Magnetic resonance imaging features of dermatofibrosarcoma protuberans; what the surgeon should know: a case series

Dermatofibrosarcoma protuberans (DFSP) is a rare, slow-growing, spindle cell neoplasm with low to intermediate grade malignant potential, commonly found in young and middle-aged adults, more in males than females. DFSP mostly originates in the dermis; rarely, it may be located in the deeper tissues without dermal involvement. Typically, DFSP appears as a multinodular mass, which then spreads into the subcutaneous tissues and muscle; it rarely dedifferentiates to high-grade fibrosarcoma, and more rarely, it may metastasise. We describe magnetic resonance imaging (MRI) features in three female patients with histologically proven DFSP and review the literature.

Observations during the COVID-19 pandemic in chronic heart failure patients with complex devices in a tertiary care cardiac centre using the HeartLogic software

Funding Acknowledgements

Type of funding sources: None.

Introduction

Decompensation of heart failure leading (HF) to hospitalisation is the single most important drain on healthcare resources when managing patients with left ventricular systolic dysfunction. Cardiac resynchronisation therapy with/without defibrillators (CRT-P/D) decreases hospitalisation due to HF and improves survival while implantable cardiac defibrillators (ICD"s) have a favourable effect on the former. Proprietary software algorithms embedded in these complex devices give an early warning to clinicians when decompensation of HF is imminent allowing preventative action to be undertaken.

HeartLogic (HL) is one such new algorithm in Boston Scientific CRT-D/ICD devices using multiple sensors to track 5 physiological parameters, combining them into one composite Index, with an Alert being triggered if the Index is >16. The COVID-19 pandemic, due to multiple reasons, resulted in a significant decrease in availability of routine HF services in the United Kingdom, especially during the initial lockdown period from 23rd March to 1st July 2020.

Aim

To assess the impact of the COVID-19 pandemic, using HL, in patients with HF and complex devices. 

Materials and Methods

Retrospective analysis of patients in a tertiary care cardiac centre in whom the HL software had been activated in March/April 2019 (n = 49) and comparison of those with (Group A n = 21) and without (Group B n = 28) an Alert (HLA) during the COVID-19 pandemic. 

Results (Table): Whole cohort n = 49. Age:  72 ± 12 years, Median: 75, Range: 36-95. 36/49 (73.5%) males. Type of device implanted: Resonate X4 CRT-D: 28/49 (57.1%); Momentum CRT-D: 8/49 (16.3%); Resonate ICD: 13/49 (26.5%). Ischaemic aetiology of HF: 35/49 (71.4%), Total duration of HL monitoring: 632 ± 7 days (median: 632; range: 626-672).  There was no difference in the age, gender, and type of device implanted between Group A and Group B. Over nearly ∼1 year of monitoring in each of the groups, Group A had more unstable HF with 10/21 (47.6%) having their first HLA during the pandemic. Multiple HLA"s, longer period in HLA and those with ischaemic aetiology of HF were higher in Group A. 17/40 (42.5%) HLA"s in Group A were within the first lockdown period (March - July). 24/28 (85.7%) patients in Group B had no HLA"s either before or during the pandemic. There was no difference in the HLA score between Groups A and B.

Conclusion

In this limited group of patients with a medium term follow-up, using the HeartLogic software, patients with ischaemic aetiology of HF and those with more HLA"s prior to the pandemic did worse than those who no HLA"s. First HLA"s, multiple alerts and longer duration of alerts in this group of patients suggests a lack of access to adequate HF services during the pandemic. It has implications with regard to how HF services are configured in future whenever resources are constrained.

Food handlers: an important reservoir of protozoans and helminth parasites of public health importance

Food handlers plays a primary role in the transmission of pathogenically important protozoans and helminth parasites. This study was aimed to evaluate the prevalence of intestinal pathogenic protozoans and helminth parasites among food handlers in and around University of Malakand, Lower Dir, Pakistan. Stool samples were collected from 642 food handlers (all of male) in a cross-sectional study from January to November, 2017. Wet Mount Techniques and concentration methods by using salt and formol-ether solutions. Three hundred and eighty four cases (59.8%) were found infected with one more parasites. Most of the individuals were found infected with helminth (47.6%) as compared to intestinal protozoans (0.93%). Seventy two cases (11.2%) of the cases presented mixed infection with both intestinal protozoan and helminth parasites. The order of prevalence for intestinal helminth was Ancylostoma duodenale (n = 258, 40.1%), followed by Taeniasa ginata (n=96, 14.9%) Ascaris lumbricoides (n = 54, 8.40%) and Trichuris trichura (n=30, 4.60%). For intestinal protozoa, Entamoeba histolytica/dispar (n = 36, 5.64%) was the only protozoan detected. Mono-parasitism was higher than poly-parasitism. Family size income and education level were the factors significantly (P<0.05) associated in the parasites prevalence. Current research showed that IPIs are primarily the foodborne pathogens still an important public health problem in Pakistan. Effective control programs on parasitic diseases transfer and their associated factors are recommended.

Pinworm infection in school children of four districts of Malakand region, Khyber Pakhtunkhwa, Pakistan

Illnesses caused by human pinworm remains a pediatric health problem in developing nations including Pakistan. This study aimed to investigate the prevalence of Enterobius vermicularis in school children of four districts in Malakand region, Pakistan. Four hundred faecal specimens were screened from May 2014 to July 2017 using normal saline and Lugol Iodine solution. Twenty three (5.75%) individuals were found infected with E. vermicularis. Five children (1.25%) were infected with only E. vermicularis and eighteen (4.5%) were mixed with other helminths. E. vermicularis 23 (5.75%), hookworm 11 (2.75%), Ascaris lumbricoides 5 (1.25%), Taenia saginata 2 (0.5%) and Trichuris trichuira 4 (1%) were detected. Age wise 5-8 years were more parasitized followed by 13-15 and 9-12 years of age (0.0296, P<0.05). Male children were highly (0.06700, P<0.05) infected than female. Children in Malakand district were found more infected followed by Dir Upper, similar infection rate was noted in children of districts Lower Dir and Swat (0.0192, P<0.05). Children in primary level were highly (0.0013, P<0.05) infected than those of middle and high levels. Enterobiosis is still the most common parasitic diseases in children. Studies on enterobiosis should be conducted time by time to recognize the hazardous of such parasitic infection in remote areas of the country.

822 Lessons Learnt During the COVID-19 Pandemic on Emergency Surgical Admissions in A District General Hospital

Introduction

Coronavirus disease (COVID-19) is an acute severe respiratory distress syndrome which resulted in an unprecedented impact on NHS service provision. We aimed to assess the impact of COVID-19 on general surgical services in a district general hospital.

Method

Electronic health care record data was retrospectively collected from 6th of April to 6th of May for both 2019 and 2020.

Results

Despite fewer referrals and admissions in 2020 (133 vs 177 admissions in 2019), there were more failed discharges (29 vs 17 in 2019) and higher associated costs. Higher numbers of biliary related pathologies and pancreatitis (50 in 2020 vs 25 in 2019), and fewer complaints of non-specific abdominal pain (10 in 2020 vs 22 in 2019) were observed. The use of outpatient investigations decreased by approximately 40% in 2020; however, utilisation of inpatient investigations was comparable.

Conclusions

Better utilisation of outpatient investigations and virtual clinic services may surmount pressures from further peaks of COVID-19. The increase in biliary related cases and pancreatitis may be consequent upon lifestyle changes during lockdown. This merits further investigation and if appropriate, public health intervention. In the absence of an efficacious vaccine, further research would be essential to streamline general surgical services based on clinical risk stratification.

258 Increase in Cycling Injuries During COVID-19: Unintended Consequences of Lockdown Restrictions in The United Kingdom

Introduction

Higher number of cycling injuries were observed during the COVID-19 period in the United Kingdom at our institution. Many were serious injuries requiring hospitalisation and some requiring surgery. We investigated whether the lockdown led to a legitimate increase in incidence of cycling related injuries, resulting in a higher number of aerosol generating procedures (AGPs). This would assess whether the guidance on exercise during lockdown was appropriate, shaping future regulation in the case of cyclical lockdowns.

Method

Records were screened retrospectively for cycling related injuries between April 1st and May 12th (lockdown) 2020 and for same period in 2019 as a control group. Injury severity, distribution and number of surgical procedures resulting from these were assessed.

Results

The proportion of injuries due to cycling rose threefold (n = 55) during the COVID-19 lockdown. Injuries included fractures, soft tissue injuries and mixed injuries. An increase in the number of operative procedures (n = 13) and AGPs was also noted.

Conclusions

Vague guidance and allowance of one form of outdoor exercise per day may have unintentionally contributed to rise in cycling injuries as many took to cycling for recreation. To make the guidance appropriate, usual forms of exercise should be encouraged, risk taking behaviours discouraged and safe cycling practices endorsed.

Current and future best practice in imaging, staging, and response assessment for Non-Hodgkin's lymphomas: the Specialist Integrated Haematological Malignancy Imaging Reporting (SIHMIR) paradigm shift

Non-Hodgkin's lymphoma (NHL) encompasses over 40 different haematological malignancies, including low and high-grade neoplasms, such as follicular lymphoma (FL) and diffuse large B-cell lymphoma (DLBCL) respectively. A key clinical issue in the context of NHL is delayed and inaccurate diagnosis, which contributes adversely to patient morbidity and mortality. This article will address relevant imaging aspects, with particular reference to advancements in NHL imaging, including computed tomography (CT), integrated positron-emission tomography (PET)-CT, and magnetic resonance imaging (MRI). We provide multiparametric (anato-functional) imaging display items, including histological correlation. We will also introduce our original concept of "Specialist Integrated Haematological Malignancy Imaging Reporting" (SIHMIR), a paradigm shift in lymphoma radiology.

Effect of differential music tempo on post-exercise cardiovascular recovery parameters in hypertensive individuals: a randomised control trial

Hypertensive individuals tend to have autonomic dysfunction indicated by sympathetic dominance or delayed parasympathetic reactivation. A complimentary therapy such as music following exercise is considered to be beneficial in improving autonomic recovery. The purpose of this study was to assess the effect of differential music tempo on post-exercise cardiovascular recovery parameters in hypertensive individuals. Thirty hypertensive individuals were recruited for the present study which were randomly allocated to no music (n=10), slow music (n=10) and fast music (n=10) group. Participants in all three groups were subjected to submaximal exercise bout by Harvard step test. The cardiovascular recovery parameters i.e. heart rate recovery (HRR), blood pressure recovery (BPR) and rating of perceived exertion recovery (RPER) were assessed in all three groups after 1 min, 2 min and 3 min following termination of exercise. A significant decline was observed in HRR (P=0.002) and RPER (P=0.008) following exercise in slow music group as compared to fast and no music while no significant differences were observed in BPR between the three groups. The study concluded that music accelerates post-exercise recovery and slow music has greater effect as compared to fast or no music. These findings may have potential implications in the cardiovascular recovery dynamics in hypertensive individuals participating in submaximal exercise.

Anorectal Malformations and Associated Anomalies in Children

Anorectal malformations (ARM) incorporate a broad spectrum of diseases, can affect both sexes, and involve the distal anus and rectum as well as the uro-genital tracts. Defects range from the minor which can be treated easily with an excellent outcome, to those are complex and often associated with other anomalies are difficult to manage with poor functional prognosis. This study was done to observe the hospital incidence of Anorectal malformations, frequency of types, sex distribution and spectrum of associations with ARM. The effects of presence of associated anomalies on morbidity and mortality also observed. Detailed history, clinical examinations and relevant investigations were performed for the primary and as well as the associated anomalies. A total of 80 patients were admitted in the department of pediatric surgery in Mymensingh Medical College Hospital during the period of June 2016 to May 2017. Age of the patients was ranging from 1-180 days with the mean age of 0.49±1.002 months. Male: Female ratio was 1.6: 1. Among them 48(60%) were high and 32(40%) were low variety of ARM. In male 37(46.2%) had high and 13(13.7%) were low variety whereas in female 11(13.7%) were high and 19(23.7%) had low ARM. Associated anomalies were seen in 25(31.2%) patient -18 in males and 7 in females; 20 in high and 5 in low ARM. Associated anomalies were uro-genital 11(13.8%), cardiovascular 10(12.5%), vertebral 4(5%), limb defects 3(3.5%) and others 2(2.5%). Four patients have more than one anomaly. Anorectal malformations occur more in boys than girls. Males were more likely to have high lesions and without fistula was the common defect. Low variety ARM were found more in females with Anovestibular fistula is the commonest defect. The most common associated anomalies were recto urinary fistula (13.8%). Associations were more in high than low ARM but not significant (p>0.05). Post operative complications were more in high ARM in both sexes with associated anomalies. The effects of types and associations on morbidity and mortality were significantly different (p<0.05).

Prognostic utility of cardiopulmonary exercise testing indices in arrhythmogenic right ventricular cardiomyopathy

Introduction

Cardiopulmonary exercise testing (CPET) has an established role in the clinical evaluation of exercise intolerance and in the risk stratification of patients with heart failure. There is limited data assessing its prognostic utility in the evaluation of patients with Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC). The predisposition of patients with ARVC for ventricular arrhythmias and sudden cardiac death has led to recommendations for exercise restrictions and limits our understanding of how the impairment in oxygen extraction and cardiac output impact disease progression and outcomes in these patients.

Purpose

We examined the association between CPET indices and event free survival (time to mortality or cardiac transplantation) in patients with Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC).

Methods

Patients with definite ARVC based on 2010 task force criteria and genetically positive were enrolled into our institutional ARVC registry. 43 patients underwent CPET and have been included in our analyses. Indications for testing included: Evaluation of exercise-induced palpitations/arrhythmias or syncope (37%), pharmacotherapy optimization (28%), heart failure evaluation (19%), and ARVC management decisions (16%). CPET data (peak oxygen consumption (pVO2), respiratory exchange ratio (RER), and ventilatory efficiency (VE/VCO2) were assessed in patients at time of initial evaluation. Median follow-up time was 4.9 years (IQR 9 years).

Results

126 patients were studied (age 43.7+ 15 yrs; 41% women; LVEF 57+ 11%; 15% with LVEF &lt;50%) and 43 underwent CPET evaluation. 41 patients (95%) performed at near maximal effort (RER &gt;1) and no fatal events were reported during testing. During the follow up period, the outcome (death or cardiac transplantation) occurred in 31 patients. On Kaplan Meier analysis, pVO2 ≤14 mL/kg/min was associated with worse outcomes (unadjusted p&lt;0.001). Peak oxygen consumption (pVO2) ≤14 mL/kg/min and ventilatory efficiency (VE/VCO2) &gt;34 were associated with shorter event free survival (HR 5.58, p=0.002 and HR 5.56 p=0.005, respectively). After adjusting for age, sex, and right ventricular function, the association between peak oxygen consumption (pVO2) and event free survival remained significant (p=0.02).

Conclusions

In patients with ARVC, peak oxygen consumption (pVO2) was a prognostic indicator of worse outcomes. Our findings suggest a potential role for pVO2 in disease surveillance and early assessment for advanced heart failure therapies.

Figure 1. KM plot pVO2 & event free survival

Funding Acknowledgement

Type of funding source: Other. Main funding source(s): Mayo Clinic

MRI Head Coil Malfunction Producing Artifacts Mimicking Malformation of Cortical Development in Pediatric Epilepsy Work-Up

We recently observed a type of MR imaging artifact that consistently mimics an abnormal appearance of the cerebral cortex, leading to initial misinterpretation and repeat scans. The artifact is caused by malfunction of part of the multichannel phased array head coil and is manifested by irregularity of cortical surface and gray-white matter junctions. The presence of such an artifact can be confirmed by assessing the background noise of the MR images and checking the coil element status on the MR imaging operator console.

THU0218 INCIDENCE AND RISK FACTORS FOR HERPES ZOSTER IN RHEUMATOID ARTHRITIS PATIENTS RECEIVING UPADACITINIB

Background:

Upadacitinib (UPA) is an oral JAK inhibitor approved for the treatment of rheumatoid arthritis (RA). The background rate of herpes zoster (HZ) in patients (pts) with RA is around 0.98/100 person years (PY)1. Pts with RA receiving JAK inhibitors have been reported to have an increased risk of HZ.

Objectives:

To evaluate the incidence and risk factors for HZ in pts with RA receiving UPA relative to active comparators in the Phase 3 clinical trial program.

Methods:

The incidence rate of HZ was determined in pts receiving UPA (as monotherapy [mono] or combination therapy) in five randomized Phase 3 trials (SELECT-EARLY, SELECT-MONOTHERAPY, SELECT-NEXT, SELECT-COMPARE, and SELECT-BEYOND), of which 4 evaluated both the UPA 15 and 30 mg once-daily (QD) doses and 1 trial (SELECT-COMPARE) evaluated only the 15 mg QD dose. Incidence of HZ was also determined in pts receiving adalimumab (ADA) + methotrexate (MTX) in SELECT-COMPARE and MTX mono in SELECT-EARLY. Risk factors for HZ were assessed using univariate and multivariate Cox regression models. Data cut-off was 30 June 2019.

Results:

Overall, 2629 pts who received UPA 15 mg QD (4565.8 patient-years [PY]), 1204 pts who received UPA 30 mg QD (2309.7 PY), 579 pts who received ADA + MTX (768.6 PY), and 314 pts who received MTX mono (456.0 PY) were analyzed. Fewer than 5% of pts across the treatment groups reported prior HZ vaccination. HZ (n/100 PY [95% CI]) occurred in 142 pts (3.1 [2.6–3.7]) with UPA 15 mg, 126 pts (5.5 [4.5–6.5]) with UPA 30 mg, 8 pts (1.0 [0.4–2.1]) with ADA + MTX, and 5 pts (1.1 [0.4–2.6]) with MTX mono. Most of the HZ cases (~71%) with UPA (Table) and all cases with ADA + MTX and MTX mono involved a single dermatome. Ophthalmic involvement was seen in 6 (4.2%) and 3 (2.4%) cases in the UPA 15 and 30 mg groups, respectively, and unilateral involvement with multiple dermatomes was seen in 26 (18.3%) and 23 (18.3%) cases. There was a single case of HZ meningitis reported in a Japanese pt on UPA 30 mg. In multivariate analyses, prior history of HZ and Asian region were associated with an increased risk of HZ in both the UPA groups (p≤0.01;Figure). In addition, pts ≥65 years old had increased risk of HZ in the 15 mg group.

Conclusion:

HZ events in pts with RA receiving UPA were more common in the 30 mg vs 15 mg group, and in both UPA groups compared with the ADA + MTX and MTX groups.

References:

[1]Smitten AL, et al. Arthritis Rheum 2007;57:1431–8

Table.

Summary of extent of involvement in pts with HZ

Categories, n (%)aAny UPA 15 mg QD(N=2629)Any UPA 30 mg QD(N=1204)Total patients with ≥1 HZ event142 (5.4)126 (10.5)Single dermatome101 (71.1)89 (70.6)Ophthalmic involvement6 (4.2)3 (2.4)HZ Oticus (Ramsay Hunt Syndrome)2 (1.4)1 (0.8)Multidermatomal (unilateral)b26 (18.3)23 (18.3)Disseminated, cutaneous only (no CNS involvement)c7 (4.9)8 (6.3)Disseminated with CNS or visceral involvement01 (0.8)dMissing8 (5.6)5 (4.0)

aPts may fall into >1 category;b≤2 adjacent dermatomes;c≥3 dermatomes, unilateral nonadjacent dermatomes, or bilateral dermatomes;dHZ meningitis

Figure.

Multivariable-adjusted risk factors for HZ in pts receiving UPA

Disclosure of Interests: :

Kevin Winthrop Grant/research support from: Bristol-Myers Squibb, Consultant of: AbbVie, Bristol-Myers Squibb, Eli Lilly, Galapagos, Gilead, GSK, Pfizer Inc, Roche, UCB, Peter Nash Grant/research support from: AbbVie, Bristol-Myers Squibb, Celgene, Eli Lilly and Company, Gilead, Janssen, MSD, Novartis, Pfizer Inc, Roche, Sanofi, UCB, Consultant of: AbbVie, Bristol-Myers Squibb, Celgene, Eli Lilly, Gilead, Janssen, MSD, Novartis, Pfizer Inc, Roche, Sanofi, UCB, Speakers bureau: AbbVie, Bristol-Myers Squibb, Celgene, Eli Lilly, Gilead, Janssen, MSD, Novartis, Pfizer Inc, Roche, Sanofi, UCB, Kunihiro Yamaoka Speakers bureau: AbbVie GK, Astellas Pharma Inc., Bristol-Myers Squibb, Chugai Pharmaceutical Co. Ltd, Mitsubishi-Tanabe Pharma Corporation, Pfizer Japan Inc., and Takeda Pharmaceutical Company Ltd, Eduardo Mysler Grant/research support from: AbbVie, Lilly, Pfizer, Roche, BMS, Sandoz, Amgen, and Janssen., Consultant of: AbbVie, Lilly, Pfizer, Roche, BMS, Sandoz, Amgen, and Janssen., Leonard Calabrese Consultant of: AbbVie, GSK, Bristol-Myers Squibb, Genentech, Janssen, Novartis, Sanofi, Horizon, Crescendo, and Gilead, Speakers bureau: Sanofi, Horizon, Crescendo, Novartis, Genentech, Janssen, and AbbVie, Nasser Khan Shareholder of: AbbVie Inc., Employee of: AbbVie Inc., Jose Jeffrey Enejosa Shareholder of: AbbVie, Employee of: AbbVie, Yanna Song Shareholder of: AbbVie Inc., Employee of: AbbVie Inc., Jessica Suboticki Shareholder of: AbbVie Inc., Employee of: AbbVie Inc., Jeffrey R. Curtis Grant/research support from: Abbvie, Amgen, BMS, Corrona, Crescendo, Janssen, Pfizer, Regeneron/Sanofi, and UCB, Consultant of: AbbVie, Amgen, BMS, Corrona, Crescendo, Janssen, Pfizer, Sanofi/Regeneron, and UCB

Pituitary metastases: presentation and outcomes from a pituitary center over the last decade

PURPOSE

Highlight and characterize manifestations, diagnostic/management approaches and outcomes in a contemporary cohort of patients with pituitary metastases (PM) from a large European pituitary center-over 10 years.

METHODS

Retrospective review of PM cases between 1/2009 and 12/2018. Clinical, laboratory, imaging data at PM detection and during follow-up were analysed.

RESULTS

18 cases were identified (14 females; median age at diagnosis 61.5 years). Most common primary malignancies were lung (39%) and breast (32%). Most frequent presenting manifestation was visual dysfunction (50%). Gonadotrophin, ACTH, TSH deficiency were diagnosed in 85%, 67%, 46% of cases, respectively; diabetes insipidus (DI) was present in 17%. 33% of cases were detected during investigation for symptoms unrelated to PM. PM management included radiotherapy (44%), transsphenoidal surgery (17%), transsphenoidal surgery and radiotherapy (6%) or monitoring only (33%). One-year survival was 49% with median survival from PM detection 11 months (range 2-47).

CONCLUSIONS

In our contemporary series, clinical presentation of PM has evolved; we found increased prevalence of anterior hypopituitarism, decreased rates of DI and longer survival compared with older literature. Increased availability of diagnostic imaging, improvements in screening and recognition of pituitary disease and longer survival of patients with metastatic cancer may be contributing factors.

SAT0151 EFFICACY AND SAFETY OF UPADACITINIB VERSUS ABATACEPT IN PATIENTS WITH ACTIVE RHEUMATOID ARTHRITIS AND PRIOR INADEQUATE RESPONSE OR INTOLERANCE TO BIOLOGIC DISEASE-MODIFYING ANTI-RHEUMATIC DRUGS (SELECT-CHOICE): A DOUBLE-BLIND, RANDOMIZED CONTROLLED PHASE 3 TRIAL

Background:

Upadacitinib (UPA) is an oral, reversible, selective JAK 1 inhibitor approved for the treatment of moderate to severe rheumatoid arthritis (RA). The efficacy/safety of UPA has been demonstrated in phase 3 studies, including superiority to adalimumab in patients (pts) with prior inadequate response (IR) to methotrexate.1-4

Objectives:

To assess the efficacy/safety of UPA vs abatacept (ABA) in pts with prior IR or intolerance to biologic DMARDs (bDMARDs).

Methods:

Pts were randomized to once daily UPA 15 mg or intravenous ABA (at Day 1, Weeks [Wks] 2, 4, 8, 12, 16 and 20 [< 60 kg: 500 mg; 60-100 kg: 750 mg; >100 kg: 1,000 mg]), with all pts continuing background stable csDMARDs. The study was double-blind for 24 wks. Starting at Wk 12, pts who did not achieve ≥20% improvement from baseline (BL) in both tender and swollen joint counts at two consecutive visits, had background medication(s) adjusted or initiated. The primary endpoint was change from BL in DAS28(CRP) at Wk 12 (non-inferiority). The non-inferiority of UPA vs ABA was tested using the 95% CI of treatment difference against a non-inferiority margin of 0.6. The two key secondary endpoints at Wk 12 were change from BL in DAS28(CRP) and the proportion of pts achieving clinical remission (CR) based on DAS28(CRP), defined as DAS28(CRP) <2.6. Both endpoints were to demonstrate the superiority of UPA vs. ABA. Treatment-emergent adverse events (TEAEs) are reported up to Wk 24 for all pts who received at least one dose of study drug.

Results:

Of 612 pts treated; 67% of pts had received 1 prior bDMARD, 22% received 2 prior bDMARDs, and 10% received ≥ 3 prior bDMARDs. 549 (90%) completed 24 wks of treatment. Common reasons for study drug discontinuation were AEs (UPA, 3.6%; ABA, 2.6%) and withdrawal of consent (UPA, 1.7%; ABA, 2.6%).

Non-inferiority and superiority were met for UPA vs ABA at Wk 12 for change from BL in DAS28(CRP) (-2.52 vs -2.00; -0.52 [-0.69, -0.35]; p <0.001 for UPA vs ABA). UPA also demonstrated superiority to ABA in achieving DAS28(CRP) <2.6 (30.0% vs 13.3%; p <0.001 for UPA vs ABA; Figure 1). Improvements in disease activity and remission rates were maintained through Wk 24. The proportions of pts achieving low disease activity (defined as DAS28(CRP) ≤3.2), ACR20, ACR50, and ACR70 responses were greater with UPA compared with ABA at Wk 12 (nominal p <0.05). More stringent outcome measures – CR, ACR50, and ACR70 responses - remained higher with UPA than ABA through Wk 24 (nominal p <0.05). Incidence of serious TEAEs, AEs leading to discontinuation, hepatic disorders, and CPK elevations were numerically higher with UPA versus ABA (Figure 2). Eight cases of herpes zoster were reported (4 in each treatment arm). No malignancies were reported. One case of adjudicated MACE, two adjudicated cases of VTE (1 pt with DVT and 1 pt with PE; both pts had at least one risk factor for VTE), and one treatment-emergent death were reported with UPA.

Conclusion:

In RA pts with a prior IR or intolerance to bDMARDs, UPA demonstrated superior improvement in signs and symptoms vs ABA based on change in DAS28(CRP) and in achieving CR at Wk 12. The safety profile of UPA was consistent with the phase 3 RA studies with no new risks identified.

References:

[1]Burmester GR, et al. Lancet. 2018;391(10139):2503-12

[2]Fleischmann R, et al. Arthritis Rheumatol. 2019;71(11):1788-800

[3]Genovese MC, et al. Lancet. 2018;391(10139):2513-24

[4]Smolen JS, et al. Lancet. 2019;393(10188):2303-11

Disclosure of Interests:

Andrea Rubbert-Roth Consultant of: Abbvie, BMS, Chugai, Pfizer, Roche, Janssen, Lilly, Sanofi, Amgen, Novartis, Jeffrey Enejosa Shareholder of: AbbVie Inc., Employee of: AbbVie Inc., Aileen Pangan Shareholder of: AbbVie Inc., Employee of: AbbVie Inc., Ricardo Xavier Consultant of: AbbVie, Pfizer, Novartis, Janssen, Eli Lilly, Roche, Boulos Haraoui Grant/research support from: Abbvie, Amgen, Pfizer, UCB, Grant/research support from: AbbVie, Amgen, BMS, Janssen, Pfizer, Roche, and UCB, Consultant of: Abbvie, Amgen, Lilly, Pfizer, Sandoz, UCB, Consultant of: AbbVie, Amgen, BMS, Celgene, Eli Lilly, Janssen, Merck, Pfizer, Roche, and UCB, Speakers bureau: Pfizer, Speakers bureau: Amgen, BMS, Janssen, Pfizer, and UCB, Maureen Rischmueller Consultant of: Abbvie, Bristol-Meyer-Squibb, Celgene, Glaxo Smith Kline, Hospira, Janssen Cilag, MSD, Novartis, Pfizer, Roche, Sanofi, UCB, Nasser Khan Shareholder of: AbbVie Inc., Employee of: AbbVie Inc., Ying Zhang Shareholder of: AbbVie Inc., Employee of: AbbVie Inc., Naomi Martin Shareholder of: AbbVie Inc., Employee of: AbbVie Inc., Mark C. Genovese Grant/research support from: Abbvie, Eli Lilly and Company, EMD Merck Serono, Galapagos, Genentech/Roche, Gilead Sciences, Inc., GSK, Novartis, Pfizer Inc., RPharm, Sanofi Genzyme, Consultant of: Abbvie, Eli Lilly and Company, EMD Merck Serono, Genentech/Roche, Gilead Sciences, Inc., GSK, Novartis, RPharm, Sanofi Genzyme

THU0213 UPADACITINIB AS MONOTHERAPY IN PATIENTS WITH RHEUMATOID ARTHRITIS AND PRIOR INADEQUATE RESPONSE TO METHOTREXATE: RESULTS AT 84 WEEKS FROM THE SELECT-MONOTHERAPY STUDY

Background:

In the SELECT-MONOTHERAPY trial, upadacitinib (UPA), an oral JAK inhibitor, demonstrated significantly greater efficacy compared to continuing methotrexate (MTX) when used as monotherapy over 14 weeks (wks) in patients (pts) with rheumatoid arthritis (RA) and prior inadequate response to MTX.1

Objectives:

To describe the long-term safety and efficacy of UPA monotherapy in an ongoing long-term extension (LTE) of the SELECT-MONOTHERAPY trial.

Methods:

Pts on stable MTX were randomized to either continue MTX (cMTX, given as blinded study drug) or switch to once-daily (QD) UPA 15 (UPA15) or 30 (UPA30) mg monotherapy for 14 wks. From Wk14, pts could enter a blinded LTE and continue to receive UPA15 or UPA30; pts randomized to cMTX were switched to UPA15 or UPA30 per pre-specified assignment at baseline. Treatment-emergent adverse events (TEAEs) per 100 pt yrs (PYs) of exposure are summarized up to a cut-off data of 5 February 2019, when all pts had reached Wk84. Efficacy outcomes through Wk84 are reported as observed and using non-responder imputation.

Results:

Of 648 pts randomized, 598 (92%) completed 14 wks and entered the LTE on blinded UPA. By the cut-off date, 20% in total had discontinued due to the following: AE (6%), consent withdrawal (4%), lost to follow-up (2%), lack of efficacy (1%), or other reasons (7%). Cumulative exposures were 421.5 and 425.9 PYs for UPA15 and UPA30, respectively. The most frequently reported TEAEs were urinary tract infection, creatine phosphokinase (CPK) increase, upper respiratory tract infection, nasopharyngitis, worsening of RA, bronchitis, herpes zoster (HZ), and alanine aminotransferase increase; the most common serious AE was pneumonia. Events of HZ, hepatic disorder, and CPK elevations were higher among pts receiving UPA30, while rates of serious infection and malignancy appeared comparable between doses (Figure). Most HZ events involved 1-2 dermatomes, with a single disseminated cutaneous event (UPA30) and none with CNS involvement. Five patients experienced MACE, and there were 5 VTE events (UPA15: 4; UPA30: 1). All MACE and VTE events occurred in pts with underlying risk factors. Pts continuing to receive UPA15 and UPA30 achieved stringent endpoints at Week 84 (Table). Pts who switched from cMTX to UPA15 or UPA30 demonstrated comparable efficacy responses to those initially randomized to UPA.

Conclusion:

The adverse event profile associated with long-term exposure to UPA15 or 30 as monotherapy was consistent with an integrated analysis of UPA safety across the entire phase 3 program, with no new safety signals identified. Further, UPA15 or 30 monotherapy resulted in continued and sustained improvements in RA signs and symptoms through 84 wks.

References:

[1]Smolen, et al.Lancet2019;393(10188):2303-11.

Table.

Proportion of Patients at Week 84

Parameter (%)cMTX→UPA 15 mgn=108cMTX→UPA 30 mgn=108UPA 15 mgn=217UPA 30 mgn=215AONRIAONRIAONRIAONRIACR20/50/7086/71/4967/56/3990/68/5066/51/3888/71/5465/53/4196/78/6674/62/52DAS28(CRP) ≤3.2/<2.680/5664/4479/6362/4976/6057/4685/7767/61CDAI ≤10/≤2.878/3862/3085/2965/2274/3455/2585/4967/39Boolean Remission2722231826204133

AO, as observed; NRI, non-responder imputation.

Disclosure of Interests: :

Josef S. Smolen Grant/research support from: AbbVie, Eli Lilly, Janssen, Merck Sharp & Dohme, Pfizer, Roche – grant/research support, Consultant of: AbbVie, Amgen Inc., AstraZeneca, Astro, Celgene Corporation, Celtrion, Eli Lilly, Glaxo, ILTOO, Janssen, Medimmune, Merck Sharp & Dohme, Novartis, Pfizer, Roche, Samsung, Sanofi, UCB – consultant, Speakers bureau: AbbVie, Amgen Inc., AstraZeneca, Astro, Celgene Corporation, Celtrion, Eli Lilly, Glaxo, ILTOO, Janssen, Medimmune, Merck Sharp & Dohme, Novartis, Pfizer, Roche, Samsung, Sanofi, UCB – speaker, Paul Emery Grant/research support from: AbbVie, Bristol-Myers Squibb, Merck Sharp & Dohme, Pfizer, Roche (all paid to employer), Consultant of: AbbVie (consultant, clinical trials, advisor), Bristol-Myers Squibb (consultant, clinical trials, advisor), Lilly (clinical trials, advisor), Merck Sharp & Dohme (consultant, clinical trials, advisor), Novartis (consultant, clinical trials, advisor), Pfizer (consultant, clinical trials, advisor), Roche (consultant, clinical trials, advisor), Samsung (clinical trials, advisor), Sandoz (clinical trials, advisor), UCB (consultant, clinical trials, advisor), William Rigby Grant/research support from: Bristol-Myers Squibb, Consultant of: AbbVie, Bristol-Myers Squibb, Genentech, Pfizer, Yoshiya Tanaka Grant/research support from: Asahi-kasei, Astellas, Mitsubishi-Tanabe, Chugai, Takeda, Sanofi, Bristol-Myers, UCB, Daiichi-Sankyo, Eisai, Pfizer, and Ono, Consultant of: Abbvie, Astellas, Bristol-Myers Squibb, Eli Lilly, Pfizer, Speakers bureau: Daiichi-Sankyo, Astellas, Chugai, Eli Lilly, Pfizer, AbbVie, YL Biologics, Bristol-Myers, Takeda, Mitsubishi-Tanabe, Novartis, Eisai, Janssen, Sanofi, UCB, and Teijin, Juan Ignacio Vargas Consultant of: AbbVie, Nemanja Damjanov Grant/research support from: from AbbVie, Pfizer, and Roche, Consultant of: AbbVie, Gedeon Richter, Merck, Novartis, Pfizer, and Roche, Speakers bureau: AbbVie, Gedeon Richter, Merck, Novartis, Pfizer, and Roche, Manish Jain Grant/research support from: AbbVie, Novartis, Celgene, Medac, and Takeda, Speakers bureau: AbbVie, Novartis, Celgene, Medac, and Takeda, Yanna Song Shareholder of: AbbVie Inc., Employee of: AbbVie Inc., Nasser Khan Shareholder of: AbbVie Inc., Employee of: AbbVie Inc., Jose Jeffrey Enejosa Shareholder of: AbbVie, Employee of: AbbVie, Stanley B. Cohen Grant/research support from: Amgen, Abbvie, Boehringer Ingelheim, Pfizer and Sandoz, Consultant of: Amgen, Abbvie, Boehringer Ingelheim, Pfizer and Sandoz

Patient and Public Involvement (PPI) in evidence synthesis: how the PatMed study approached embedding audience responses into the expression of a meta-ethnography

Background

Patient and public involvement (PPI) has become enshrined as an important pillar of health services empirical research, including PPI roles during stages of research development and analysis and co-design approaches. Whilst user participation has been central to qualitative evidence synthesis (QES) for decades, as seen in the Cochrane consumer network and guidelines, meta-ethnography has been slow to incorporate user participation and published examples of this occurring within meta-ethnography are sparse.

In this paper, drawing upon our own experience of conducting a meta-ethnography, we focus on what it means in practice to ‘express a synthesis’ (stage 7). We suggest the methodological importance of ‘expression’ in Noblit and Hare’s seven stage process (Noblit, GW and Hare, RD. Meta-ethnography: synthesizing qualitative studies, 1988) has been overlooked, and in particular, opportunities for PPI user participation within it.

Methods

Meta-ethnography comprises a seven-stage process of evidence synthesis. Noblit and Hare describe the final 7th stage of the meta-ethnography process as ‘expression of synthesis’, emphasizing co-construction of findings with the audience. In a previous study we conducted a meta-ethnography exploring patient and student experience of medical education within primary care contexts. We subsequently presented and discussed initial meta-ethnography findings with PPI (students and patients) in focus groups and interviews. We transcribed patient and student PPI interpretations of synthesis findings. As a research team, we then translated these into our existing meta-ethnography findings.

Results

We describe, with examples, the process of involving PPI in stage 7 of meta-ethnography and discuss three methodological implications of incorporating PPI within an interpretative approach to QES: (1) we reflect on the construct hierarchy of user participants’ interpretations and consider whether incorporating these additional 1st order, 2nd level constructs implies an additional logic of 3rd order 2nd level constructs of the QES team; (2) we discuss the link between PPI user participation and what Noblit and Hare may have meant by ideas of ‘expression’ and ‘audience’ as integral to stage 7; and (3) we link PPI user participation to Noblit and Hare’s underlying theory of social explanation, i.e. how expression of the synthesis is underpinned by ideas of translation and that the synthesis must be ‘translated in the audience’s (user participants) particular language’.

Conclusions

The paper aims to complement recent attempts in the literature to refine and improve guidance on conducting a meta-ethnography, highlighting opportunities for PPI user participation in the processes of interpretation, translation and expression. We discuss the implications of user participation in meta-ethnography on ideas of ‘generalisability’.