Virtual Reality Experience during Labour (VIREL); a qualitative study

BACKGROUND

There is increasing evidence that virtual reality (VR) is effective in the reduction of labour pain. The implementation of alternative methods like VR to reduce labour pain can contribute to reduce patient request for pharmacological pain management methods and associated side effects. The aim of this study is to examine women's experiences, preferences and satisfaction in regard to the use of VR during labour.

METHODS

A qualitative interview study was conducted in a non-university teaching hospital in The Netherlands. Two VR applications, respectively a guided meditation and an interactive game were tested in eligible women with a singleton pregnancy, scheduled for induction of labour. For the primary outcome, patients' VR experience and application preference (meditation vs. game) were examined using a post-intervention questionnaire and a semi-structured interview. Three categories (with sub-categories) were used to guide interviews: "The VR experience", "Pain reduction", and "Usability of the VR application". Labour pain before and directly after VR was evaluated using the NRS score.

RESULTS

Twenty-four women, of whom 14 were nulliparous and ten multiparous, were included and 12 of these women participated in semi-structured interviews. Using within-subject paired t-test comparisons, compared to pain pre-VR, patients reported a highly significant 26% decrease in mean NRS scores during VR meditation (pain pre-VR = 6.71 + - 1.65 vs. pain after VR = 4.96 + - 2.01) [p < 0.001]. Compared to pain before VR game, patients also reported a highly significant 19% decrease in mean NRS scores during VR game (pain before VR game = 6.89 + - 1.88 vs. pain after VR game = 5.61 + - 2.23) [p = 0.001].

CONCLUSION

All women were highly satisfied with VR use during labour. Patients reported a highly significant reduction in pain during the interactive VR game and during meditation, patients preferred guided meditation. These results can contribute to the development of a potential promising new non-pharmacological tool to reduce labour pain.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04858984, date of registration: 26/04/2021 (retrospectively registered).

AB1313 THE RATIONAL USE OF BIOLOGICS IN REFRACTORY IMMUNE-MEDIATED INFLAMMATORY DISEASES CONSORTIUM (RUBRIC) NATIONAL REGISTRY: RESULTS ON GLUCOCORTICOID USE AND WORK PRODUCTIVITY

Background

Rare therapy-refractory immune-mediated inflammatory diseases (IMIDs) are increasingly treated with new targeted therapies such as biological (b) or targeted synthetic (ts) DMARDs. However, in the Dutch healthcare system these treatments are not reimbursed for off-label use unless there is sufficient evidence of efficacy. Currently, no official guidelines or treatment protocols exist for many of these rare diseases. To overcome this issue we set up a national registry to document off-label use of b/tsDMARDs in patients with rare therapy-refractory IMIDs and to document efficacy and safety of these therapies.

Objectives

To report results on glucocorticoid use and work productivity of patients with rare therapy-refractory IMIDs treated off-label with b/tsDMARDs.

Methods

Using the web-based RUBRIC registry patients with rare therapy-refractory IMIDs treated off-label with b/tsDMARDs were prospectively followed to document efficacy and safety. Physicians supplied data on disease activity (i.e. VAS physician and ESR/CRP) and concomitant medication, including glucocorticoid use. Patients filled out questionnaires on patient reported outcomes (PROs; i.e. HAQ, WPAI-GH, SF-36, PASS, EQ-5D) prior to starting off-label treatment and at regular intervals afterwards. Any potential serious adverse events were also recorded.

Results

Many different diagnosis-treatment combinations were recorded (i.e. undifferentiated vasculitis, TRAPS, Hyper-IgD syndrome, auto-inflammatory diseases treated with various b/tsDMARDs). Of the 82 patients currently followed in RUBRIC, for 61 patients multiple questionnaires over a time period of > 1 year were available for analysis. Glucocorticoid use was documented accurately in 55 patients. Analysis of glucocorticoid use demonstrated that the majority of patients (38/55; 69.1%) used glucocorticoids prior to off-label treatment and all patients remained at a stable dose (10/55; 18.2%) or could reduce the dose (23/55; 41.8%), whereas (5/55; 9.1%) could eventually even stop glucocorticoids completely. Of the patients that did not use glucocorticoids prior to off-label b/tsDMARD therapy, no glucocorticoids were initiated. Analysis of WPAI-GH over time revealed that off-label treatment resulted in a significant gain in work productivity in all working patients and 15% of patients who were not employed prior to initiating off-label treatment were able to resume work again, whereas none of the patients became unemployed during off-label treatment. No serious adverse events associated with off-label b/tsDMARD therapy were reported.

Conclusion

Off-label treatment of rare therapy-refractory IMIDs with b/tsDMARDs results in a clear beneficial effect as glucocorticoid use could be reduced or stopped in the majority of patients and a clear increase in work productivity/employment was observed. Despite these positive outcomes, at present not enough patients per diagnosis-treatment combination have been included in the registry to draw definitive conclusions on efficacy and safety of specific off-label treatments or to formulate treatment recommendations for certain diseases. Consequently, it is important to continue the registry and include more patients or link various (inter)national registries to obtain sufficient data and promote evidence-based and effective use of biologics in rare therapy-refractory IMIDs. This may eventually also help to facilitate reimbursement of these therapies.

Disclosure of Interests

Anne Musters: None declared, Marjolijne Kleijn-de Graaf: None declared, Sander Tas Consultant of: Gebro, GSK, AbbVie, Galvani, Arthrogen/MeiraGTx, Galapagos, Grant/research support from: Pfizer, GSK, Celgene, BMS, Sanofi, AstraZeneca

AB1318-HPR VAGUS NERVE STIMULATION IN PATIENTS WITH RHEUMATOID ARTHRITIS: 48 MONTH SAFETY AND EFFICACY

Background:

Rheumatoid arthritis (RA) is a disease with significant remaining unmet medical needs for better treatments. Vagus nerve stimulation (VNS) to activate the inflammatory reflex (cholinergic anti-inflammatory pathway) represents a novel experimental therapy for RA.1Previously, we reported that inflammatory reflex activation by VNS reduced pro-inflammatory cytokine production and improved disease activity in a 17-patient rheumatoid arthritis (RA) proof-of-concept study using a reprogrammed epilepsy stimulator2; clinical improvement was sustained for 24 months without untoward safety signals.3Here we report the 48 months results from this long-term observational study.

Objectives:

Determine the long-term safety and efficacy of VNS for the treatment of RA

Methods:

In the primary study, a VNS device was implanted into 17 RA patients, mostly with insufficient response to multiple conventional and biologic DMARDs, on stable background of methotrexate (≤25 mg weekly) therapy2. The device electrically stimulated the vagus nerve, 1-4 min/day, over a 12-week open label period. On completion, subjects were offered to enroll into a follow-up study, where the study physicians were given flexibility to alter VNS dosing parameters and/or to add a biologic disease-modifying antirheumatic drug (DMARD) to the treatment regimen to induce disease remission. Clinical disease activity measures and safety were accessed over 4 years.

Results:

All patients electively continued VNS treatment in the long-term follow-up study, 4 subjects withdrew prior to month 48. Reasons for discontinuation were withdrawal of consent (N=3) and adverse event due to device discomfort (N=1). At the start of the follow-up study, the mean DAS28-CRP, CDAI and HAQ-DI were significantly reduced compared to the pre-implant baseline (mean difference± SD: DAS28-CRP=-1.60± 1.13, p<0.001; CDAI=-21.19± 13.5, p<0.001; HAQ-DI=-0.44± 0.49, p<0.01), and this effect was retained through 48 months. Patients using VNS monotherapy and those using a combination of VNS with biologic DMARDs exhibited stable improvements in DAS28-CRP, CDAI and HAQ-DI at month 48 (Table 1). Improvements were observed for patients who both previously had an insufficient response to targeted biological therapies as well those who had an insufficient response to standard DMARDs. No association was seen between DAS28-CRP and stimulation frequency (Range= 1X-8X/day). There was no difference in the adverse events profile between the two groups.

Table 1.

Efficacy of VNS treatment.

Treatment ReinitiatedN=9VNS MonotherapyN=8TotalN=17Mo. 24Mo. 36Mo.48Mo. 24Mo. 36Mo. 48Mo. 24Mo. 36Mo. 48Mean change from baseline (SD)DAS28-CRP-2.58 (1.0)***-2.40 (1.0)**-2.28 (1.3)**-2.61 (1.3)*-1.77 (1.8)-2.0(1.7)-2.59 (1.1)***-2.19(1.2)**-2.17(1.4)**CDAI-24.06 (8.3)***-18.02 (13.3) *-16.2 (19.6)-33.5 (11.1)***-27.8 (16.0)*-27.9 (12.7)*-28.20 (10.5)***-21.93 (14.5)*-20.83(17.5)*HAQ-DI-.60 (0.64)*-.63(0.45)*-.31(0.60)-.89 (0.69)*-.88 (0.92)-.88(0.61)-0.73(0.66)***-0.73(0.64)**-0.54(0.64)*

*P<0.05, **P<0.01, ***P<0.001 versus primary study baseline (month -3.5)

Conclusion:

VNS was safe, well-tolerated, and resulted in significant and clinically important improvements in disease activity measures that were maintained over 48 months. These results support development of VNS devices as a new therapeutic option for RA treatment.

References:

[1]van Maanen MA, et al.Nat Rev Rheum2009

[2]Koopman FA, et al.PNAS2016

[3]Koopman FA, et al.Arthritis Rheum2018

Disclosure of Interests:

Frieda Koopman: None declared, Anne Musters: None declared, Marieke Backer: None declared, Danielle Gerlag Shareholder of: GlaxoSmithKline, Employee of: GlaxoSmithKline, Sanda Miljko: None declared, Simeon Grazio Speakers bureau: Abbvie., Roche, MSD, Eli Lilly, Pfizer, Mylan, Amgen, Fresenius Kabi, Stada, Berlin-Chemie, Sekib Sokolovic: None declared, Yaakov Levine Shareholder of: SetPoint Medical, Employee of: SetPoint Medical, Emmett Glass Employee of: SetPoint Medical, David Chernoff Shareholder of: SetPoint Medical, Adamas Pharmaceuticals, Olly Nutrition, NAIA Pharma, Aquinox Pharma, Consultant of: Adamas Pharmaceuticals, Olly Nutrition, NAIA Pharma, Aquinox Pharma, Crescendo Bioscience, Employee of: SetPoint Medical, Niek de Vries Grant/research support from: AbbVie, Janssen, Ergomed Clinical Research, GlaxoSmithKline, Pfizer, Boehringer Ingelheim, Roche, Consultant of: MSD, Pfizer, Paul P. Tak Shareholder of: GlaxoSmithKline, Employee of: GlaxoSmithKline

Error Producing Conditions in the Intensive Care Unit

Up to 98,000 patients die annually in U.S. hospitals due to human error. One of the areas where error occurs frequently is the Intensive Care Unit. Despite the impact of error, there is very little work that attempts to identify the human factors contributors to error in the ICU. The current study used the framework of error producing conditions to identify factors that are contributing to error. By modifying the method of assessing error producing conditions we were able to identify the extent to which individual conditions contribute to the prevalence of error. Also, we were able to identify the contribution certain devices have in the prevalence of error. Most importantly, the most critical devices for patient care were also identified as the ones that were rated the highest in their prevalence of error producing conditions and potential for hazard. Thus, developing medical devices that are reducing the device related potential for patient harm has to be a main goal for future patient safety work. This is a challenge sound human factors engineering should answer.

Rheumatoid arthritis synovial tissue harbours dominant B-cell and plasma-cell clones associated with autoreactivity

OBJECTIVE

To identify potential autoreactive B-cell and plasma-cell clones by quantitatively analysing the complete human B-cell receptor (BCR) repertoire in synovium and peripheral blood in early and established rheumatoid arthritis (RA).

METHODS

The BCR repertoire was screened in synovium and blood of six patients with early RA (ERA) (<6 months) and six with established RA (ESRA) (>20 months). In two patients, the repertoires in different joints were compared. Repertoires were analysed by next-generation sequencing from mRNA, generating >10 000 BCR heavy-chain sequence reads per sample. For each clone, the degree of expansion was calculated as the percentage of the total number of reads encoding the specific clonal sequence. Clones with a frequency ≥ 0.5% were considered dominant.

RESULTS

Multiple dominant clones were found in inflamed synovium but hardly any in blood. Within an individual patient, the same dominant clones were detected in different joints. The majority of the synovial clones were class-switched; however, the fraction of clones that expressed IgM was higher in ESRA than ERA patients. Dominant synovial clones showed autoreactive features: in ERA in particular the clones were enriched for immunoglobulin heavy chain gene segment V4-34 (IGHV4-34) and showed longer CDR3 lengths. Dominant synovial clones that did not encode IGHV4-34 also had longer CDR3s than peripheral blood.

CONCLUSIONS

In RA, the synovium forms a niche where expanded--potentially autoreactive--B cells and plasma cells reside. The inflamed target tissue, especially in the earliest phase of disease, seems to be the most promising compartment for studying autoreactive cells.

Beta-cell dysfunction and insulin resistance after subarachnoid haemorrhage

BACKGROUND

Hyperglycaemia is a common finding and an independent risk factor for increased morbidity and mortality in aneurysmal subarachnoid haemorrhage (SAH). Although in these patients hyperglycaemia is commonly ascribed to insulin resistance, there is little understanding of underlying mechanisms.

AIMS

To prospectively study temporal disturbances of glucose metabolism after aneurysmal SAH in patients without known abnormalities of glucose metabolism and to explore possible correlations with markers of stress.

METHODS

In consecutive aneurysmal SAH patients not subjected to insulin therapy, in-hospital and follow-up oral glucose tolerance tests (OGTTs) and assessments of insulin resistance, pancreatic β-cell function, free fatty acids (FFA) and cortisol were performed and compared with reference values.

RESULTS

We included 13 patients. In the first 2 weeks of admission, median fasting glucose and FFA levels were elevated while insulin levels were not. OGTTs were indicative of glucose intolerance in all patients at days 3 and 7, while on follow-up 1 patient had glucose intolerance and all patients had normal fasting glucose levels. Pancreatic β-cell function was impaired throughout the first week and insulin resistance from day 4 to 10. Levels of cortisol correlated with higher fasting glucose and increased FFA. FFA in turn correlated with pancreatic β-cell dysfunction.

CONCLUSIONS

Aneurysmal SAH patients have transient abnormalities of glucose metabolism. During the first week, it appears to result predominantly from transient pancreatic β-cell dysfunction, in combination with insulin resistance.

Communication with breast cancer survivors

Breast cancer survivors must manage chronic side effects of original treatment. To manage these symptoms, communication must include both biomedical and contextual lifestyle factors. Sixty breast cancer survivors and 6 providers were recruited to test a conceptual model developed from uncertainty in illness theory and the dimensions of a patient-centered relationship. Visits were audio-taped, then coded using the Measure of Patient-Centered Communication (Brown, Stewart, & Ryan, 2001). Consultations were found to be 52% patient-centered. Chi-square Automatic Interaction Detection (CHAID) analysis showed that survivor self-reported fatigue level and conversation about symptoms were associated with survivor uncertainty, mood state, and survivor perception of patient-centered communication. Survivors may want to discuss persistent symptom concerns with providers, due to concerns about recurrence, and discuss lifestyle contextual concerns with others.

Exploring genetic counseling communication patterns: the role of teaching and counseling approaches

The educational and counseling models are often touted as the two primary professional approaches to genetic counseling practice. Yet, research has not been conducted to examine how these approaches are used in practice. In the present study, we conducted quantitative communication analyses of BRCA1 genetic counseling sessions. We measured communication variables that represent content (e.g., a biomedical focus) and process (e.g., passive listening) to explore whether genetic counselor approaches are consistent with prevailing professional models. The Roter Interaction Analysis System (RIAS) was used to code 167 pre-test genetic counseling sessions of members of a large kindred with an identified BRCA1 mutation. Three experienced genetic counselors conducted the sessions. Creating composite categories from the RIAS codes, we found the sessions to be largely educational in nature with the counselors and clients devoting the majority of their dialogue to providing biomedical information (62 and 40%, respectively). We used cluster analytic techniques, entering the composite communication variables and identified four patterns of session communication: Client-focused psychosocial, biomedical question and answer, counselor-driven psychosocial, and client-focused biomedical. Moreover, we found that the counselors had unique styles in which they combined the use of education and counseling approaches. We discuss the importance of understanding the variation in counselor communication to advance the field and expand prevailing assumptions.

Uncertainty inBRCA1 cancer susceptibility testing

This study investigated uncertainty in individuals undergoing genetic counseling/testing for breast/ovarian cancer susceptibility. Sixty-three individuals from a single kindred with a known BRCA1 mutation rated uncertainty about 12 items on a five-point Likert scale before and 1 month after genetic counseling/testing. Factor analysis identified a five-item total uncertainty scale that was sensitive to changes before and after testing. The items in the scale were related to uncertainty about obtaining health care, positive changes after testing, and coping well with results. The majority of participants (76%) rated reducing uncertainty as an important reason for genetic testing. The importance of reducing uncertainty was stable across time and unrelated to anxiety or demographics. Yet, at baseline, total uncertainty was low and decreased after genetic counseling/testing (P = 0.004). Analysis of individual items showed that after genetic counseling/testing, there was less uncertainty about the participant detecting cancer early (P = 0.005) and coping well with their result (P < 0.001). Our findings support the importance to clients of genetic counseling/testing as a means of reducing uncertainty. Testing may help clients to reduce the uncertainty about items they can control, and it may be important to differentiate the sources of uncertainty that are more or less controllable. Genetic counselors can help clients by providing anticipatory guidance about the role of uncertainty in genetic testing.