining the blind to prior treatment assignment. The primary efficacy endpoint is time to pericarditis recurrence (adjudicated by an independent committee) in the randomized-withdrawal portion of the study. Secondary efficacy endpoints are the proportion of patients maintaining a clinical response, percentage of days with NRS pain score ≤1, and percentage of patients with no-to-minimal pericarditis symptoms based on patient global assessment. Safety evaluations include adverse events monitoring, physical examinations, and laboratory tests.

Figure 1

Conclusions

RHAPSODY is a pivotal Phase 3 trial evaluating the efficacy and safety of rilonacept in patients with RP using a double-blind, placebo-controlled, randomized-withdrawal design. The results of this study may inform the management of RP.

Acknowledgement/Funding

This study is sponsored by Kiniksa Pharmaceuticals, Ltd.

Dissection of TMEM165 function in Golgi glycosylation and its Mn2+ sensitivity

Since 2012, the interest for TMEM165 increased due to its implication in a rare genetic human disease named TMEM165-CDG (Congenital Disorder(s) of Glycosylation). TMEM165 is a Golgi localized protein, highly conserved through evolution and belonging to the uncharacterized protein family 0016 (UPF0016). Although the precise function of TMEM165 in glycosylation is still controversial, our results highly suggest that TMEM165 would act as a Golgi Ca²⁺/Mn²⁺ transporter regulating both Ca²⁺ and Mn²⁺ Golgi homeostasis, the latter is required as a major cofactor of many Golgi glycosylation enzymes. Strikingly, we recently demonstrated that besides its role in regulating Golgi Mn²⁺ homeostasis and consequently Golgi glycosylation, TMEM165 is sensitive to high manganese exposure. Members of the UPF0016 family contain two particularly highly conserved consensus motifs E-φ-G-D-[KR]-[TS] predicted to be involved in the ion transport function of UPF0016 members. We investigate the contribution of these two specific motifs in the function of TMEM165 in Golgi glycosylation and in its Mn²⁺ sensitivity. Our results show the crucial importance of these two conserved motifs and underline the contribution of some specific amino acids in both Golgi glycosylation and Mn²⁺ sensitivity.

Variation between hospitals in outcomes following cardiac surgery in the UK

INTRODUCTION

We examine the influence of variations in provision of cardiac surgery in the UK at hospital level on patient outcomes and also to assess whether there is an inequality of access and delivery of healthcare. Cardiothoracic surgery has pioneered the reporting of surgeon-specific outcomes, which other specialties have followed. We set out to identify factors other than the individual surgeon, which can affect outcomes and enable other surgical specialties to adopt a similar model.

MATERIALS AND METHODS

A retrospective analysis of prospectively collected data of patient and hospital level factors between 2013 and 2016 from 16 cardiac surgical units in the UK were analysed through the Society for Cardiothoracic Surgery of Great Britain and Ireland and the Royal College of Surgeons Research Collaborative. Patient demographic data, risks factors, postoperative complications and in-hospital mortality, as well as hospital-level factors such as number of beds and operating theatres, were collected. Correlation between outcome measures was assessed using Pearson's correlation coefficient. Associations between hospital-level factors and outcomes were assessed using univariable and multivariable regression models.

RESULTS

Of 50,871 patients (60.5% of UK caseload), 25% were older than 75 years and 29% were female. There was considerable variation between units in patient comorbidities, bed distribution and staffing. All hospitals had dedicated cardiothoracic intensive care beds and consultants. Median survival was 97.9% (range 96.3-98.6%). Postoperative complications included re-sternotomy for bleeding (median 4.8%; range 3.5-6.9%) and mediastinitis (0.4%; 0.1-1.0%), transient ischaemic attack/cerebrovascular accident (1.7%; range 0.3-3.0%), haemofiltration (3.7%; range 0.8-6.8%), intra-aortic balloon pump use (3.3%; range 0.4-7.4%), tracheostomy (1.6%; range 1.3-2.6%) and laparotomy (0.3%; range 0.2-0.6%). There was variation in outcomes between hospitals. Univariable analysis showed a small number of positive associations between hospital-level factors and outcomes but none remained significant in multivariable models.

CONCLUSIONS

Variations among hospital level factors exists in both delivery of, and outcomes, following cardiac surgery in the UK. However, there was no clear association between these factors and patient outcomes. This negative finding could be explained by differences in outcome definition, differences in risk factors between centres that are not captured by standard risk stratification scores or individual surgeon/team performance.

Abstract OT2-06-01: Highly innovative personalized RNA-immunotherapy for patients with triple negative breast cancer

Background: The treatment of triple negative breast cancer (TNBC) is hampered by the lack of established therapeutic targets such as hormone receptors or HER-2. Chemotherapy and radiotherapy is the standard of care, yet survival rates in TNBC remain poor. Approaches tailored to the patient's individual tumor signature may lead to improved therapeutic outcome. We have set up a clinical workflow covering drug development (from target discovery to manufacturing) and drug release providing a custom-made investigational medicinal product (IMP) for each individual patient.

Trial Design: A phase I/II trial assesses the feasibility, safety and biological efficacy of this personalized immunotherapy in three clinical sites in Germany and Sweden. TNBC patients (pT1cN0M0 – TxNxM0) after completion of initial standard of care therapy will be allocated to one of two study arms. Patients in ARM1 receive 8 vaccination cycles with a personalized combination of shared tumor-associated antigens, selected based on each patient tumor's antigen-expression profile out of a WAREHOUSE of pre-manufactured mRNA vaccine. Patients in ARM2 receive the personalized mRNA WAREHOUSE vaccine followed by 8 vaccination cycles of an on-demand manufactured mRNA MUTANOME vaccine encoding up to twenty unique neo-epitopes of the individual patient identified by next generation sequencing. The mRNAs are administered intravenously as a nanoparticulate lipoplex formulation, which protects RNA from degradation, activates innate immunity, transfects APCs and consequently induces highly potent antigen-specific T-cell responses. The treatment of 12 patients in ARM1 is completed and enrolment of patients for ARM2 has started. Preliminary data show that the RNA-WAREHOUSE approach is feasible and can be applied safely. Biomarker analysis is ongoing. This approach is promising as it addresses the heterogeneity of TNBC.

The TNBC-MERIT trial was initially funded by the EU Commission's FP7 and led by BioNTech AG.

Citation Format: Schmidt M, Bolte S, Frenzel K, Heesen L, Derhovanessian E, Bukur V, Diken M, Gruetzner J, Kreiter S, Klein A, Kuhn A, Langer D, Loewer M, Lindman H, Schneeweiss A, Tuereci O, Sahin U. Highly innovative personalized RNA-immunotherapy for patients with triple negative breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr OT2-06-01.