147 Synchronous Parathyroidectomy and Extended Thymectomy in Multiple Endocrine Neoplasia Type 1- a Case Report

In recent decades there has been a significant advancement in the management of neuroendocrine tumours (NETs) associated with multiple endocrine neoplasia type 1 (MEN-1). Hormone excess accounted for 75% of all MEN-1 deaths, however since the introduction of hormone blocking medication, deaths in patients with MEN-1 are now predominantly due to the malignant effects of the tumours. Half of all MEN-1 related deaths are due to tumours that are difficult to diagnose, including thymic NETs. Complete surgical resection is the mainstay of treatment for MEN-1 associated thymic NETs.

The case patient was a 49-year-old male who was being investigated for a 3-month history of symptoms consistent with hypercalcaemia. Initially a chest X-ray demonstrated a large anterior mediastinal mass. Further imaging revealed parathyroid lesions and a calcified lesion in the uncinate process of the pancreas. This combination of symptoms and radiological evidence raised the possibility of MEN-1 as the diagnosis. The lesions were biopsy-proven atypical carcinoid NETs and the patient later underwent simultaneous neck dissection for bilateral subtotal parathyroidectomy and a midline sternotomy for total thymectomy of the large mediastinal mass. Further testing revealed the pancreatic mass was another primary tumour and the patient is scheduled for excision of this. In addition, the patient is also being treated with Lanreotide alongside chemotherapy. Mutation of the MEN-1 gene was later confirmed on genetic testing.

Due to the increase in mortality from neuroendocrine malignancy, it is becoming ever more important to understand how to manage multiple NETs from a surgical perspective.

137 Salvage Pulmonary Resection in Stage IIIb-IV Lung Cancer After Treatment with Immune Checkpoint Inhibitors - A Case Series

Aim

Immune checkpoint inhibitors (ICIs) have been shown to prolong survival in patients that have locally advanced stage III/IV and metastatic non-small cell lung cancer (NSCLC). The role that salvages surgery plays in persistent localised disease and unresponsive synchronous cancer following treatment with a course of ICIs is not yet fully clear. We present a case series of nine patients with stage III/IV NSCLC that underwent surgical resection after treatment with the ICI, pembrolizumab.

Method

Six cases underwent salvage surgery after downstaging of the primary cancer following pembrolizumab treatment and three patients had resection of contralateral lung nodules that were unresponsive to ICI therapy. Three of the cases were open thoracotomies, 3 were robotic-assisted and 2 were video-assisted. One case was converted to open due to pulmonary artery involvement.

Results

There was complete, successful macroscopic resection in all cases with each showing histological evidence for active cancer cells. One patient died of COVID pneumonitis in the community within 60 days of surgery. All other patients are alive with no evidence of localised disease or of any disease reoccurrence within 3–18 months of their surgery.

Conclusions

Our case series demonstrates the potential for salvage pulmonary resection in select patients with advanced stage NSCLC who have persistent localised disease or unresponsive synchronous cancer after treatment with the ICI, pembrolizumab. Salvage surgery in this group of patients is safe and pragmatic despite high levels of post-immunotherapy hilar fibrosis. Further studies will be required in order to assess overall survival rates.

Clinical characteristics with inflammation profiling of long COVID and association with 1-year recovery following hospitalisation in the UK: a prospective observational study

BACKGROUND

No effective pharmacological or non-pharmacological interventions exist for patients with long COVID. We aimed to describe recovery 1 year after hospital discharge for COVID-19, identify factors associated with patient-perceived recovery, and identify potential therapeutic targets by describing the underlying inflammatory profiles of the previously described recovery clusters at 5 months after hospital discharge.

METHODS

The Post-hospitalisation COVID-19 study (PHOSP-COVID) is a prospective, longitudinal cohort study recruiting adults (aged ≥18 years) discharged from hospital with COVID-19 across the UK. Recovery was assessed using patient-reported outcome measures, physical performance, and organ function at 5 months and 1 year after hospital discharge, and stratified by both patient-perceived recovery and recovery cluster. Hierarchical logistic regression modelling was performed for patient-perceived recovery at 1 year. Cluster analysis was done using the clustering large applications k-medoids approach using clinical outcomes at 5 months. Inflammatory protein profiling was analysed from plasma at the 5-month visit. This study is registered on the ISRCTN Registry, ISRCTN10980107, and recruitment is ongoing.

FINDINGS

2320 participants discharged from hospital between March 7, 2020, and April 18, 2021, were assessed at 5 months after discharge and 807 (32·7%) participants completed both the 5-month and 1-year visits. 279 (35·6%) of these 807 patients were women and 505 (64·4%) were men, with a mean age of 58·7 (SD 12·5) years, and 224 (27·8%) had received invasive mechanical ventilation (WHO class 7-9). The proportion of patients reporting full recovery was unchanged between 5 months (501 [25·5%] of 1965) and 1 year (232 [28·9%] of 804). Factors associated with being less likely to report full recovery at 1 year were female sex (odds ratio 0·68 [95% CI 0·46-0·99]), obesity (0·50 [0·34-0·74]) and invasive mechanical ventilation (0·42 [0·23-0·76]). Cluster analysis (n=1636) corroborated the previously reported four clusters: very severe, severe, moderate with cognitive impairment, and mild, relating to the severity of physical health, mental health, and cognitive impairment at 5 months. We found increased inflammatory mediators of tissue damage and repair in both the very severe and the moderate with cognitive impairment clusters compared with the mild cluster, including IL-6 concentration, which was increased in both comparisons (n=626 participants). We found a substantial deficit in median EQ-5D-5L utility index from before COVID-19 (retrospective assessment; 0·88 [IQR 0·74-1·00]), at 5 months (0·74 [0·64-0·88]) to 1 year (0·75 [0·62-0·88]), with minimal improvements across all outcome measures at 1 year after discharge in the whole cohort and within each of the four clusters.

INTERPRETATION

The sequelae of a hospital admission with COVID-19 were substantial 1 year after discharge across a range of health domains, with the minority in our cohort feeling fully recovered. Patient-perceived health-related quality of life was reduced at 1 year compared with before hospital admission. Systematic inflammation and obesity are potential treatable traits that warrant further investigation in clinical trials.

FUNDING

UK Research and Innovation and National Institute for Health Research.

O003 Radiation-related chromosomal aberrations observed in high volume endovascular operators performing X-ray guided surgery

Introduction

The biological effects of chronic, low dose radiation, to which operators performing fluoroscopy-guided procedures are exposed, are unknown. We have previously demonstrated acute DNA damage/repair in lymphocytes from operators performing fluoroscopy-guided endovascular aneurysm repair (EVAR), but these markers normalised after 24 hours and did not inform on the residual accumulated effects of chronic radiation exposure. In the present study cytogenetic techniques were used to examine for chromosomal aberrations in endovascular operators.

Methods

Peripheral blood lymphocytes were isolated from high volume endovascular operators performing EVAR and age-matched radiation naïve general surgeons as controls. Giemsa staining was used to visualise the full complement of chromosomes and all dicentrics, where 2 centromeres are present in a single chromosome, were identified. The genome was analysed for abnormal exchanges of genetic material between chromosomes using multiplex fluorescence in situ hybridisation (mFISH).

Results

Lymphocytes from 18 operators (12 exposed, 6 controls) were analysed. A higher frequency of dicentric chromosomes were found in exposed operators compared with controls (0.0011 vs 0.0004, respectively, P=0.002) after examining 54,000 lymphocytes. Twice as many complex chromosome rearrangements were seen in endovascular operators compared with controls (0.48% vs 0.24%). Aneuploidy, the abnormal loss of chromosomes, was more frequent in endovascular operators with a median difference of 0.35 per chromosome (P=0.004).

Conclusion

We have found a higher frequency of chromosomal aberrations in endovascular operators compared with radiation naïve colleagues. This justifies further individual biological profiling for genomic instability and personalised radiation risk assessment.

Take-home message

Radiation-related DNA damage occurs in endovascular operators despite current radiation protection measures. Biological dosimetry could be a useful tool, allowing personalised risk assessment.

O079 Predictive value for elevated platelet-derived SGPVI in venous in-stent stenosis in patients with post-thrombotic syndrome

Introduction

In-stent stenosis following intervention for post-thrombotic syndrome (PTS) occurs in ∼30% of cases, despite therapeutic anticoagulation. Our aim was to investigate whether platelets are involved.

Methods

Blood was taken from case-matched patients before and after venous stenting. Flow-cytometry was used to assess platelet activation (P-selectin and/or phosphatidylserine exposure) while= functional activity was measured by plate-based aggregation and through a flow-cell model of thrombus formation. Soluble glycoprotein VI (sGPVI) was measured in plasma. Patients with in-stent stenosis requiring reintervention (>50% diameter reduction) were compared with those who did not.

Results

Forty-five patients were recruited (median age: 43yrs (33–55yrs); 65% female), and 19/45 (42%) required reintervention (median time: 3wks (1day-3mths)). There was no difference in platelet activation or reactivity after stenting, but P-selectin exposure pre-stent was significantly higher in patients who developed in-stent stenosis (2.7%±0.4 vs 1.7%±0.2; P<0.05). Pre-stent sGPVI levels were increased in patients who developed in-stent stenosis (18.9±3.6ng/mL vs. 7.4±0.9ng/mL; P<0.01). Platelet reactivity to collagen-related peptide, a GPVI-specific platelet agonist, was reduced in patients who developed in-stent stenosis (logEC50 = -6.5M±0.3 vs -7.2M±0.2; P<0.05; n=33). Pre-stent platelet accumulation (26.6AU±0.5 vs 19.0AU±8.1; P=0.04) was significantly increased in PTS patients compared with healthy controls.

Conclusion

Venous stenting does not activate platelets, but patients who developed in-stent stenosis exhibited greater levels of pre-stent platelet activation, greater loss of platelet surface GPVI in the form of sGPVI and reduction in reactivity to GPVI activation. sGPVI may have potential to risk stratify patients undergoing venous stenting and predict who requires closer surveillance.

Take-home message

Soluble GPVI may have potential to risk-stratify patients undergoing deep venous reconstruction and predict who requires closer surveillance.

Scintillation light detection in the 6-m drift-length ProtoDUNE Dual Phase liquid argon TPC

DUNE is a dual-site experiment for long-baseline neutrino oscillation studies, neutrino astrophysics and nucleon decay searches. ProtoDUNE Dual Phase (DP) is a 6  ×  6  ×  6 m 3 liquid argon time-projection-chamber (LArTPC) that recorded cosmic-muon data at the CERN Neutrino Platform in 2019-2020 as a prototype of the DUNE Far Detector. Charged particles propagating through the LArTPC produce ionization and scintillation light. The scintillation light signal in these detectors can provide the trigger for non-beam events. In addition, it adds precise timing capabilities and improves the calorimetry measurements. In ProtoDUNE-DP, scintillation and electroluminescence light produced by cosmic muons in the LArTPC is collected by photomultiplier tubes placed up to 7 m away from the ionizing track. In this paper, the ProtoDUNE-DP photon detection system performance is evaluated with a particular focus on the different wavelength shifters, such as PEN and TPB, and the use of Xe-doped LAr, considering its future use in giant LArTPCs. The scintillation light production and propagation processes are analyzed and a comparison of simulation to data is performed, improving understanding of the liquid argon properties.

Novel KEL allele associated with loss of Kpb identified in a white blood donor

The importance of identifying variant alleles among blood donors is significant to the safety of transfusion for recipients. Molecular methods have become more prominent in the routine process of antigen typing donor units. Some variant antigens cannot be detected using only serologic methods. Molecular testing allows the determination of nucleotide sequences that are used to predict a phenotype. Antigens of the Kell blood group system are known for being highly immunogenic and causing adverse reactions upon antibody formation. A female white blood donor who typed Kp(b-) using serologic methods on multiple donations since 2005 was the subject of a typing discrepancy investigation. Routine genotyping using a commercial genotyping kit (HemoID DQS Panel; Agena Bioscience, San Diego, CA) predicted the donor to type Kp(a+b+). Investigation of the discrepancy between these two results identified a rare single nucleotide variant in the KEL gene at nucleotide position c.948G>T that alters amino acid residue 316 from tryptophan (Trp) to cysteine (Cys). After discovery of the novel allele, adsorption and elution studies were performed to see if there was weakened Kp^b expression. The elution studies yielded negative results, which indicated that Kp^b is not expressed. The KEL transcripts expressed by the donor were determined using cDNA analysis, and the predicted amino acid sequence of the novel allele was modeled to investigate the impact of the amino acid sequence on the structure of the KEL polypeptide. Both SWISS-MODEL and Robetta software were used to evaluate the impact of the p.Trp316Cys on the three-dimensional protein structure. There was no conformational change noted with SWISS-MODEL, whereas the Robetta software showed a significant conformational change compared with the normal Kp(b+) reference sequence. Because the donor is homozygous for variants associated with k and Js^b expression, it was not possible to determine whether the novel allele is associated with loss of Kp^b only or loss of all Kell antigens.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

Search for an Excess of Electron Neutrino Interactions in MicroBooNE Using Multiple Final-State Topologies

We present a measurement of ν_{e} interactions from the Fermilab Booster Neutrino Beam using the MicroBooNE liquid argon time projection chamber to address the nature of the excess of low energy interactions observed by the MiniBooNE Collaboration. Three independent ν_{e} searches are performed across multiple single electron final states, including an exclusive search for two-body scattering events with a single proton, a semi-inclusive search for pionless events, and a fully inclusive search for events containing all hadronic final states. With differing signal topologies, statistics, backgrounds, reconstruction algorithms, and analysis approaches, the results are found to be either consistent with or modestly lower than the nominal ν_{e} rate expectations from the Booster Neutrino Beam and no excess of ν_{e} events is observed.

AB0424 A RANDOMIZED, DOUBLE-BLIND, PLACEBO CONTROLLED STUDY OF THE SAFETY, TOLERABILITY, PHARMACOKINETICS, AND PHARMACODYNAMICS OF ALPN-303, A POTENT DUAL BAFF/APRIL INHIBITOR, IN ADULT HEALTHY VOLUNTEERS

Background

Therapeutic agents targeting the B-cell cytokines BAFF and/or APRIL, including the wild-type (WT) TACI-Fc fusion proteins atacicept and telitacicept, have demonstrated promising clinical potential in rheumatic diseases like systemic lupus erythematosus (SLE) and/or other B-cell-related diseases such as autoantibody-related nephritides. ALPN-303 is an Fc fusion protein of a variant, engineered TACI domain which mediates significantly more potent inhibitory activity in vitro as compared to WT TACI-Fc or BAFF- or APRIL-specific monoclonal antibodies, along with enhanced pharmacokinetic (PK) and immunomodulatory properties in preclinical studies1,2. ALPN-303 may therefore significantly improve clinical outcomes in SLE and other B-cell-related diseases.

Objectives

To evaluate the safety, tolerability, PK, and pharmacodynamics (PD) of ALPN-303 in adult healthy volunteers (HV).

Methods

In this first-in-human study (NCT05034484), adult HVs are enrolled in single ascending dose cohorts of intravenously (IV) or subcutaneously (SC) administered ALPN-303. For each IV cohort, the first 2 subjects are randomized 1:1 to receive ALPN-303 or placebo, followed by the remaining 4 subjects randomized 3:1 to receive ALPN-303 or placebo. For each SC cohort, HVs are randomized 4:2 to receive a single SC dose of ALPN-303 or placebo. All subjects are followed to assess safety and PK of ALPN-303, to measure levels of circulating immunoglobulins (Ig), and to characterize leukocyte populations in peripheral blood by flow cytometry.

Results

ALPN-303 has been well tolerated and overall exhibits dose-dependent PK and expected PD effects on circulating Ig levels. Dose escalation is expected to be completed by the time of the meeting; the presentation will include all available safety, PK, and PD (circulating Ig and B-cell population) data.

Conclusion

In this first-in-human study, ALPN-303 demonstrates acceptable preliminary safety and tolerability, and exhibits expected PD effects on circulating Ig and B-cell populations. These findings support future clinical development of ALPN-303 in patients with SLE or other B-cell-mediated diseases.

References

[1]Dillon SR, Evans LS, Lewis KE, et al. OP0039 ALPN-303, an enhanced, potent dual BAFF/APRIL antagonist engineered by directed evolution for the treatment of systemic lupus erythematosus (SLE) and other B cell related autoimmune diseases. Annals of the Rheumatic Diseases 2021;80:21.

[2]Dillon SR, Evans LS, Lewis KE, et al. ALPN-303, an enhanced, potent dual BAFF/APRIL antagonist engineered by directed evolution for the treatment of systemic lupus erythematosus (SLE) and other B cell-related diseases. Arthritis Rheumatol. 2021; 73 (suppl 10).

Disclosure of Interests

Pille Harrison Employee of: Alpine Immune Sciences Inc, Jason Lickliter Consultant of: ENA Oncology and Amplia. Neither of these were developing drugs for rheumatological diseases., Stacey R. Dillon Employee of: Alpine Immune Sciences Inc, Kristi Manjarrez Employee of: Alpine Immune Sciences Inc, Alina Smith Employee of: Alpine Immune Sciences Inc, Melody Dossey Employee of: Alpine Immune Sciences Inc, Lori Blanchfield Employee of: Alpine Immune Sciences Inc, Allison Chunyk Employee of: Alpine Immune Sciences Inc, Hany Zayed Employee of: Alpine Immune Sciences Inc, Stanford L. Peng Employee of: Alpine Immune Sciences Inc

Changes in brain activity with tominersen in early-manifest Huntington’s disease

It is unknown whether alterations in EEG brain activity caused by Huntington’s disease may be responsive to huntingtin-lowering treatment. We analysed EEG recordings of 46 patients (mean age = 47.02 years; standard deviation = 10.19 years; 18 female) with early-manifest Stage 1 Huntington’s disease receiving the huntingtin-lowering antisense oligonucleotide tominersen for 4 months or receiving placebo as well as 39 healthy volunteers (mean age = 44.48 years; standard deviation = 12.94; 22 female) not receiving treatment. Patients on tominersen showed increased resting-state activity within a 4–8 Hz frequency range compared with patients receiving placebo (cluster-based permutation test, P < 0.05). The responsive frequency range overlapped with EEG activity that was strongly reduced in Huntington’s disease compared with healthy controls (cluster-based permutation test, P < 0.05). The underlying mechanisms of the observed treatment-related increase are unknown and may reflect neural plasticity as a consequence of the molecular pathways impacted by tominersen treatment.

Hawellek et al. report that patients with Huntington’s disease treated with the huntingtin-lowering antisense oligonucleotide tominersen exhibited increased EEG power in the theta/alpha frequency range. The underlying mechanisms of the observed changes are unknown and may reflect neural plasticity as a consequence of the molecular pathways impacted by tominersen treatment.

First Measurement of Energy-Dependent Inclusive Muon Neutrino Charged-Current Cross Sections on Argon with the MicroBooNE Detector

We report a measurement of the energy-dependent total charged-current cross section σ(E_{ν}) for inclusive muon neutrinos scattering on argon, as well as measurements of flux-averaged differential cross sections as a function of muon energy and hadronic energy transfer (ν). Data corresponding to 5.3×10^{19} protons on target of exposure were collected using the MicroBooNE liquid argon time projection chamber located in the Fermilab booster neutrino beam with a mean neutrino energy of approximately 0.8 GeV. The mapping between the true neutrino energy E_{ν} and reconstructed neutrino energy E_{ν}^{rec} and between the energy transfer ν and reconstructed hadronic energy E_{had}^{rec} are validated by comparing the data and Monte Carlo (MC) predictions. In particular, the modeling of the missing hadronic energy and its associated uncertainties are verified by a new method that compares the E_{had}^{rec} distributions between data and a MC prediction after constraining the reconstructed muon kinematic distributions, energy, and polar angle to those of data. The success of this validation gives confidence that the missing energy in the MicroBooNE detector is well modeled and underpins first-time measurements of both the total cross section σ(E_{ν}) and the differential cross section dσ/dν on argon.

Search for Neutrino-Induced Neutral-Current Δ Radiative Decay in MicroBooNE and a First Test of the MiniBooNE Low Energy Excess under a Single-Photon Hypothesis

We report results from a search for neutrino-induced neutral current (NC) resonant Δ(1232) baryon production followed by Δ radiative decay, with a ⟨0.8⟩  GeV neutrino beam. Data corresponding to MicroBooNE's first three years of operations (6.80×10^{20} protons on target) are used to select single-photon events with one or zero protons and without charged leptons in the final state (1γ1p and 1γ0p, respectively). The background is constrained via an in situ high-purity measurement of NC π^{0} events, made possible via dedicated 2γ1p and 2γ0p selections. A total of 16 and 153 events are observed for the 1γ1p and 1γ0p selections, respectively, compared to a constrained background prediction of 20.5±3.65(syst) and 145.1±13.8(syst) events. The data lead to a bound on an anomalous enhancement of the normalization of NC Δ radiative decay of less than 2.3 times the predicted nominal rate for this process at the 90% confidence level (C.L.). The measurement disfavors a candidate photon interpretation of the MiniBooNE low-energy excess as a factor of 3.18 times the nominal NC Δ radiative decay rate at the 94.8% C.L., in favor of the nominal prediction, and represents a greater than 50-fold improvement over the world's best limit on single-photon production in NC interactions in the sub-GeV neutrino energy range.

Social determinants of health influence disease activity and functional disability in Polyarticular Juvenile Idiopathic Arthritis

BACKGROUND

Social determinants of health (SDH) greatly influence outcomes during the first year of treatment in rheumatoid arthritis, a disease similar to polyarticular juvenile idiopathic arthritis (pJIA). We investigated the correlation of community poverty level and other SDH with the persistence of moderate to severe disease activity and functional disability over the first year of treatment in pJIA patients enrolled in the Childhood Arthritis and Rheumatology Research Alliance Registry.

METHODS

In this cohort study, unadjusted and adjusted generalized linear mixed effects models analyzed the effect of community poverty and other SDH on disease activity, using the clinical Juvenile Arthritis Disease Activity Score-10, and disability, using the Child Health Assessment Questionnaire, measured at baseline, 6, and 12 months.

RESULTS

One thousand six hundred eighty-four patients were identified. High community poverty (≥20% living below the federal poverty level) was associated with increased odds of functional disability (OR 1.82, 95% CI 1.28-2.60) but was not statistically significant after adjustment (aOR 1.23, 95% CI 0.81-1.86) and was not associated with increased disease activity. Non-white race/ethnicity was associated with higher disease activity (aOR 2.48, 95% CI: 1.41-4.36). Lower self-reported household income was associated with higher disease activity and persistent functional disability. Public insurance (aOR 1.56, 95% CI 1.06-2.29) and low family education (aOR 1.89, 95% CI 1.14-3.12) was associated with persistent functional disability.

CONCLUSION

High community poverty level was associated with persistent functional disability in unadjusted analysis but not with persistent moderate to high disease activity. Race/ethnicity and other SDH were associated with persistent disease activity and functional disability.