226Ra, 210Po and lead isotopes in a pit lake water profile in Sweden

A pit lake arises as a consequence of anthropogenic activities in opencast mining areas. These water bodies may be enriched in hazardous stable contaminants and/or in naturally occurring radionuclides depending on the local geological conditions. Mining legacy in Sweden produced hundreds of these pit lakes and most of them are used for recreational purposes in the southern part of the country. In this paper, one pit lake was selected for having enhanced levels of natural radionuclides. Physico-chemical parameters (temperature, pH, oxidation-reduction potential, dissolved oxygen and depth), elemental composition (via Inductive Coupled Plasma Mass Spectrometry) and radiometric characterization (via alpha spectrometry of ²²⁶Ra, ²¹⁰Po and ²¹⁰Pb) were carried along the depth of a 60 m depth pit lake, with the main aim to describe how natural radionuclides and elements behaves with depth in a non-uraniferous pit lake. Based on observed changes in physico-chemical parameters, a thermocline and a chemocline region were identified at around 10 and 30 m depth respectively. Concerning radionuclides, ²²⁶Ra ranged from 75 ± 3 up to 360 ± 12 mBq/kg while ²¹⁰Po ranged from 11 ± 1 up to 71 ± 3 mBq/kg. ²¹⁰Pb distribution with depth was also determined via secular equilibrium with ²¹⁰Po after 2 years and also stable Pb was measured. Disequilibrium ²²⁶Ra-²¹⁰Pb was found and the residence time of ²¹⁰Pb in the water column was assessed. Additionally, different vertical distributions between ²¹⁰Pb and Pb were found which points out different sources for different lead isotopes in the water body.

Is obligation the proper policy to increase immunization coverage? A comparison of 16 OECD countries

Issue

Globally, between 2016 and 2018, low vaccination coverage rates led to an increase of measles cases and related deaths. The WHO European Region reported a total of 83540 measles cases and 74 deaths in 2018, versus the 5273 cases and 13 deaths in 2016, with WHO global estimates reporting 333445 cases. In order to contrast these outbreaks, the European Vaccine Action Plan 2015-2020 states that the ideal immunization coverage for measles must be 95%. Although, this rate is not reached and maintained everywhere, thus one debated solution is to adopt compulsory vaccination plans rather than recommended. Our aim is to analyse if compulsory policies may increase coverage.

Description

Between 2014 and 2018 3 countries (Italy, France and California) changed their measles vaccination policies from recommended to compulsory to fight low immunization. In order to describe the effects of this action, we compared their measles coverage rates in 2014 and 2018 together with other 12 OECD countries rates who adopt both recommendation and obligation, evaluating the trend variations. Data were collected from OECD's, WHO's and Ministries of Health's documents.

Results

After the introduction of obligation, California (91% in 2014; 95% in 2018) and Italy (87% to 94%) coverage rates increased, while France's reduced (91% to 90%). Of other mandatory countries, only Australia showed an increase (94% to 95%); totally, 37.5% mandatory countries showed an increase among the analysed ones. Through the same period, 50% of analysed countries with recommendation maintained rates over 95%, 10% increased, while 40% remained below 95%.

Lessons

Even if mandatory vaccinations can lead to a sharp increase of coverage in a short time in response to emergency situations, the causes and solutions of hesitancy are more complex than law enforcement. Some countries without obligation show rates constantly above 95% throughout the years, demonstrating that other measures can be taken to fight low immunization.

Key messages

Apart from estimates coming from WHO and OECD, it is difficult to find extensive and official information about the application and the effectiveness of vaccination policies in different countries. Low immunization coverage rates rely on different causes (information, religion, personal beliefs, trust), thus the application of mandatory vaccination alone is not sufficient to fight hesitancy.

Plus-minus lid syndrome with ataxia and severe apathy-A rare manifestation of midbrain infarct

Plus-minus lid syndrome is a rare manifestation of midbrain infarct, characterized by ptosis of one eye and lid retraction in the other eye. It has also been described in ocular myasthenia gravis, orbital myositis, or after lesions of the oculomotor nerve. Our patient was a 55-year-old man with hypertension and atrial fibrillation, who presented to us with acute onset left-sided ptosis and right-sided eyelid retraction. He was apathic and had right-sided ataxia. His MRI of the brain showed acute infarct involving the paramedian midbrain. To our knowledge, severe apathy and resultant executive function disorder have not been described previously in a patient having plus-minus lid syndrome with ataxia.

FRI0297 COMPARISON OF EFFICACY OF SECUKINUMAB VS ANTI-TNF AS SECOND LINE BIOLOGIC THERAPY IN AXIAL SPONDYLOARTHROPATHY BASED ON BASDAI RESPONSE IN AN OBSERVATIONAL STUDY

Background:

Modern biologic therapies have demonstrated encouraging results in the treatment of axial spondylarthropathy (AxSpA). The benefits of interleukin-17 inhibitors (IL-17i), as first and second line therapies, are well established [1, 2]. A systematic literature review by Navarro-Compán has shown some benefit of second line therapies using both anti-tumour necrosis factor (anti-TNF) and IL-17i [3]. To our knowledge, there are currently no studies that have directly compared which pathway has a better overall outcome. This is therefore the first observational study directly comparing both treatment arms after anti-TNF had been administered as first line therapy.

Objectives:

To investigate which second line therapy is superior, anti TNF or IL-17i (secukinumab), in patients with AxSpA, that have failed first line anti-TNF therapy.

Methods:

Patient data was extracted from the Whipps Cross Hospital Rheumatology biologics registry database. All patients selected were required to have a diagnosis of AxSpA on magnetic resonance imaging (MRI). The patient cohort that was selected had previously been treated with anti-TNF as a first line therapy and were being considered for second line therapy with either anti-TNF or IL-17i. Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) scores were recorded at 3, 6 and 12 months to assess treatment response. The unpaired t-test was used to assess the significance between the treatment groups and were analysed using the R statistical package.

Results:

Seventy patients were identified for this study of which, 57% (46/70) were male and 37% (26/70) were female. The age ranged from 30-97 years, with an average age of 72. The HLA-B27 gene association in this cohort was 71% (50/70). Three patients out of the cohort had psoriatic spondylarthropathy and the remaining had isolated AxSpA. There were an equal number of secukinumab and anti-TNF patients. The anti-TNF patients were subdivided into their respective anti-TNF drug (listed in Table 1).

Table 1.

Frequency of individual anti-TNF drugs used in this cohort.

Anti-TNF drugFrequency usedAdalimumab9/35Certolizumab8/35Etanercept17/35Golimumab1/35

This study revealed that the patients experienced an average of a 52% reduction in the BASDAI score after 6 months of anti-TNF treatment compared to only a 6% reduction in patients on secukinumab (P 0.009). However, the disease activity improvement at 12 months was not sustained in the anti-TNF group and at this stage there was no difference between the groups. Overall both treatment groups showed an average reduction in the BASDAI score by more than 30% at each 3 monthly interval.

Figure 1.

BASDAI percentage reduction at 3 monthly intervals between the two second line treatment groups using anti-TNF and Secukinumab.

Conclusion:

A significant difference could not be demonstrated between the anti-TNF and secukinumab groups in this observational cohort. Interestingly, at 6 months, anti-TNF demonstrated better outcomes according to BASDAI scores than Secukinumab but this efficacy was lost at 12 months. It was difficult to interpret these isolated results without further testing, as this is a small non-randomised study. We observed similar outcomes to the Navarro-Compán review where there was a low percentage change in the BASDAI improvement in patients on second line therapy when compared to first line treatment BASDAI scores. Therefore, exploring the mechanism for the reduction in the BASDAI response would be an interesting future study. Moreover, to fully understand these results, randomised controlled studies would need to be conducted.

References:

[1]Baeten el al. NEJM 2015.

[2]van der Heijde et al. ARD 2018.

[3]Navarro-Compán et al. RMD Open 2017.

Disclosure of Interests:

None declared

0348 Sleep EEG-Based Brain Age Index is Reduced Under Continuous Positive Airway Pressure Treatment

Introduction

Continuous positive airway pressure (CPAP) is a treatment for apnea. With long-term CPAP, changes in electroencephalogram (EEG) include increased delta power (1 - 4Hz) and sigma power (11 - 15Hz, spindle). However, the short-term EEG response to CPAP in a split-night study is less quantified. We recently developed a “brain age” model using sleep EEG features. The brain age index (BAI) is defined as the difference between chronological age and brain age (BA - CA). Here we first quantify how BAI changes during CPAP in the same patient, and then investigate how much brain age features during the diagnostic part can predict the reduction in apnea-hypopnea index (AHI) during CPAP.

Methods

The dataset consisted of 160 subjects. The average age was 59 years with 53% male, 24% female and 23% unknown. We extracted 480 features including band powers, and then computed the BAIs for both diagnostic and CPAP parts. To predict the reduction in AHI during CPAP, we fit a Bayesian regression model using the brain age features, demographics, and sleep parameters during the diagnostic part, and assessed the feature importance using dominance analysis.

Results

The BAI from the diagnostic part is significantly reduced compared to BAI during CPAP for the same subject (paired t-test, p < 0.01). The diagnostic part has an average BAI 2.24 years; and the CPAP part -4.75 years. The brain age features that are increased during CPAP include sigma powers in N2 and N3. The prediction of AHI reduction has Pearson’s correlation 0.85. The features predictive of reduced AHI are the diagnostic AHI (explained variance 69%), followed by high/low waveforms during N2 (e.g. K-complex, measured by kurtosis) (8.6%), delta power during REM (4.5%) and N1 (2%). The feature predictive of increased AHI is frontal alpha power during quiet awake (2.6%).

Conclusion

The average BAI is reduced during CPAP. BAI provides a novel view of the acute response to CPAP in sleep EEG. Future study with more CPAP failure patients has the potential of predicting CPAP failure.

Support

MBW is supported by Glenn Foundation for Medical Research. RJT is supported by Category I AASM Foundation.

0661 Comparison Between Ventilator Detected Apnea Hypopnea Index and Manual Scored Results

Introduction

The apnea hypopnea index and percentage of periodic breathing detected by the ventilator machine are often used by sleep doctors to evaluate whether sleep apnea has been adequately treated or need further interventions. There are concerns about the accuracy of this autodetection.

Methods

Patients with sleep apnea who were treated with positive airway pressure at the Beth Israel Deaconess Medical Center (Boston) and tracked by the EncoreAnywhere system were included. The machine detected AHI(AHIm) and PB(PBm) were extracted from the first week data in every month from the start of use. The manual scored AHI(AHIs) and PB(PBs) were calculated from the last waveform graph during every month. The apnea hypopnea index as well as periodic breathing in 1st, 2nd, 3rd,6th month AHIm, AHIs, PBm and PBs were compared respectively.

Results

A total of 128 patients were included. The mean age was 56.5 and 66% of them were male. In the first month, the mean AHIs was significantly higher than AHIm, 16.27 vs. 5.36, p<0.001. There was also a large difference between percentage of PBs and PBm, 15.55% vs. 1.96, p<0.001. 78% patients whose AHIm <5 were actually has AHIs >5. The Kappa value for the AHIm and AHIs were 0.074, p=0.069; the value of PBm and PBs was 0.216, p=0.015. In the 2nd, 3rd and 6th months, the mean difference between AHIs and AHIm was 10.58, 10.68, 10.12, respectively. The mean difference between PBs and PBm was 12.32%,11.53%,and 9.18%.

Conclusion

Autodetection of respiratory events consistently under-estimates the severity of residual events. Mean differences remained stable over 6 months. Caution is recommended when attributing non-apnea reasons for residual symptoms in patients with apparently low machine estimated AHI and PB.

Support

This study is supported by American Academy of Sleep Medicine Foundation, category-I award to RJT

0592 Prevalence of Sleep Apnea in Patients with Tracheobronchomalacia

Introduction

Tracheobronchomalacia (TBM) is a pathologic weakness in the trachea and bronchi leading to excessive dynamic narrowing of the airway. A relationship between sleep disordered breathing (SDB) and TBM has been observed before. SBD may be an important contributor to development or progression of TBM. The objective was to determine the Prevalence and characteristics of sleep disordered breathing in patients with tracheobronchomalacia.

Methods

We performed a retrospective chart review of patients who have been diagnosed with tracheobronchomalacia and who also underwent a polysomnogram (PSG) at the AASM - accredited Sleep Center of Beth Israel Deaconess Medical Center.

Results

In our 24 patient cohort of TBM, 71% were females, mean age 55 years (SD ± 12.3 years) and mean BMI 31.7 kg/m2 (SD ± 9.4 kg/m2). In patients with TBM we found a sleep apnea prevalence of 62.5% (n= 15), defined as an apnea-hypopnea index>5/hour (hour) with a desaturation greater than 4%. Of the 15 patients, 73.3% (n = 11) had mild sleep apnea, 20% (n = 3) had moderate sleep apnea, 6.6% (n = 1) had severe sleep apnea, defined per the AASM criteria with oxygen desaturation greater than 4%. The TBM cohort had a mean sleep efficiency of 72.7% (SD ± 22.2%) with a mean REM of 16.3% (SD ± 9.8 %). Other characteristics included a median AHI 3% of 19.9/hour (95% CI 3.9 - 25.0), median AHI 4% of 5.5/hour (95% CI 3.9 - 9.3), Respiratory disturbance index of 22/hour (95% CI 15.1 to 28.4). No unique challenges for treatment with positive airway pressure were noted.

Conclusion

Sleep apnea may be more common in patients with tracheobronchomalacia and could be regularly screened.

Support

none

Replicating group-based education interventions for the management of type 2 diabetes: a review of intervention reporting

AIMS

To assess the completeness of reporting of group-based education interventions for the management of type 2 diabetes.

METHODS

A previous systematic review of group-based education programmes for adults with type 2 diabetes identified eligible intervention studies. Data were extracted and assessed using the Template for Intervention Description and Replication ('TIDieR') checklist. Missing data were sourced from other published material, or by contacting authors.

RESULTS

Fifty-three publications describing 47 studies were included. No publications sufficiently described all items. Authors of 43 of the 47 included studies (91%) were contacted via e-mail to obtain missing data in order to complete the TIDieR checklist. Seven (16%) did not respond. Additional data were obtained for 33/47 studies (70%). Most studies (45/47, 96%) described the intervention duration and frequency, detailed the procedures and rationale (40/47, 85%), provided a brief intervention name and explained any individual tailoring (38/47, 81%), defined whether providers received training and adequately described how the programme was delivered (37/47, 79%). However, few described any modifications (28/47, 60%), whether the intervention was delivered as planned (27/47, 57%), where it was delivered (21/47, 45%), whether materials were provided (19/47, 40%), and who delivered the intervention (13/47, 28%).

CONCLUSIONS

Group-based education interventions for the management of type 2 diabetes are poorly reported. To translate effective research into practice, practitioners need sufficient detail to implement evidence-based interventions. Researcher adoption of the TIDieR checklist will assist the translation and replication of published interventions.

A digital feedback controller for stabilizing large electric currents to the ppm level for Feshbach resonance studies

Magnetic Feshbach resonances are a key tool in the field of ultracold quantum gases, but their full exploitation requires the generation of large, stable magnetic fields up to 1000 G with fractional stabilities of better than 10^-4. Design considerations for electromagnets producing these fields, such as optical access and fast dynamical response, mean that electric currents in excess of 100 A are often needed to obtain the requisite field strengths. We describe a simple digital proportional-integral-derivative current controller constructed using a field-programmable gate array and off-the-shelf evaluation boards that allows for gain scheduling, enabling optimal control of current sources with non-linear actuators. Our controller can stabilize an electric current of 337.5 A to the level of 7.5 × 10^-7 in an averaging time of 10 min and with a control bandwidth of 2 kHz.

Impact of TP53 mutation status on systemic treatment outcome in ALK-rearranged non-small-cell lung cancer

Background

We analyzed whether co-occurring mutations influence the outcome of systemic therapy in ALK-rearranged non-small-cell lung cancer (NSCLC).

Patients and methods

ALK-rearranged stage IIIB/IV NSCLC patients were analyzed with next-generation sequencing and fluorescence in situ hybridization analyses on a centralized diagnostic platform. Median progression-free survival (PFS) and overall survival (OS) were determined in the total cohort and in treatment-related sub-cohorts. Cox regression analyses were carried out to exclude confounders.

Results

Among 216 patients with ALK-rearranged NSCLC, the frequency of pathogenic TP53 mutations was 23.8%, while other co-occurring mutations were rare events. In ALK/TP53 co-mutated patients, median PFS and OS were significantly lower compared with TP53 wildtype patients [PFS 3.9 months (95% CI: 2.4–5.6) versus 10.3 months (95% CI: 8.6–12.0), P < 0.001; OS 15.0 months (95% CI: 5.0–24.9) versus 50.0 months (95% CI: 22.9–77.1), P = 0.002]. This difference was confirmed in all treatment-related subgroups including chemotherapy only [PFS first-line chemotherapy 2.6 months (95% CI: 1.3–4.1) versus 6.2 months (95% CI: 1.8–10.5), P = 0.021; OS 2.0 months (95% CI: 0.0–4.6) versus 9.0 months (95% CI: 6.1–11.9), P = 0.035], crizotinib plus chemotherapy [PFS crizotinib 5.0 months (95% CI: 2.9–7.2) versus 14.0 months (95% CI: 8.0–20.1), P < 0.001; OS 17.0 months (95% CI: 6.7–27.3) versus not reached, P = 0.049] and crizotinib followed by next-generation ALK-inhibitor [PFS next-generation inhibitor 5.4 months (95% CI: 0.1–10.7) versus 9.9 months (95% CI: 6.4–13.5), P = 0.039; OS 7.0 months versus 50.0 months (95% CI: not reached), P = 0.001).

Conclusions

In ALK-rearranged NSCLC co-occurring TP53 mutations predict an unfavorable outcome of systemic therapy. Our observations encourage future research to understand the underlying molecular mechanisms and to improve treatment outcome of the ALK/TP53 co-mutated subgroup.

Constraints on Light Dark Matter Particles Interacting with Electrons from DAMIC at SNOLAB

We report direct-detection constraints on light dark matter particles interacting with electrons. The results are based on a method that exploits the extremely low levels of leakage current of the DAMIC detector at SNOLAB of 2-6×10^{-22}  A cm^{-2}. We evaluate the charge distribution of pixels that collect <10e^{-} for contributions beyond the leakage current that may be attributed to dark matter interactions. Constraints are placed on so-far unexplored parameter space for dark matter masses between 0.6 and 100  MeV c^{-2}. We also present new constraints on hidden-photon dark matter with masses in the range 1.2-30  eV c^{-2}.

Childhood life events and disturbed eating behaviors in a population-based cohort in the Netherlands

Background

Adversities such as maltreatment and physical and emotional abuse are recognized risk factors for eating disorders (EDs) in adolescents and adults, but whether such adversities are also associated with eating behaviors in childhood has been less explored. Our aim was to examine whether a wide range of life events can predict emotional overeating and restrained eating in childhood, which are potential precursors of EDs.

Methods

The study is embedded in Generation R, a prospective population-based cohort. The sample included 4653 children aged 10 years. Emotional overeating was assessed with the Children’s Eating Behavior Questionnaire, and restrained eating with the Dutch Eating Behavior Questionnaire. Mothers reported the occurrence of 24 adverse events in their offspring’s childhood. Regression analyses were conducted, both unadjusted and adjusted for gender, ethnicity, and parental education and psychopathology.

Results

Unadjusted models showed that a higher number of life events is associated with more emotional overeating and more restrained eating; effect estimates attenuated slightly in the adjusted model, but remained significant (per 1 more life event: B = 0.05, 95%CI 0.02-0.08; B = 0.04, 95%CI 0.02-0.07, respectively). Particularly, participants who experienced at least 3 life events had high levels of emotional overeating and restrained eating (adjusted model: B = 0.20, 95%CI 0.06-0.33; B = 0.21, 95%CI 0.08-0.33, respectively). The specific maltreatment related life events were not significantly associated with eating behaviors, probably due to low prevalence of these events (n = 149).

Conclusions

This novel, population-based study shows that early life adversities may predict disordered eating behaviors in childhood. The results are in line with clinical studies on life events and EDs. If the studied eating behaviors are indeed precursors of EDs, these results may offer potential for prevention and early intervention to avoid the development of full-blown EDs.

Key messages

Eating disorders account for more than 2% of the global disease burden, thus representing a major Public Mental Health topic in the EU; more and new measures are required for early detection purposes. Life adversities predict disordered eating behaviors in childhood, which are considered precursors of eating disorders: early detection of this association may avoid development of eating disorders.

Training on health communication and social media: European public health residents’ perceptions

Background

Theoretical knowledge about health communication (HC) and expertise in planning, implementation and evaluation of HC interventions are essential tools for Public Health (PH) specialists. In the social media (SM) era, specific abilities and digital communication skills are gaining importance.

Objective

Our aim is to describe European PH residents’ perceptions regarding their training in the HC field, with a focus on SM. We piloted a survey using Google Forms during the European Network of Medical Residents in PH (EuroNet MRPH) meeting in Turin, April 2019. We then spread the survey to other PH residents across Europe in July 2019. The survey consists of 25 questions (Likert scales from 1=strongly disagree to 5=strongly agree, or multiple-choices) divided in 5 thematic sections (HC theory, public speaking, traditional media based HC, SM based HC, HC impact evaluation). Questions aim to map HC topics covered in residency educational programs, learning methods, and the perceived importance of HC skills.

Results

The study included 114 residents from 10 countries (37% Italy, 23% Portugal, 10% UK, 9% Spain, 8% France, 13% other). Participants perceived they receive the best training in the areas of public speaking, impact assessment and HC theory (median 3, IQR 2-4). Conversely, for traditional and SM based HC, training was perceived as unsatisfactory (median 2, IQR 1-4 and 1-3 respectively) with self-education as main learning method (51%). Public speaking and traditional HC were identified as the most important HC skills for PH specialists (median 5, IQR 5-5), while less importance was attributed to SM based HC (median 3,5, IQR 3,25-5).

Conclusions

Despite SM are playing a crucial role in public HC, specific training seems to be scarce in this sample. Although residents perceive SM based HC skills as important, they consider them less important than other HC skills. Further analysis is needed in order to explore the perceived relevance of SM in PH residents training.

Key messages

Training on health communication via social media is scarce among European public health residencies. Common training programs across European residencies in PH should address this educational need. European public health residents perceive social media based health communication skills as important, but not as important as traditional media based health communication skills.

Reducing Asthma Attacks in Children using Exhaled Nitric Oxide as a biomarker to inform treatment strategy: a randomised trial (RAACENO)

Background

Childhood asthma is a common condition. Currently there is no validated objective test which can be used to guide asthma treatment in children. This study tests the hypothesis that the addition of fractional exhaled nitric oxide (F_ENO) monitoring in addition to standard care reduces the number of exacerbations (or attacks) in children with asthma.

Methods

This is a multi-centre, randomised controlled study. Children will be included of age 6–16 years who have a diagnosis of asthma, currently use inhaled corticosteroids (ICSs) and have had an exacerbation in the previous 12 months. Exclusion criteria include being unable to provide F_ENO measurement at baseline assessment, having another chronic respiratory condition and being currently treated with maintenance oral steroids. Participants will be recruited in both primary and secondary care settings and will be randomised to either receive asthma treatment guided by F_ENO plus symptoms (F_ENO group) or asthma treatment guided by symptoms only (standard care group). Within the F_ENO group, different treatment decisions will be made dependent on changes in F_ENO. Participants will attend assessments 3, 6, 9 and 12 months post randomisation. The primary outcome is asthma exacerbation requiring prescription and/or use of an oral corticosteroid over 12 months as recorded by the participant/parent or in general practitioner records. Secondary outcomes include time to first attack, number of attacks, asthma control score and quality of life. Adherence to ICS treatment is objectively measured by an electronic logging device. Participants are invited to participate in a “phenotyping” assessment where skin prick reactivity and bronchodilator response are determined and a saliva sample is collected for DNA extraction. Qualitative interviews will be held with participants and research nurses. A health economic evaluation will take place.

Discussion

This study will evaluate whether F_ENO can provide an objective index to guide and stratify asthma treatment in children.

Trial registration

ISRCTN, ISRCTN67875351. Registered on 12 April 2017. Prospectively registered.