CariesCare International adapted for the pandemic in children: Caries OUT multicentre single-group interventional study protocol

Background

Comprehensive caries care has shown effectiveness in controlling caries progression and improving health outcomes by controlling caries risk, preventing initial-caries lesions progression, and patient satisfaction. To date, the caries-progression control effectiveness of the patient-centred risk-based CariesCare International (CCI) system, derived from ICCMS™ for the practice (2019), remains unproven. With the onset of the COVID-19 pandemic a previously planned multi-centre RCT shifted to this “Caries OUT” study, aiming to assess in a single-intervention group in children, the caries-control effectiveness of CCI adapted for the pandemic with non-aerosols generating procedures (non-AGP) and reducing in-office time.

Methods

In this 1-year multi-centre single-group interventional trial the adapted-CCI effectiveness will be assessed in one single group in terms of tooth-surface level caries progression control, and secondarily, individual-level caries progression control, children’s oral-health behaviour change, parents’ and dentists’ process acceptability, and costs exploration. A sample size of 258 3–5 and 6–8 years old patients was calculated after removing half from the previous RCT, allowing for a 25% dropout, including generally health children (27 per centre). The single-group intervention will be the adapted-CCI 4D-cycle caries care, with non-AGP and reduced in-office appointments’ time. A trained examiner per centre will conduct examinations at baseline, at 5–5.5 months (3 months after basic management), 8.5 and 12 months, assessing the child’s CCI caries risk and oral-health behaviour, visually staging and assessing caries-lesions severity and activity without air-drying (ICDAS-merged Epi); fillings/sealants; missing/dental-sepsis teeth, and tooth symptoms, synthetizing together with parent and external-trained dental practitioner (DP) the patient- and tooth-surface level diagnoses and personalised care plan. DP will deliver the adapted-CCI caries care. Parents’ and dentists’ process acceptability will be assessed via Treatment-Evaluation-Inventory questionnaires, and costs in terms of number of appointments and activities. Twenty-one centres in 13 countries will participate.

Discussion

The results of Caries OUT adapted for the pandemic will provide clinical data that could help support shifting the caries care in children towards individualised oral-health behaviour improvement and tooth-preserving care, improving health outcomes, and explore if the caries progression can be controlled during the pandemic by conducting non-AGP and reducing in-office time.

Trial registration: Retrospectively-registered-ClinicalTrials.gov-NCT04666597-07/12/2020: https://register.clinicaltrials.gov/prs/app/action/SelectProtocol?sid=S000AGM4&selectaction=Edit&uid=U00019IE&ts=2&cx=uwje3h. Protocol-version 2: 27/01/2021.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12903-021-01674-1.

Multisensory contribution in visuospatial orientation: an interaction between neck and trunk proprioception

A coherent perception of spatial orientation is key in maintaining postural control. To achieve this the brain must access sensory inputs encoding both the body and the head position and integrate them with incoming visual information. Here we isolated the contribution of proprioception to verticality perception and further investigated whether changing the body position without moving the head can modulate visual dependence-the extent to which an individual relies on visual cues for spatial orientation. Spatial orientation was measured in ten healthy individuals [6 female; 25-47 years (SD 7.8 years)] using a virtual reality based subjective visual vertical (SVV) task. Individuals aligned an arrow to their perceived gravitational vertical, initially against a static black background (10 trials), and then in other conditions with clockwise and counterclockwise background rotations (each 10 trials). In all conditions, subjects were seated first in the upright position, then with trunk tilted 20° to the right, followed by 20° to the left while the head was always aligned vertically. The SVV error was modulated by the trunk position, and it was greater when the trunk was tilted to the left compared to right or upright trunk positions (p < 0.001). Likewise, background rotation had an effect on SVV errors as these were greater with counterclockwise visual rotation compared to static background and clockwise roll motion (p < 0.001). Our results show that the interaction between neck and trunk proprioception can modulate how visual inputs affect spatial orientation.

Integrated quality assessment for diabetes care in Portuguese primary health care using prevention quality indicators

AIMS

This study evaluates the prevention quality indicators (PQI) for Diabetes Mellitus (DM) in Portugal using contemporary data and explores their variability according to Primary Health Care (PHC) quality indicators.

METHODS

We conducted a retrospective observational analysis of secondary data comprising Portuguese PHC indicators by health centres group (ACES) and the National Hospital Morbidity Database. We calculated and analysed age-sex-adjusted rates for each PQI. Worse-performing ACES were identified using the 2017 median PQI values as an assessment cut-off. A multivariate logistic analysis was carried to find variables associated with the likelihood of being a worse-performing ACES for the biennium.

RESULTS

The median values of the indicator PQI93 - Prevention Quality Diabetes Composite were 79 and 65.2 hospitalizations per 100 000 pop, in 2016 and 2017 respectively. Diabetes long term complications (PQI 03) accounted for most of the hospitalizations. The quality indicator in PHC with greater influence on PQI93 was the proportion of DM patients with <65 years with test results for HbA1c < = 6.5%.

CONCLUSIONS

This study shows that some PHC quality indicators are closely related to DM care, and so their monitoring is of high importance. Diabetes long term complications (PQI 03) demand greater attention from PHC professionals.

Dosimetric impact of rectum and bladder anatomy and intrafractional prostate motion on hypofractionated prostate radiation therapy

OBJECTIVE

The objective of this study was to evaluate the dosimetric impact on hypofractionated prostate radiation therapy of two geometric uncertainty sources: rectum and bladder filling and intrafractional prostate motion.

MATERIALS AND METHODS

This prospective study included 544 images (375 pre-treatment cone-beam CT [CBCT] and 169 post-treatment CBCT) from 15 prostate adenocarcinoma patients. We recalculated the dose on each pre-treatment CBCT once the positioning errors were corrected. We also recalculated two dose distributions on each post-treatment CBCT, either using or not intrafractional motion correction. A correlation analysis was performed between CBCT-based dose and rectum and bladder filling as well as intrafraction prostate displacements.

RESULTS

No significant differences were found between administered and planned rectal doses. However, we observed an increase in bladder dose due to a lower bladder filling in 66% of treatment fractions. These differences were reduced at the end of the fraction since the lower bladder volume was compensated by the filling during the treatment session. A statistically significant reduction in target volume coverage was observed in 27% of treatment sessions and was correlated with intrafractional prostate motion in sagittal plane > 4 mm.

CONCLUSIONS

A better control of bladder filling is recommended to minimize the number of fractions in which the bladder volume is lower than planned. Fiducial mark tracking with a displacement threshold of 5 mm in any direction is recommended to ensure that the prescribed dose criteria are met.

Tocilizumab reduces the risk of ICU admission and mortality in patients with SARS-CoV-2 infection

Objectives

In some patients the immune response triggered by SARS-CoV-2 is unbalanced, presenting an acute respiratory distress syndrome which in many cases requires intensive care unit (ICU) admission. The limitation of ICU beds has been one of the major burdens in the management around the world; therefore, clinical strategies to avoid ICU admission are needed. We aimed to describe the influence of tocilizumab on the need of transfer to ICU or death in non-critically ill patients.

Material and methods

A retrospective study of 171 patients with SARS-CoV-2 infection that did not qualify as requiring transfer to ICU during the first 24h after admission to a conventional ward, were included. The criteria to receive tocilizumab was radiological impairment, oxygen demand or an increasing of inflammatory parameters, however, the ultimate decision was left to the attending physician judgement. The primary outcome was the need of ICU admission or death whichever came first.

Results

A total of 77 patients received tocilizumab and 94 did not. The tocilizumab group had less ICU admissions (10.3% vs. 27.6%, P=0.005) and need of invasive ventilation (0 vs 13.8%, P=0.001). In the multivariable analysis, tocilizumab remained as a protective variable (OR: 0.03, CI 95%: 0.007-0.1, P=0.0001) of ICU admission or death.

Conclusions

Tocilizumab in early stages of the inflammatory flare could reduce an important number of ICU admissions and mechanical ventilation. The mortality rate of 10.3% among patients receiving tocilizumab appears to be lower than other reports. This is a non-randomized study and the results should be interpreted with caution.

Real-life use of remdesivir in hospitalized patients with COVID-19

Objective

Controversial results on remdesivir efficacy have been reported. We aimed to report our real-life experience with the use of remdesivir from its availability in Spain.

Methods

We performed a descriptive study of all patients admitted for ≥48 hours with confirmed COVID-19 who received remdesivir between the 1st of July and the 30th of September 2020.

Results

A total of 123 patients out of 242 admitted with COVID-19 at our hospital (50.8%) received remdesivir. Median age was 58 years, 61% were males and 56.9 % received at least one anti-inflammatory treatment. No adverse events requiring remdesivir discontinuation were reported. The need of intensive care unit admission, mechanical ventilation and 30-days mortality were 19.5%, 7.3% and 4.1%, respectively.

Conclusion

In our real-life experience, the use of remdesivir in hospitalized patients with COVID-19 was associated with a low mortality rate and good safety profile.

Impact of Biological Therapies on the Immune Response after Pneumococcal Vaccination in Patients with Autoimmune Inflammatory Diseases

Patients with different autoimmune inflammatory diseases (AIID) on biological therapy are at risk of pneumococcal disease. Adults with inflammatory arthropathies, connective tissue diseases, psoriasis, or inflammatory bowel disease on biological therapy such as anti-TNFα, rituximab, tocilizumab, abatacept, or anakinra were included in this study. Patients completed a protocol combining the pneumococcal vaccines PCV13 and PPV23. Immune response against pneumococcal serotypes 1, 3, 7F, 14, 19A, and 19F were assessed evaluating functional antibodies by an opsonophagocytosis killing assay (OPKA). In this study, 182 patients with AIID completed the sequential vaccination protocol. Patients on etanercept tended to achieve OPKA titers against a larger number of serotypes than the rest of patients on other biological therapies, while adalimumab was associated to a lower number of serotypes with OPKA titers. Rituximab was not associated with a worse response when compared with the rest of biological agents. Not glucocorticoids, nor synthetic disease-modifying antirheumatic drugs, interfered with the immune response. OPKA titers against serotype 3 which is one of the most prevalent, was obtained in 44% of patients, increasing up to 58% in those on etanercept. Hence, almost 50% of patients on biological therapy achieved functional antibodies after the administration of a complete pneumococcal vaccination protocol.

Abstract IA15: Development of Novel Models and Identification of Therapeutic Vulnerabilities in Highly Aggressive Prostate Cancer In African American Men

African Americans have the highest mortality rate and shortest survival of any racial/ethnic group in the US for most cancers. An estimated 29,570 cases of prostate cancer are expected to be diagnosed in AA men in 2020. The average annual incidence rate for African American men is 76% higher than the rate in Caucasian Americans. Prostate cancer is the second leading cause of cancer death in African American men, with an estimated 5,350 deaths expected in 2020, which is the highest of all ethnic groups (2.2X higher than Caucasian men). These disparities are appalling and demand immediate action. While the underlying causes are multifactorial, recent studies demonstrate that African American men are at higher risk of being diagnosed with prostate cancer, have higher Gleason grades, and increased risk of progression after radical prostatectomy (RP), even in equal access settings and after accounting for socioeconomic status. These data strongly argue that there is a significant underlying biological/genetic difference between African Americans and Caucasian American men with prostate cancer. Importantly, they highlight an unmet need in order to deliver personalized therapeutic options and ultimately, improve clinical outcomes. Unfortunately, most preclinical studies are performed in prostate cancer cell lines and patient-derived xenografts (PDXs) isolated from patients of Caucasian origin. At Baylor College of Medicine, we are leveraging the high numbers of minority cancer patients in our GU clinics, to generate and utilize innovative prostate cancer PDX and organoid models of diverse racial/ethnic minority origin, which will broaden our understanding of the molecular basis of the disease as well as expedite the drug discovery process. We will discuss preliminary findings from our ongoing studies in genomic and transcriptomic profiling of African American patients, progress in our development of novel prostate cancer models, and lastly, emerging therapeutic opportunities based on precision oncology.

Citation Format: Salma Kaochar, Patricia Castro, Sandra Grimm, Darlene Skapura, Matthew Rodriguez, Maurice Dufilho, Cammy Mason, Maria Machado Heredia, Quentxia Wrighting, Jami Daly, Matthew Robertson, Nora Navone, Jacob Berchuck, Matthew Freeman, Zoltan Szallasi, Albert Dobi, Guiherme Godoy, Michael Scheurer, Heidi Dowst, Susan Hilsenbeck, Martha Mims, Anita Sabichi, Edward Yen, Cristian Coarfa, Michael Ittmann, Nicholas Mitsiades. Development of Novel Models and Identification of Therapeutic Vulnerabilities in Highly Aggressive Prostate Cancer In African American Men [abstract]. In: Proceedings of the AACR Virtual Conference: Thirteenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2020 Oct 2-4. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(12 Suppl):Abstract nr IA15.

Evaluación de un programa piloto para trabajar habilidades narrativas en niños con hipoacusia usuarios de ayudas auditivas

El Discurso Narrativo (DN) es una unidad lingüística compleja utilizada en ciertos contextos y que refleja la organización del pensamiento. La evidencia científica muestra que la población sorda, usuaria de ayudas auditivas, presenta dificultades en los diferentes niveles del lenguaje, tanto expresivos como comprensivos, incluida la habilidad para narrar. Además, existe evidencia de que la intervención terapéutica ayudaría a mejorar su rendimiento. Sin embargo, los datos disponibles sobre las características y abordaje del DN en esta población son escasos. El objetivo del estudio es evaluar un programa piloto para trabajar habilidades narrativas en niños chilenos usuarios de ayudas auditivas. Se estudiaron 22 niños con un promedio de edad de 6,5 años, adaptados con audífonos y/o implante coclear. Se aplicó a este grupo de niños una evaluación inicial del DN utilizando el instrumento Evaluación del Discurso Narrativo (EDNA), obteniéndose la Etapa y Desempeño narrativo de cada niño. Luego, se creó y aplicó individualmente un programa de estimulación del discurso narrativo de 12 sesiones una vez por semana. Finalmente, se repitió la evaluación al final del programa. Se encontraron diferencias significativas entre los resultados obtenidos previo y posterior a la implementación del programa de estimulación. En relación con la Etapa del DN, antes de la intervención el 45,5% de los niños no estructuraba, lo cual se redujo a un 9.1% en la evaluación final. En cuanto al Desempeño, previo a la intervención el 72,7% de los niños presentaba un “déficit narrativo”, lo cual se redujo a un 18,2% posterior a la aplicación del programa.

Patient characteristics, clinical course and factors associated to ICU mortality in critically ill patients infected with SARS-CoV-2 in Spain: A prospective, cohort, multicentre study

Background

The clinical course of COVID-19 critically ill patients, during their admission in the intensive care unit (UCI), including medical and infectious complications and support therapies, as well as their association with in-ICU mortality has not been fully reported.

Objective

This study aimed to describe clinical characteristics and clinical course of ICU COVID-19 patients, and to determine risk factors for ICU mortality of COVID-19 patients.

Methods

Prospective, multicentre, cohort study that enrolled critically ill COVID-19 patients admitted into 30 ICUs from Spain and Andorra. Consecutive patients from March 12th to May 26th, 2020 were enrolled if they had died or were discharged from ICU during the study period. Demographics, symptoms, vital signs, laboratory markers, supportive therapies, pharmacological treatments, medical and infectious complications were reported and compared between deceased and discharged patients.

Results

A total of 663 patients were included. Overall ICU mortality was 31% (203 patients). At ICU admission non-survivors were more hypoxemic [SpO₂ with non-rebreather mask, 90 (IQR 83–93) vs 91 (IQR 87–94); p < 0.001] and with higher sequential organ failure assessment score [SOFA, 7 (IQR 5–9) vs 4 (IQR 3–7); p < 0.001]. Complications were more frequent in non-survivors: acute respiratory distress syndrome (ARDS) (95% vs 89%; p = 0.009), acute kidney injury (AKI) (58% vs 24%; p < 10⁻¹⁶), shock (42% vs 14%; p < 10⁻¹³), and arrhythmias (24% vs 11%; p < 10⁻⁴). Respiratory super-infection, bloodstream infection and septic shock were higher in non-survivors (33% vs 25%; p = 0.03, 33% vs 23%; p = 0.01 and 15% vs 3%, p = 10⁻⁷), respectively. The multivariable regression model showed that age was associated with mortality, with every year increasing risk-of-death by 1% (95%CI: 1–10, p = 0.014). Each 5-point increase in APACHE II independently predicted mortality [OR: 1.508 (1.081, 2.104), p = 0.015]. Patients with AKI [OR: 2.468 (1.628, 3.741), p < 10⁻⁴)], cardiac arrest [OR: 11.099 (3.389, 36.353), p = 0.0001], and septic shock [OR: 3.224 (1.486, 6.994), p = 0.002] had an increased risk-of-death.

Conclusions

Older COVID-19 patients with higher APACHE II scores on admission, those who developed AKI grades II or III and/or septic shock during ICU stay had an increased risk-of-death. ICU mortality was 31%.

Local policy for managing the risk of the proliferation and spread of Legionella in the Girona area

Issue

The towns in the Girona area are mostly small (70% have fewer than 1.500 inhabitants) and employ few public health technicians. Difficulties exist in municipal facilities when it comes to carrying out self-assessment tests and fulfilling regulatory requirements.

Description

In 2009, Dipsalut designed a programme to offer support to local councils in the management and control of the sanitation of municipal facilities at risk of transmitting Legionella.

Main Objectives

To improve the control of the health risk, to ensure the technical capacitation of personnel and to achieve territorial equity in health protection. The programme methodology comprised: a service provision programme with structured actions, a network of public health stakeholders and an information system shared between the stakeholders. The programme includes the structural description of the facilities, the study of the risk factors for the proliferation and spread of Legionella, the drawing up of control plans based on the HACCP system, analyses to determine and quantify Legionella, preventive cleaning and disinfection, on-site advice for workers, and training courses.

Results

Regarding the improvement in the control of the health risk: - In 2019, 905 facilities were controlled in 105 towns. In the last 8 years, the refurbishment of 239 facilities has been carried out, involving a total investment of 2,075.857€.Reduction in the concentration of Legionella where more exhaustive sampling is carried out.

Regarding the technical capacitation of personnel: 2.012 people on courses and 10.121 people in visits on-site.

Lessons

Realising the importance of ensuring the co-responsibility of facility managers. Adapting actions to be carried out in facilities according to risk: the greater the risk, the greater the effort.

Key messages

The application of an area-wide programme improves facility risk management. Ensuring technical capacitation, incorporating improvements based on common experiences and optimising resources.

Abstract 1251: Epigenetics in early onset colorectal cancer (EOCRC)

Colorectal cancer (CRC) incidence rates have increased among young adults while the rates have decreased among older adults over 50 years of age. While the etiology of the growing prevalence of young adults with newly diagnosed CRC is unknown, there has been growing interest in the roles implicated for diabetes, obesity, environmental changes, and epigenetics. Among the epigenetic marks implicated in EOCRC, the most widely studied are the global DNA hypomethylation. Using mouse studies, our group has demonstrated that DNA methylation as an epigenetic mechanism to control gene expression is essential to postnatal development. We have discovered a key set of genes that undergo epigenetic changes in colonic epithelial stem cells, and these changes are stable over a lifetime. We have shown that the gut microbiome influences this process. Importantly, perturbation of established intestinal DNA methylation leads to accelerated intestinal tumor development. To translate our mechanistic studies in the animal model to humans, we have confirmed these CpG loci that are concordant between the two species (i.e. homologous regions and/or conserved CpG islands). Here, we hypothesize that the dysregulation of developmentally programmed intestinal DNA methylation is associated with enhanced susceptibility to colon cancer in young adult. We have identified a population of patients within the Harris Health and Baylor College of Medicine system under the age of 50 with mismatch repair stable colorectal adenocarcinoma. Patient characteristics including age, sex, race, and primary tumor profile (stage at diagnosis, histology, and RAS status) have been defined. Using a panel of 6 genes and bisulfite pyrosequencing for quantitative assessment of DNA methylation, we compared the level of methylation in EOCRC tumors to paired normal adjacent tissues as well as normal adult tissue (age 50 or greater) to traditional CRC tumors. Our preliminary data suggest hypermethylation patterns are distinct in patients of EOCRC relative to traditional CRC. Our ultimate goal is to better understand the etiology of EOCRC in order to devise better prevention and treatment strategies for EOCRC.

Citation Format: Karen Riggins, Benjamin Musher, Michael Scheurer, Li Yang, Patricia Castro, Neda Zarrin-Khameh, Lanlan Shen. Epigenetics in early onset colorectal cancer (EOCRC) [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 1251.

Dissociated motor learning and de-adaptation in patients with functional gait disorders

Walking onto a stationary platform that had been previously experienced as moving generates a locomotor after-effect—the so-called ‘broken escalator’ phenomenon. The motor responses that occur during locomotor after-effects have been mapped theoretically using a hierarchal Bayesian model of brain function that takes into account current sensory information that is weighted according to prior contextually-relevant experiences; these in turn inform automatic motor responses. Here, we use the broken escalator phenomenon to explore motor learning in patients with functional gait disorders and probe whether abnormal postural mechanisms override ascending sensory information and conscious intention, leading to maladaptive and disabling gait abnormalities. Fourteen patients with functional gait disorders and 17 healthy control subjects walked onto a stationary sled (‘Before’ condition, five trials), then onto a moving sled (‘Moving’ condition, 10 trials) and then again onto the stationary sled (‘After’ condition, five trials). Subjects were warned of the change in conditions. Kinematic gait measures (trunk displacement, step timing, gait velocity), EMG responses, and subjective measures of state anxiety/instability were recorded per trial. Patients had slower gait velocities in the Before trials (P &lt; 0.05) but were able to increase this to accommodate the moving sled, with similar learning curves to control subjects (P = 0.87). Although trunk and gait velocity locomotor after-effects were present in both groups, there was a persistence of the locomotor after-effect only in patients (P &lt; 0.05). We observed an increase in gait velocity during After trials towards normal values in the patient group. Instability and state anxiety were greater in patients than controls (P &lt; 0.05) only during explicit phases (Before/After) of the task. Mean ‘final’ gait termination EMG activity (right gastrocnemius) was greater in the patient group than controls. Despite a dysfunctional locomotor system, patients show normal adaptive learning. The process of de-adaptation, however, is prolonged in patients indicating a tendency to perpetuate learned motor programmes. The trend to normalization of gait velocity following a period of implicit motor learning has implications for gait rehabilitation potential in patients with functional gait disorders and related disorders (e.g. fear of falling).

Pathophysiological dissociation of the interaction between time pressure and trait anxiety during spatial orientation judgments

Spatial orientation is achieved by integrating visual, vestibular and proprioceptive cues. Individuals that rely strongly upon visual cues to facilitate spatial orientation are termed visually dependent. Heightened visual reliance commonly occurs in patients following vestibular dysfunction and can influence clinical outcome. Additionally, psychological factors, including anxiety, are associated with poorer clinical outcome following vestibular dysfunction. Given that visual dependency measures are affected by psychological and contextual influences, such as time pressure, we investigated the interaction between time pressure and anxiety upon visual dependency in healthy controls and vestibular migraine patients. Visual dependency was assessed using a "Rod and Disk" task at baseline and under time pressure (3 s to complete the task). Non-situational (trait) and situational (state) anxiety levels were quantified using the Spielberg State-Trait Anxiety Inventory. We calculated the change in visual dependency (VD) [∆VD = VD_{time pressure}  - VD_baseline ] and correlated it with participants' trait anxiety scores. We observed a significant negative correlation between trait anxiety and the change in VD (R²  = .393, p < .001) in healthy controls and a positive correlation in dizzy patients (R²  = .317, p < .001). That is, healthy individuals that were more anxious became less visually dependent under time pressure (i.e., more accurate), whereas less anxious individuals became more visually dependent. The reverse was observed in vestibular migraine patients. Our results illustrate that anxiety can differentially modulate task performance during spatial orientation judgements under time pressure in healthy individuals and dizzy patients. These findings have potential implications for individualised patient rehabilitation therapies.

Patient characteristics, clinical course and factors associated to ICU mortality in critically ill patients infected with SARS-CoV-2 in Spain: A prospective, cohort, multicentre study

Antecedentes

No se ha reportado plenamente la evolución clínica de los pacientes críticos de COVID-19 durante su ingreso en la unidad de cuidados intensivos (UCI), incluyendo las complicaciones médicas e infecciosas y terapias de soporte, así como su asociación con la mortalidad en UCI.

Objetivo

El objetivo de este estudio es describir las características clínicas y la evolución de los pacientes ingresados en UCI por COVID-19 y determinar los factores de riesgo de la mortalidad en UCI de dichos pacientes.

Métodos

Estudio prospectivo, multicéntrico y de cohorte, que incluyó a los pacientes críticos de COVID-19 ingresados en 30 UCI de España y Andorra. Se incluyó a los pacientes consecutivos del 12 de marzo al 26 de mayo del 2020 si habían fallecido o habían recibido el alta de la UCI durante el periodo de estudio. Se reportaron los datos demográficos, los síntomas, los signos vitales, los marcadores de laboratorio, las terapias de soporte, terapias farmacológicas y las complicaciones médicas e infecciosas, realizándose una comparación entre los pacientes fallecidos y los pacientes dados de alta.

Resultados

Se incluyó a un total de 663 pacientes. La mortalidad general en UCI fue del 31% (203 pacientes). Al ingreso en UCI los no supervivientes eran más hipoxémicos (SpO₂ con mascarilla de no reinhalación, de 90 [RIC 83-93] vs. 91 [RIC 87-94]; p < 0,001] y con mayor puntuación en la escala SOFA-Evaluación de daño orgánico secuencial (SOFA, 7 [RIC 5-9] vs. 4 [RIC 3-7]; p <0,001]). Las complicaciones fueron más frecuentes en los no supervivientes: síndrome de distrés respiratorio agudo (SDRA) (95% vs. 89%; p = 0,009), insuficiencia renal aguda (IRA) (58% vs. 24%; p < 10^–6), shock (42% vs. 14%; p < 10^–13) y arritmias (24% vs. 11%; p < 10^–4). Las superinfecciones respiratorias, infecciones del torrente sanguíneo y los shock sépticos fueron más frecuentes en los no supervivientes (33% vs. 25%; p = 0,03, 33% vs. 23%; p = 0,01 y 15% vs. 3%, p = 10^–7, respectivamente). El modelo de regresión multivariable reflejó que la edad estaba asociada a la mortalidad y que cada año incrementaba el riesgo de muerte en un 1% (IC del 95%: 1-10, p = 0,014). Cada incremento de 5 puntos en la escala APACHE II predijo de manera independiente la mortalidad (odds ratio [OR]: 1,508 [1,081, 2,104], p = 0,015). Los pacientes con IRA (OR: 2,468 [1,628, 3,741], p < 10^–4)], paro cardiaco (OR: 11,099 [3,389, 36,353], p = 0,0001] y shock séptico [OR: 3,224 [1,486, 6,994], p= 0,002) tuvieron un riesgo de muerte incrementado.

Conclusiones

Los pacientes mayores de COVID-19 con puntuaciones APACHE II más altas al ingreso, que desarrollaron IRA en grados ii o iii o shock séptico durante la estancia en UCI tuvieron un riesgo de muerte incrementado. La mortalidad en UCI fue del 31%.

AB1150 ECONOMIC IMPACT ASSOCIATED TO BIOLOGICAL THERAPY / SYNTHETIC FAME OPTIMIZATION IN A COHORT OF PATIENTS WITH CHRONIC INFLAMMATORY RHEUMATIC DISEASES TREATED BY OBJECTIVES

Background:

Therapeutic decision-making for biologic-therapies/ synthetic FAME (BT/SD) dose optimization, should be based on optimal disease activity results according to a treatment strategy by objectives. The goal of BT optimization is to guarantee long-term effectiveness and safety, maximising economic savings

Objectives:

To evaluate BT optimization patterns in patients with rheumatic diseases (RD) and associated economic savings.

Methods:

An observational and prospective study, which included a cohort of patients with rheumatoid arthritis (RA), spondyloarthropathies (SA) and psoriatic arthritis (PsA) treated with BT from January 2014 to December 2019. BT optimization, achieved by reducing or prolonging the interval at least one dose, was indicated when patients have more than 6 months of treatment and are in clinical remission (DAS28 <2.6 for RA and PsA, and BASDAI<2 for SA) or minimal clinical activity (DAS28<3.2 for RA and PsA, and BASDAI<4 for SA).

Variables were described as frequencies and means. Diagnosis, BT (abatacept, adalimumab, apremilast, baricitinib, certolizumab, etanercept, golimumab, ixekizumab, secukinumab, tocilizumab, tofacitinib, and ustekinumab), dose regimens, total treatment duration, time on BT optimization (TO) and treatment costs were collected.

Cost savings were calculated per patient by comparing optimization treatment costs to conventional treatment and globally by comparing real cost to theoretical conventional doses cost.

Results:

A total of 260 patients were included in the study. Switching were observed in 32.7%. From all patients, 53% were candidates for BT optimization (according to diagnosis: 60.9% with RA, followed by 52.2% with SA and 43.4% with PsA)

A 40% of patients with BT optimization were treated with adalimumab and etanercept being also the most common BT used in RD treatment

BT optimization allowed a pharmaceutical saving of€ 177,539.40per year against the use of conventional therapy, resulting in a reduction of the total cost of€1,065,236.40in the last 6 years. The saving per patient / year was € 707.63 for RA; € 850,40 for SA and of €493,21 for the PsA.

Conclusion:

Therapeutic decision-making based on validated disease activity scales has allowed the BT optimization in approximately 53% of patients with RD.

BT optimization allowed a pharmaceutical saving of € 177,539.40 per year being higher in the SA (€ 850.40) followed by the RA (€ 707.63) and finally the PsA (€ 493.21)

The BT optimization allows to reduce costs maintaining the effectiveness and safety.

Disclosure of Interests:

None declared

THU0168 GESTATIONAL DESIRE AND CERTOLIZUMAB PEGOL IN PATIENTS WITH CHRONIC INFLAMMATORY RHEUMATIC DISEASE. PRELIMINARY RESULTS OF THE GESTAMAD COHORT

Background:

The use of biological therapies during pregnancy has been contraindicated since the beginning of the use of these drugs. In recent years several studies have demonstrated the minimal-to-no transfer of certolizumab pegol (CZP) to the placenta and breast milk, which has allowed its approval for use in pregnancy and breastfeeding if clinically necessary. However, there are no studies evaluating the use of CZP during this period in real life or the characteristics of this subgroup of patients.

Objectives:

To describe the profile of women of childbearing age diagnosed with chronic inflammatory rheumatic disease (CIRD): Rheumatoid Arthritis (RA), Psoriatic Arthritis (PsA) and axial Spondyloarthritis (axSpA), who initiate CZP by gestational desire using the GESTAMAD registry (multicenter study of women with chronic inflammatory rheumatic disease of childbearing age who are initiated on CPZ by gestational desire from the Madrid community).

Methods:

Prospective multicenter study that aims to know the characteristics of women of childbearing age diagnosed with CIRD and gestational desire to which CZP is initiated for this reason. The comorbidities of the patients such as hypertension, diabetes and cardiovascular disease were collected. Disease activity was measured by DAS28 using CRP in RA and PsA and BASDAI in axSpA. The present study presents preliminary data from the initial cohort and will be followed prospectively for 24 months to assess the efficacy and safety of the drug during pre-conception, pregnancy and lactation.

Results:

A total of 45 patients have been recruited in 6 Madrid hospitals from June to December 2019. Patients had a mean age of 35.9, (36.6 in RA, 35.2 in PA and 35.1 in SPA). Fifty-one percent had RA, 20.0 percent had PA and 28.8 percent had SPA. The mean disease duration for RA, PA and SPA was 9.5, 7.3 and 6.9 years, respectively. 48.9% of women were nulliparous. The abortion rate of patients diagnosed with spondyloarthropathy was upper of 25%. 33.3% of the patients had been treated with previous biologicals, with gestational desire/pregnancy being the reason for the change.

75.5% of the patients had been treated with synthetic disease modifying antirheumatic drugs (DMARD) previously. With regard to disease activity, the mean DAS 28 at the start of treatment was 4.5 in RA and 3.8 in PA and BASDAI 7.0 in axSPA.

In RA the highest values of CRP and ESR were found prior to initiation with CZP, but this difference was not statistically significant (p=0.644 and 0.605, respectively). 22.2% of patients had previous comorbidities.

Conclusion:

The mean age of patients with gestational desire in CIRD is high. Women diagnosed with PsA and axSpA have a high rate of previous abortions, upper than 25%. The duration of the disease is equally long at the time of manifesting gestational desire. The use of treatments such as CZP, compatible with pregnancy and lactation would allow a better control of inflammatory joint disease in this period of life, encouraging patients not to postpone their gestational desire.

Disclosure of Interests:

None declared

Evaluation of the immune response to hepatitis B vaccine in patients on biological therapy: results of the RIER cohort study

To evaluate the response to hepatitis B virus (HBV) vaccine in patients on biological therapy. Adults with autoimmune inflammatory diseases on biological therapy such as anti-TNFα, rituximab, tocilizumab, abatacept, or anakinra were included. Hepatitis B surface antibody (anti-HBs) was measured by ELISA before and after vaccination. Seroconversion was considered when an anti-HBs titer > 10 mIU/mL was achieved. The effect of treatment on the immunoprotective state was studied. The response was compared with that obtained in patients on synthetic disease modifying anti-rheumatic drugs (DMARDs) and healthy controls. A total of 187 patients on biologicals, 48 on synthetic DMARDs, and 49 on healthy controls were analyzed. More than 80% of patients on biologics responded to the vaccine but required more boosters and second vaccine series. Patients who achieved seroconversion were younger than those who did not (47.10 ± 12.99 vs. 53.18 ± 10.54 years, p = 0.012). Being on etanercept or golimumab was associated with seroconversion, while being on rituximab was not. Seroconversion was achieved in 93.75% of patients on synthetic DMARDs and 97.96% of healthy controls. The seroconversion rate in the biologics group was lower than in the synthetic DMARD group (p = 0.043) and tended to be lower than in the healthy group (p = 0.056). In patients on biological therapy, a high rate of HBV vaccine response can be achieved when a complete vaccination schedule is administered. Vaccination while not on biological agents reduces the requirement for boosters and revaccination. Key points: • Patients on biological therapy can achieve high rates of immune response to HBV vaccine when complete vaccination schedules are administered. • However, to achieve such a high seroconversion rate, more boosters and second vaccination series are required. • This supports the proposal already made to provide HBV vaccination to all patients with an autoimmune inflammatory disease after the diagnosis is made and not when the use of a biological treatment is under consideration.