POS0761 TIME-DEPENDENT ANALYSES OF CLINICAL MANIFESTATIONS OF SYSTEMIC LUPUS ERYTHEMATOSUS IDENTIFY PATIENTS AT HIGH RISK OF INCIDENT PROTEINURIA

Background

Nephritis (LN) in systemic lupus erythematosus (SLE) is still a major determinant of poor prognosis[1].

The vast majority of LN occurs in proximity to the SLE diagnosis[2]. Identification of individuals at high risk, especially early onset SLE, is therefore warranted. Inclusion of risk factors prior to the SLE diagnosis may thus be of importance to enable sufficient risk factor profiling. SLE-patients seem to cluster according to clinical and serological phenotypes suggesting distinct disease trajectories[3-5].

Objectives

To determine if incident proteinuria associated with the debut age of non-renal SLE characteristics.

Methods

Data of SLE patients from six Danish centers were obtained from the Danbio-database from 2017 – 2020. The occurrence and timing of proteinuria was compared with first time onset of any non-renal manifestations as defined by the 1997 American College of Rheumatology Classification Criteria. Cox-regression models were used to identify risk factors for incident proteinuria. Time from first occurring non-renal manifestation to incident proteinuria or censoring defined time at risk. Covariates were eliminated if p >0.01 in a ‘backwards’ manner. After the model reduction process p-values <0.05 were considered statistically significant.

Results

586 SLE patients, mainly white (94%) women (88%), mean age at inclusion of 34.6 years (standard deviation, SD = 0.6 years) and observed for a mean of 14.9 years (SD =0.5 years), were recruited. The cumulative prevalence of proteinuria was 40%. Male gender hazard ratio, HR = 1.35 (range 0.77-2.35), p=0.009, lymphopenia HR = 1.77 (range 1.24-2.52), p=0.005 were associated with incident proteinuria. In contrast, patients with discoid rash had lower risk of incident proteinuria HR 0.42 (range 0.21-0.83), p=0.01. Male patients with lymphopenia had the highest risk of proteinuria with a one-, 5- and 10-year risk of proteinuria ranging from 9-27%, 34-75% and 51-89 %, depending on the age at presentation (debut at 20, 30, 40 or 50 years). The corresponding risk-profiles for women with lymphopenia were 3-9%, 8-34% and 12-58%, respectively, as illustrated in Figure 1.

Conclusion

The occurrences of lymphopenia and discoid rash were oppositely associated with risk of incident proteinuria and the risk effects varied according to gender and patient age at onset of these manifestations. Thus, the risk of proteinuria may not be constant but could vary according to presentation of non-renal manifestations that may call for a differentiated clinical follow-up. Based on these findings, we suggest that the debut age of known prognostic factors, even prior to the SLE diagnosis should be considered when designing prognostic statistical models.

References

[1]Faurschou, M., et al., Prognostic factors in lupus nephritis: diagnostic and therapeutic delay increases the risk of terminal renal failure. J Rheumatol, 2006. 33(8): p. 1563-9.

[2]Hanly, J.G., et al., The frequency and outcome of lupus nephritis: results from an international inception cohort study. Rheumatology (Oxford), 2016. 55(2): p. 252-62.

[3]Diaz-Gallo, L.M., et al., Four Systemic Lupus Erythematosus Subgroups, Defined by Autoantibodies Status, Differ Regarding HLA-DRB1 Genotype Associations and Immunological and Clinical Manifestations. ACR Open Rheumatol, 2022. 4(1): p. 27-39.

[4]Jacobsen, S., et al., A multicentre study of 513 Danish patients with systemic lupus erythematosus. II. Disease mortality and clinical factors of prognostic value. Clin Rheumatol, 1998. 17(6): p. 478-84.

[5]Leffers, H.C.B., et al., Smoking associates with distinct clinical phenotypes in patients with systemic lupus erythematosus: a nationwide Danish cross-sectional study. Lupus Sci Med, 2021. 8(1).

Disclosure of Interests

Martin Andersen Employee of: Novo Nordisk A/S: 2010-2014, Anders Stockmarr: None declared, Henrik Leffers: None declared, Anne Troldborg: None declared, Anne Voss: None declared, Salome Kristensen: None declared, Bent Deleuran: None declared, Lene Dreyer Speakers bureau: Speakers bureau: Eli Lilly, Galderma and Janssen, Grant/research support from: Grant from BMS outside the present work, Laura Johnsen: None declared, Ada Colic: None declared, Søren Jacobsen: None declared

AB0006 ESTABLISHED RISK LOCI FOR SYSTEMIC LUPUS ERYTHEMATOSUS AT NCF2, STAT4, TNPO3, IRF5 AND ITGAM ASSOCIATE WITH DISTINCT CLINICAL MANIFESTATIONS: A DANISH GENOME-WIDE ASSOCIATION STUDY

Background

Systemic lupus erythematosus (SLE) has been associated with more than 100 genetic loci. This parallels positively to the clinical diversity that is reflected by the classification of SLE.

Objectives

We aimed to investigate associations between disease manifestations of SLE and risk gene variants relevant to Danish subjects of European ancestry.

Methods

We included 427 SLE patients of European ancestry similar to previous reports.[1] We also included 89,699 controls from the Danish Blood Donor Study Genomic Cohort. SLE risk loci in this population were identified by genome-wide association methodology and hereafter correlated to cumulative occurrence of SLE classification items.

Results

Fourteen variants mapped to the following genes: NCF2, STAT4, TNPO3/TPI1P2, IRF5, and ITGAM, were significantly associated (p<5E-8) with SLE.

The five lead variants were associated (p<0.05) with the following manifestations; NCF2: proteinuria and anti-phospholipid antibodies, STAT4: arthritis, serositis, neurologic disorder, lymphopenia, and anti-Smith antibodies, IRF5: seizures and proteinuria, TNPO3: proteinuria, and ITGAM: photosensitivity (Table 2).

Conclusion

Our findings support the future use of select, relevant genetic markers in predicting various SLE phenotypes.

References

[1]Leffers HCB, Troldborg A, Voss A, et al. Smoking associates with distinct clinical phenotypes in patients with systemic lupus erythematosus: a nationwide Danish cross-sectional study. Lupus Sci Med 2021;8(1).

Table 1.

Associations between five SLE risk loci and specific disease manifestations in 427 Danish patients with SLE*.

NCF2STAT4IRF5TNPO3ITGAMrs17849502_Trs7574865_Trs4728142_Ars13239597_Ars11860650_TN (%)Malar rash233 (55%)1.28 (0.84-1.96)0.83 (0.62-1.11)1.01 (0.74-1.38)1.44 (0.97-2.12)1.14 (0.80-1.61)Discoid rash46 (11%)1.49 (0.81-2.73)0.90 (0.56-1.45)1.01 (0.62-1.66)1.16 (0.63-2.12)0.76 (0.42-1.41)Photosensitivity219 (51%)0.96 (0.63-1.46)1.09 (0.81-1.47)0.98 (0.71-1.34)0.84 (0.57-1.25)0.67 (0.47-0.97)Oral ulcers132 (31%)0.96 (0.61-1.50)0.90 (0.65-1.23)0.83 (0.60-1.16)1.30 (0.87-1.96)1.43 (0.99-2.05)Non-erosive Arthritis342 (80%)0.84 (0.52-1.37)1.49 (1.02-2.18)0.93 (0.63-1.36)1.04 (0.64-1.68)1.16 (0.74-1.80)Serositis-Pleuritis124 (29%)0.63 (0.38-1.05)1.38 (1.01-1.89)1.22 (0.87-1.72)0.85 (0.56-1.29)0.84 (0.57-1.24)-Pericarditis72 (17%)0.75 (0.41-1.40)1.35 (0.93-1.96)1.05 (0.70-1.58)1.15 (0.70-1.89)1.09 (0.70-1.72)Persistent proteinuria158 (37%)1.63 (1.07-2.49)1.08 (0.80-1.46)0.68 (0.49-0.94)1.74 (1.16-2.61)1.09 (0.76-1.57)Neurologic disorder-Seizures23 (5%)1.58 (0.75-3.35)1.49 (0.80-2.76)2.10 (1.04-4.25)0.61 (0.26-1.44)0.93 (0.42-2.06)-Psychosis8 (2%)0.76 (0.097-5.87)2.77 (0.94-8.15)0.35 (0.10-1.23)0 (0)2.96 (0.85-10.3)Haematologic disorder-Haemolytic anaemia38 (9%)0.78 (0.34-1.76)1.37 (0.85-2.22)0.75 (0.44-1.29)1.11 (0.57-2.19)1.24 (0.70-2.20)-Leukopenia130 (30%)1.04 (0.67-1.61)1.19 (0.87-1.63)1.00 (0.72-1.39)0.90 (0.60-1.37)0.94 (0.64-1.37)-Lymphopenia228 (53%)0.95 (0.63-1.44)1.35 (1.01-1.81)0.95 (0.70-1.29)1.16 (0.79-1.70)1.09 (0.77-1.54)-Thrombocytopenia102 (24%)1.42 (0.91-2.22)0.84 (0.60-1.18)0.83 (0.58-1.18)1.35 (0.86-2.11)0.91 (0.60-1.37)Immunologic disorder-anti-DNA ab.330 (77%)0.69 (0.44-1.09)1.02 (0.72-1.44)0.94 (0.65-1.35)0.97 (0.62-1.53)1.08 (0.71-1.65)-anti-Smith ab.44 (10%)1.44 (0.79-2.64)1.58 (1.00-2.49)1.23 (0.73-2.07)1.47 (0.80-2.69)1.07 (0.61-1.84)-anti-phospholipid ab.183 (43%)1.63 (1.07-2.49)1.05 (0.79-1.41)0.84 (0.61-1.14)1.14 (0.77-1.68)1.14 (0.80-1.62)

* Logistic regression models for each manifestation included all five lead variants (multivariate) and were adjusted for age and sex

Disclosure of Interests

Henrik Leffers: None declared, David Westergaard: None declared, Saedis Saevarsdottir: None declared, Ingileif Jonsdottir: None declared, Ole Birger Pedersen: None declared, Anne Troldborg: None declared, Anne Voss: None declared, Salome Kristensen: None declared, Jesper Lindhardsen: None declared, Prabhat Kumar: None declared, Asta Linauskas: None declared, Lars Juul: None declared, Niels Steen Krogh: None declared, Bent Deleuran: None declared, Lene Dreyer Speakers bureau: Speakers bureau: Eli Lilly, Galderma and Janssen, Grant/research support from: from BMS outside the present work, Michael Schwinn: None declared, Lise wegner Thørner: None declared, Lotte Hindhede: None declared, Christian Erikstrup: None declared, Henrik Ullum: None declared, Søren Brunak Shareholder of: SB has ownerships in Intomics A/S, Hoba Therapeutics Aps, Novo Nordisk A/S, Lundbeck A/S, Kari Stefansson: None declared, Karina Banasik: None declared, Søren Jacobsen: None declared

Cardiovascular and Respiratory Interactions in Idiopathic Pulmonary Fibrosis by Extended Partial Directed Coherence: Short-term Effects of Supplemental Oxygen

Idiopathic pulmonary fibrosis (IPF) is a progressive interstitial lung disease that can lead to chronic arterial hypoxemia, hypercapnia, and dyspnea. To improve clinical symptoms in IPF patients, supplemental oxygen (SupplO₂) has been prescribed with the aim to maintain SpO₂ level, and consequently to relieve dyspnea, increase physical activity and improve quality of life. In this study, we investigated the effect of disease and short-term SupplO₂ on cardiovascular and respiratory autonomic regulation. Linear and nonlinear indices were extracted from the beat-to-beat variability of heart rate (HR), systolic (SYS) blood pressure and respiration (RESP) in IPF patients and healthy subjects spontaneously breathing ambient air (AA) and during SupplO₂ at 3 L/min. It was found that the effects on autonomic nervous systems (ANS) regulation were better demonstrated by the Granger causality (GC) method. GC was significantly higher (p<0.01) in patients compared to controls for the interactions RESP→SYS and BBI→SYS.Clinical Relevance-Short-term SupplO2 in IPF could adversely affect systolic blood pressure variability in particular. This study may help in the management of SupplO2 administration.

Why psychiatry is different - challenges and difficulties in managing a nosocomial outbreak of coronavirus disease (COVID-19) in hospital care

Objective

Coronavirus disease (COVID-19) was officially declared a pandemic in March 2020. Many cases of COVID-19 are nosocomial, but to the best of our knowledge, no nosocomial outbreaks on psychiatric departments of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) have been reported in Europe. The different nature of psychiatry makes outbreak management more difficult. This study determines which psychiatry specific factors contributed to a nosocomial outbreak taking place in a psychiatric department. This will provide possible interventions in future outbreak management.

Method

A case series describing a nosocomial outbreak in a psychiatric department of an acute care hospital in the Netherlands between March 13, 2020 and April, 14 2020. The outbreak was analyzed by combining data from standardized interviews, polymerase chain reaction (PCR) tests and whole genome sequencing (WGS).

Results

The nosocomial outbreak in which 43% of staff of the psychiatric department and 19% of admitted patients were involved, was caused by healthcare worker (HCW)-to-HCW transmissions, as well as patient-to-HCW-to-patient transmission. We identified four aspects associated with the mental health care system which might have made our department more susceptible to an outbreak.

Conclusions

Infection control measures designed for hospitals are not directly applicable to psychiatric departments. Psychiatric patients should be considered a high-risk group for infectious diseases and customized measures should be designed and implemented. Extra attention for psychiatric departments is necessary during a pandemic as psychiatric HCWs are less familiar with outbreak management. Clear communication and governance is crucial in correctly implementing these measures.

Time-Frequency Analysis of Cardiovascular Variability during an Orthostatic Stress by Complete EMD

Diverse analysis techniques have been used to comprehend the regulation by the autonomic nervous system (ANS) of the cardiovascular system when a human being faces a stressor. Recently, however, the complete ensemble empirical mode decomposition (EMD) with adaptive noise (CEEMDAN) allows analyzing nonstationary signals in a nonlinear and time- variant way. Consequently, CEEMDAN may provide a means to obtain clues about ANS regulation in health and disease. In this study, we analyze the average Hilbert-Huang spectrum (HHS) of cardiovascular variability signals by CEEMDAN during a head-up tilt test (HUTT) in 12 healthy female subjects and 18 orthostatic intolerance female patients. Beat-to-beat intervals (BBI) as well as systolic (SYS) blood pressure variability time series were analyzed. In addition, instantaneous amplitudes and frequencies of specific intrinsic mode functions (IMF) were investigated separately to define the influence of the disease on ANS regulation. Female groups demonstrated statistical differences in the high-frequency band of BBI but higher differences for the high and low-frequency bands of SYS from the mechanical transition of HUTT.Clinical Relevance- A relevant outcome of the study is the average HHS of healthy female subjects along HUTT. This HHS may be used as reference to help diagnose OI when HHS of the cardiovascular variability signals of any subject deviates from the normal course.

SAT0233 CHARACTERISTICS OF PRIMARY SJÖGREN’S SYNDROME INCLUDING ULTRASOUND FINDINGS OF THE SALIVARY GLANDS, ESSDAI AND ESSPRI

Background:

Studies have shown that salivary gland ultrasonography (SGUS) may have a potential value in the diagnosis of Sjogren’s Syndrome (SS).

Knowledge of the association between ultrasonography findings, disease activity and damage, serologic markers and patient report outcome is limited.

Objectives:

To investigate whether the results of SGUS are associated with disease manifestations and damage measured by doctor-reported activity score index (ESSDAI) and serologic markers. Furthermore to investigate the contribution of patient reported outcome measure (ESSPRI) in disease monitoring.

Methods:

Patients registered at Odense University Hospital with the diagnosis primary SS were included in a Danish cohort. The patients were characterized using the ESSDAI, ESSPRI, serologic markers and SGUS-findings in submandibular and parotid glands. Schirmer’s test and salivary test were performed for measurement of tear and salivary production.

SGUS was performed using a linear transducer, Siemens (ACUSON Sequoia Ultrasound System) on the two parotid and two submandibular glands. SGUS images was scored according to the OMERACT SS severity scoring system from 0 to 3, where 2 is moderate and 3 severe(1). A reliability study was performed in advance of the present study.

Spearman´s r correlation coefficient was used to assess correlation between scores.

Results:

The cohort consisted of 48 Caucasian patients diagnosed with primary SS. Details on patient characteristics are shown in table 1.

Table 1.Sex, n (%)Women46 (95.8)Age, mean (95%CI)60 (57-62)Smoking, n (%)Smoker1 (2.1)BMI, n (%)< 18.55 (10.4)18.5 – 24.920 (41.7)25.0 – 29.912 (25.0)30.0 – 34.910 (20.8)> 35.01 (2.1)Serologic markers, n (%)SSa positive33 (68.8)SSb positive22 (45.8)ANA positive38 (79.2)Cryoglobulin positive9 (18.8)ESSPRI 0-10, mean (95%CI)Dryness7.3 (6.7-7.9)Fatigue7.1 (6.4-7.7)Pain5.9 (5.1-6.7)SGUS, n (%)Score 06 (12.5)Score 115 (31.3)Score 213 (27.1)Score 314 (29.2)ESSDAI, n (%)ESSDAI < 5 (low-activity)22 (45.8)≤ 5 ESSDAI ≤ 13 (moderate-activity) ESSDAI ≥17 (35.4)14 (high-activity)9 (18.8)

The correlation between ESSDAI-scores and SGUS-scores was r = 0.153 (p = 0.299). The correlation between ESSDAI-scores and ESSPRI-scores (dryness, fatique, pain) was r = 0.071 (p = 0.632), r = 0.254 (p = 0.082) and r = -0.002 (p = 0.987). The correlation between SGUS-scores and ESSPRI-scores (dryness, fatique, pain) was r = 0.124 (p = 0.400), r = -0.292 (p = 0.044) and r = -0.459 (p = 0.001).

Conclusion:

In a Danish cohort of SS most patients had SSa and ANA autoantibodies. SGUS demonstrated high damage (score 2-3) in approximately half of the patients. ESSDAI activity score did not correlate with SGUS damage scores or the ESSPRI. SGUS damage scores correlated with ESSPRI-scores of fatique and pain, but not dryness.

Associations between other factors of importance for damage and SGUS scores are to be analyzed. SGUS and the ESSPRI describe different SS-related dimensions and will probably contribute in disease monitoring in the future.

References:

[1]Jousse-Joulin S, D’Agostino MA, Nicolas C, Naredo E, Ohrndorf S, Backhaus M, et al. Video clip assessment of a salivary gland ultrasound scoring system in Sjogren’s syndrome using consensual definitions: an OMERACT ultrasound working group reliability exercise. Annals of the rheumatic diseases. 2019;78(7):967-73.

Disclosure of Interests:

None declared

THU0272 BASEMENT MEMBRANE SEROLOGICAL MARKERS OF COLLAGEN TYPE IV AND LAMININ REMODELING ARE DIFFERENTIALLY EXPRESSED IN SLE

Background:

Collagen type IV and laminin are the main constituents of basement membranes (BMs). Epitopes on these molecules are targeted in various autoimmune diseases, systemic lupus erythematosus (SLE) in particular. Accelerated large vessel disease is a well-recognized cause of premature cardiovascular morbidity and mortality in SLE. Novel tools for quantification of soluble MMP-derived fragments of collagen type IV (C4M) and laminin (LG1M) have emerged as promising biomarkers for BM remodeling in atherosclerosis.

Objectives:

To study serum levels of collagen type IV and laminin metabolites in patients with SLE and in healthy controls. And to search for associations with disease activity, organ damage and cardiovascular comorbidity.

Methods:

One hundred and six SLE patients without and 20 with previous CVD events were included (1). One hundred and twenty male and female blood donors aged 20-65 years served as healthy reference. Disease activity (SLEDAI) and damage (SLICC) scores were calculated. Coronary artery calcification (CAC) was studied by CT scan and expressed as Agatston score. Carotid intima-media thickness (IMT) was measured by ultrasound (LOGIQ E9, GE Healthcare). In either subgroup atherosclerosis was defined as Agatston > 99 U and/or IMT>1 mm and/or presence of plaque. C4M and LG1M were measured by competitive ELISAs (2).

Results:

Patient characteristics are presented in Table 1. Overall, C4M and LG1M were significantly increased in the entire SLE cohort vs. healthy controls (35.7 ± 17.5 vs. 22.3 ± 9.4 ng/mL, p<0.0001 and 20.9 ± 21.1 vs. 9.7 ± 8.0 ng/mL, p<0.0001, respectively) (Fig 1). Highly significant positive correlations were detected between C4M and LG1M in the entire SLE cohort and in the healthy control group (Fig 2).In terms of CVD and atherosclerosis LG1M was significantly higher in SLE patients with manifest CVD vs. those without (34.47 ± 41.22 vs. 18.34 ± 13.55, p=0.0015) and in those with atherosclerosis by imaging (25.53 ± 28.12 vs 17.53 ± 13.35, p=0.036). There were no associations between C4M and CVD or atherosclerosis. There was a weak association between LG1M and SLICC (r=0.22, p=0.01), but not with SLEDAI. Details on associations with other CVD risk factors and specific organ involvement will be presented.

Table 1

Characteristics for SLE patients with and without CVD

Patients characteristicsAll (126)SLE + CVD (20)SLE without CVD (106)pFemales, no. (%)113 (89)18 (90)95 (89)0.95Age, yrs., mean ± SD50.6± 14.454.8 ± 15.346.8± 14.10.15Disease duration, yrs., mean ± SD13.9 ± 9.319.0± 11.313.0± 11.30.007SLEDAI, median, range4 (0-14)4 (0-10)4 (0-14)0.717SLICC, median, range1 (0-11)3 (1-11)1 (0-10)0.0001Atherosclerosis, no. (%)53 (42)14 (70)39 (37)0.0006LG1M (ng/ml), mean ± SD20.9± 21.234.5± 41.218.3 ± 13.60.0015C4M (ng/ml), mean ± SD35.7 ± 17.538.1± 20.635.3± 16.90.518

Conclusion:

Serological levels of collagen type IV and laminin biomarkers were elevated and interrelated in an unstratified SLE population. Moreover, LG1M but not C4M was significantly elevated in SLE patients with previous CVD events and in those with atherosclerosis by imaging. These findings indicate that LG1M may serve as a serological marker for SLE-related large vessel disease. However, additional extravascular sites of increased basement membrane remodeling may contribute to the abnormal biomarker pattern.

References:

[1]Kay SD, Poulsen MK, Diederichsen AC, Voss A. J Rheumatol 2016;43:315–22

[2]Sand JM, Larsen L, Hogaboam C et al. PLoS One 2013;8:e84934

Kay SD and Genovese F contributed equally to this work.

Figure 1.

Levels of C4M and LG1M in serum of patients with SLE and healthy controls; graphs are presented as box and whiskers plot (in the style of Tukey). Statistical significance: ****p<0.0001.

Figure 2.

Correlation plots (Spearman r) of C4M and LG1M in SLE patients and healthy controls.

Disclosure of Interests:

Susan Due Kay: None declared, Federica Genovese Shareholder of: Own Nordic Bioscience stocks, Employee of: Nordic Bioscience, Anne Sofie Siebuhr Employee of: Nordic Bioscience, Morten Karsdal Shareholder of: Nordic Bioscience A/S., Employee of: Full time employee at Nordic Bioscience A/S., Anne Voss: None declared, Peter Junker: None declared

AB0450 DANISH PATIENTS WITH SYSTEMIC LUPUS ERYTHEMATOSUS SELF-REPORT HIGH LEVELS OF PHYSICAL ACTIVITY, AND MOST PATIENTS FULFILL THE WHO RECOMMENDATIONS ON PHYSICAL ACTIVITY

Background:

Physical activity is important for enhancing health and the World Health Organization (WHO) recommends that adults aged 18-64 engage in at least 150 minutes of moderate-intensity physical activity throughout the week, or 75 minutes of vigorous-intensity physical activity (1). Swedish patients with SLE reported a lower frequency and capacity of exercise than a control group, and in an Italian study, 60% of the SLE patients did not meet WHO’s recommendations for physical activity.

Mental health is important for the individual’s level of physical activity, and symptoms of depression have been associated with a lower level of physical activity in SLE patients (2).

Objectives:

The aim of this study is to describe the pattern of physical activity in a population of Danish SLE patients, and to investigate the association to depression.

Methods:

The study was conducted at the Department of Rheumatology at Odense University Hospital, Denmark, in 2018 and 2019. Two questionnaires were handed out before routine outpatient consultation: self-reported physical activity was evaluated using the International Physical Activity Questionnaire (IPAQ), and a continuous variable on energy requirement in the form of the metabolic equivalent (MET) was calculated, and the Major Depression Inventory (MDI) questionnaire was used to screen for depression. Medicine intake was registered, and disease activity and damage were scored using SLEDAI-2K and SLICC/ACR DI.

Results:

Two hundred and fifteen patients completed the IPAQ and MDI, 5 were excluded. The population consist of 89.5% women and the mean age was 51.7 ± 15.2 years. The mean disease duration was 16.1 ± 10.1 years.

The SLE patients reported a mean total MET-score of 5319.9 ± 3650 MET-min/week. If divided into categories, 7.6% reported low level, 21.9% moderate and 70.5% of the patients reported a high level of physical activity and 89.5% fulfilled WHO recommendations. The participants reported 363.7 ± 201 minutes per day in sitting time.

Mean MDI score was 12.7 ± 10.1, and if divided into groups, 89.5% were not depressed, 1.9% had a mild depression, 5.3% had a moderate depression and 2.9% had a severe depression. Significantly lower mean MET-scores were observed for the severely depressed patients.

An inverse association was found in the univariate analysis, indication that increasing disease duration and SLICC/ACR DI scores were significantly associated with decreasing total MET-scores. In the multivariate analysis time spent sitting was inversely associated with MET-score.

Our results were similar to a Brazilian study, where 68% of the patients reported, that they were “physical active” according to IPAQ. In contrast, only 22% of the patients in an Italian study reported high level physical activity. Our proportion of active patients were high when comparing with studies on patients with rheumatoid arthritis and spondylarthritis, where only 25-50% fulfilled the WHO recommendations compared to our 89.5%.

A Danish study on registered ICD diagnoses found a prevalence of depression in SLE patients to be 4.3%, which was lower than our prevalence. Foreign studies reported very diverse prevalences of depression, e.g. 16.6% in the Netherlands and 51% in Sweden.

Conclusion:

A high portion of the SLE patients reported a high level of physical activity and 89.5% fulfilled the WHO recommendations. Significant predictors for a lower level of physical activity were increasing disease duration, higher SLICC/ACR DI score and longer time spent sitting. However, further studies are needed, where more suitable questionnaires could be considered.

References:

[1]WHO recommendations, Geneva 2010;60:1-58.

[2]Gen Hosp Psychiatry. 2009;31:306-15.

Disclosure of Interests:

None declared

[Diagnostic algorithm for COVID-19 at the ER]

OBJECTIVE

Evaluation of a diagnostic algorithm for estimating the risk of COVID-19 in patients who are referred to an emergency department for being suspected of having the disease.

DESIGN

Retrospective study.

METHOD

Patients with fever with no apparent cause and patients with recently developed respiratory symptoms, whether or not in combination with fever, were routinely given a PCR test, blood tests (lymphocyte count and LDH levels) and a chest CT scan. The CT scan was assessed according to the CO-RADS classification. Based on the findings, the patients were divided into 3 cohorts (proven COVID-19, strong suspicion of COVID-19, and low suspicion of COVID-19) and the appropriate isolation measures were taken.

RESULTS

In the period from 8 to 31 March 2020, the algorithm was applied to 312 patients. COVID-19 was proven for 69 (22%) patients. COVID-19 was strongly suspected for 151 (48%) patients and suspicion was low for the remaining 92 (29%) patients. The percentage of patients with positive PCR results and the percentage of patients with abnormal laboratory test results increased as the CO-RADS score increased. Among patients with a CO-RADS score of 4 or 5, this percentage increased further when they also had lymphopenia or elevated LDH levels. We have adjusted the flowchart based on our findings.

CONCLUSION

In case of patients who have been referred to an emergency department for suspected COVID-19, a good COVID-19 risk assessment can be made on the basis of clinical signs, laboratory abnormalities and low-dose CT scans. Even before the results of the PCR test are known and even if the results are negative, patients can be classified as 'proven COVID-19 patients' using the algorithm.

Product dose considerations for real-world hand sanitiser efficacy

BACKGROUND

Alcohol based hand rubs (ABHR) are extremely effective at reducing microbial contamination and have an essential role in best practice hand hygiene described by the World Health Organization.

METHODS

We determined ABHR drying time when performing hand hygiene in a laboratory setting. Which was followed by identifying the amount of ABHR needed for complete hand coverage. When the aforementioned was analyzed real-time data were gathered to examine the amount used for hand hygiene in a hospital setting. In parallel hands of healthcare workers (HCWs) were monitored for drying time and perception on ABHR use.

RESULTS

In 86% (24,446,397/28,280,383) of the events a single dose of ABHR was used on clinical wards. Twenty-four HCWs expected hand hygiene to take 7.5 seconds (median; range 3-30 seconds). Forty-three HCWs show that 1.5 mL ABHR dose achieves the desired drying time according to World Health Organization guidelines (av. median 26 seconds), but is consistently perceived to have a longer drying time than expected (av. median 18 seconds). In-vivo results (n = 10) indicate that 2.25 mL ABHR is required for adequate coverage (82%-90%) of both sides of the hand.

CONCLUSIONS

Results indicate that set standards for the use of ABHR do not match "in-vivo" behaviour of HCWs. Perceived drying times are shorter than actual drying time. The needed drying time to reach acceptable antimicrobial efficacy of ABHRs should be revisited.

Erratum: Precision Mass Measurements on Neutron-Rich Rare-Earth Isotopes at JYFLTRAP: Reduced Neutron Pairing and Implications for r-Process Calculations [Phys. Rev. Lett. 120, 262701 (2018)]

This corrects the article DOI: 10.1103/PhysRevLett.120.262701.

Risk detection in patients with obstructive sleep apnea syndrome based on cardiovascular time series analysis

Obstructive sleep apnea represents the most common form of sleep-disordered breathing and has a high prevalence in patients with cardiovascular disease. Disturbed sleep is a potential risk factor for cardiovascular disorders such as arterial hypertension, cardiac ischemia, sudden cardiac death, and stroke. In this study we investigated polysomnographic records and analyzed the ECG, plethysmogram, respiration and SpO2 time series during wakefulness (WK), NREM, and REM sleep stages applying variability and coupling analyses methods. We enrolled 55 patients with obstructive sleep apnea syndrome (OSAS) and 29 healthy control subjects (CON: 45.9±14.9 years, 21 male) in this study. OSAS patients were subdivided into a low- and high-risk group (LR: 50.8±14.1 years, n=29, 21 male; HR: 57.2±13.4 years, n=26, 19 male) based on the Apnea-Hypopnea Index (AHI) (CON: 0-5 AHI, LR: 5-15 AHI, HR: >15 AHI). We could demonstrate the presence of an altered autonomic function in OSAS patients, differing from healthy controls. This altered autonomic function was mainly based on heart rate-, respiratory-, SpO2- and plethysmogram variability and their couplings. The discriminant analysis showed that the optimal set consisting of two autonomic indices revealed a high classification power (ACC=86.7%, AUC=90.3%, SENS=89.5% and SPEC=84.6%) when comparing low-risk and high-risk OSAS patients during WK. These results were slightly improved when analyzing REM sleep stages. Based on these results it seems to be possible to perform optimal risk stratification for OSAS patients based on autonomic indices. Based on our findings it is possible to differentiate between high-risk OSAS patient and low-risk OSAS patient at an early stage and in a promising manner allowing to set up therapy strategies for those patients in an early stage.

Temporal cardiovascular causality during orthostatic stress by extended partial directed coherence

The aim of this study was to investigate the temporal dynamic behavior of cardiovascular interactions between heart period and systolic blood pressure during a 20-min head-up tilt test at 70° in young women with orthostatic intolerance compared to healthy women. Methods included the lagged and extended partial directed coherence applied to short-term windows shifted by 5 seconds, extracted from a multivariate set of cardiovascular and respiratory time series. Findings revealed significantly increased information flow (p <; 0.01) in patients from: a) heart period to blood pressure during supine position which subsequently decreased and b) blood pressure to heart period during the progression of orthostatic phase. Controls developed balanced cardiovascular interactions with smaller information flows than patients.

Large Impact of the Decay of Niobium Isomers on the Reactor ν[over ¯]_{e} Summation Calculations

Even mass neutron-rich niobium isotopes are among the principal contributors to the reactor antineutrino energy spectrum. They are also among the most challenging to measure due to the refractory nature of niobium, and because they exhibit isomeric states lying very close in energy. The β-intensity distributions of ^{100gs,100m}Nb and ^{102gs,102m}Nb β decays have been determined using the total absorption γ-ray spectroscopy technique. The measurements were performed at the upgraded Ion Guide Isotope Separator On-Line facility at the University of Jyväskylä. Here, the double Penning trap system JYFLTRAP was employed to disentangle the β decay of the isomeric states. The new data obtained in this challenging measurement have a large impact in antineutrino summation calculations. For the first time the discrepancy between the summation model and the reactor antineutrino measurements in the region of the shape distortion has been reduced.

Summation Calculations for Reactor Antineutrino Spectra, Decay Heat and Delayed Neutron Fractions Involving New TAGS Data and Evaluated Databases

Three observables of interest for present and future reactors depend on the β decay properties of the fission products: antineutrinos from reactors, the reactor decay heat and delayed neutron emission. In these proceedings, we present new results from summation calculations of the first two quantities quoted above, performed with evolved independent yields coupled with fission product decay data, from various nuclear data bases or models. New TAGS results from the latest experiment of the TAGS collaboration at the JYFL facility of Jyväskylä will be displayed as well as their impact on the antineutrino spectra and the decay heat associated to fission pulses of the main actinides.

Propagation-based phase-contrast tomography of a guinea pig inner ear with cochlear implant using a model-based iterative reconstruction algorithm

Propagation-based phase-contrast computed tomography has become a valuable tool for visualization of three-dimensional biological samples, due to its high contrast between materials with similar attenuation properties. However, one of the most-widely used phase-retrieval algorithms imposes a homogeneity assumption onto the sample, which leads to artifacts for numerous applications where this assumption is violated. Prominent examples are biological samples with highly-absorbing implants. Using synchrotron radiation, we demonstrate by the example of a guinea pig inner ear with a cochlear implant electrode, how a recently developed model-based iterative algorithm for propagation-based phase-contrast computed tomography yields distinct benefits for such a task. We find that the model-based approach improves the overall image quality, removes the detrimental influence of the implant and accurately visualizes the cochlea.

Study of impaired cardiovascular and respiratory coupling during orthostatic stress based on joint symbolic dynamics

The present study investigates the instantaneous coupling among the cardiac, vascular, and respiratory systems, using the heart rate, respiration, and systolic and diastolic blood pressure variability in 12 healthy and 16 vasovagal syncope female subjects during a head-up tilt (HUT) testing protocol at 70° This study contributes to the coupling analysis by using a nonlinear joint symbolic dynamics (JSD) in a high-temporal resolution scheme, based on 5 min segments of the time series that are shifted every minute. For each segment, a bivariate JSD matrix was constructed to obtain global and local coupling indices in accordance to Shannon's entropy and the probability of occurrence of various bivariate words, respectively. The novel approach revealed important findings in the coupling dynamics of the systems, thus allowing the detection of group differences during the early orthostatic phase, and during the HUT test, before the occurrence of any pre-syncopal symptoms. In patients, the global indices indicated a significant decrease of cardiovascular coupling, starting at 10 min after the tilt-up, manifested by reduced baroreflex sensitivity and cardiorespiratory coupling that was initiated 8 min after the onset of the orthostatic phase (OP). A decreased autonomic control on cardiovascular-respiratory couplings was further evidenced by increased alterations of the JSD indices during the OP compared to the supine position in patients compared to controls. Furthermore, findings based on local indices demonstrated that female patients showed reductions and disengagements in cardiovascular (p < 0.001) and cardiorespiratory (p < 0.01) couplings, as early as the first 5 min and during the complete OP.

Prevalence of healthcare-associated infections in Dutch nursing homes: follow-up 2010-2017

Following the first point-prevalence study in Dutch nursing homes conducted each November from 2007 to 2009, we conducted a follow-up point-prevalence study of healthcare-associated infections (HCAIs) each November from 2010 to 2017. Similar methods and criteria were used. Resident characteristics were recorded, data collection was performed by the attending elderly care physicians via an online survey, as well as via a specifically designed App from 2012. As of the same year, information on incontinence was added. Between 2010 until 2017 on average 1786 residents per year were included, ranging from 1571 to 2185. HCAI prevalence with respect to age (mean: 83 years) and sex (31% men and 69% women) were similar over all the years. The overall mean prevalence rate in the first four years was 6.7% versus 2.2% in the last six years. Urinary tract infection was the most prevalent HCAI (1.5%). Most HCAIs occurred among residents of rehabilitation units. The prevalence of HCAI varied by nursing home (0.0-37.0%). The average use of antibiotics was stable over the years (6.0%) irrespective of HCAI rate. Use of incontinence materials was on average 73.5% with 64.3% of residents being reported as incontinent. Those implementing improvement of infection control and surveillance within a new setting do need to continue for multiple years before seeing the success of their endeavour.

Cardiovascular variability in young male and female subjects in health and orthostatic intolerance

The aim of this study was to investigate the effect of head-up tilt (HUT) test on male and female young patients, diagnosed with orthostatic intolerance (OI), in comparison to male and female healthy subjects. Twenty seven OI patients (21 women, 6 men) and 26 age-matched healthy subjects (13 women, 13 men) were enrolled in a 70° HUT test. In addition to hemodynamic variables, cardiovascular and respiratory parameters were determined using linear and nonlinear methods to analyze heart rate (HRV) and blood pressure variability (BPV). During the complete test, HRV was lower in healthy men than in female controls. Decreased HRV and increased BPV were observed in female patients compared to healthy women. Furthermore, systolic BPV was increased in male and female patients. However, linear (rmssd) and nonlinear (plvar2) parameters indicated that diastolic BPV decreased in male patients during orthostatic phase, but remained unchanged in female patients. Findings indicated gender dependent mechanisms for the regulation of diastolic blood pressure during orthostatic stress in patients.

Precision Mass Measurements on Neutron-Rich Rare-Earth Isotopes at JYFLTRAP: Reduced Neutron Pairing and Implications for r-Process Calculations

The rare-earth peak in the r-process abundance pattern depends sensitively on both the astrophysical conditions and subtle changes in nuclear structure in the region. This work takes an important step towards elucidating the nuclear structure and reducing the uncertainties in r-process calculations via precise atomic mass measurements at the JYFLTRAP double Penning trap. ^{158}Nd, ^{160}Pm, ^{162}Sm, and ^{164-166}Gd have been measured for the first time, and the precisions for ^{156}Nd, ^{158}Pm, ^{162,163}Eu, ^{163}Gd, and ^{164}Tb have been improved considerably. Nuclear structure has been probed via two-neutron separation energies S_{2n} and neutron pairing energy metrics D_{n}. The data do not support the existence of a subshell closure at N=100. Neutron pairing has been found to be weaker than predicted by theoretical mass models. The impact on the calculated r-process abundances has been studied. Substantial changes resulting in a smoother abundance distribution and a better agreement with the solar r-process abundances are observed.

An international survey of cleaning and disinfection practices in the healthcare environment

BACKGROUND

Antimicrobial resistance has become an urgent global health priority. Basic hygiene practices and cleaning and disinfection of the hospital environment are key in preventing pathogen cross-transmission.

AIM

To our knowledge no studies have assessed the worldwide differences in cleaning and disinfection practices in healthcare facilities. The electronic survey described here was developed in order to evaluate differences in healthcare facility cleaning practices around the world.

METHODS

The International Society of Antimicrobial Chemotherapy (ISAC, formerly ISC), Infection Prevention and Control work group developed a survey with 30 multiple-choice questions. The questions were designed to assess the current cleaning practices in healthcare settings around the world.

FINDINGS

A total of 110 healthcare professionals, representing 23 countries, participated in the online survey. In 96% of the facilities a written cleaning policy was present. Training of cleaning staff occurred in 70% of the facilities at the start of employment. Cleaning practices and monitoring of these practices varied.

CONCLUSIONS

The survey enabled assessment and recognition of widely differing global practices in approaches to environmental cleaning and disinfection. Development of guideline recommendations for cleaning and disinfection could improve practices and set minimum standards worldwide.

Epidemiology of cutaneous lupus erythematosus and the associated risk of systemic lupus erythematosus: a nationwide cohort study in Denmark

Objectives The objectives of this paper are to describe the epidemiology of cutaneous lupus erythematosus (CLE) and its subtypes in Denmark, and to investigate the probability of receiving a subsequent diagnosis of systemic lupus erythematosus (SLE) and the related time course. Methods A nationwide registry-based cohort study was conducted in Denmark based on data from the Danish National Patient Registry from 1998 to 2013 using International Classification of Diseases, Revision 10. Results We identified 2380 patients with CLE. The annual incidence rate (IR) of CLE was 2.74/100,000 with a female:male ratio of 4:1. During 12,047 person-years of follow-up, 8% were diagnosed with SLE. The probability of receiving a subsequent diagnosis of SLE was 12.9% after 10 years taking death as a competing risk into consideration, and the probability was highest among women and patients diagnosed with subacute CLE. The median time until a diagnosis of SLE was 2.05 years. Conclusions This is the first nationwide study on CLE in Denmark. Although we found the annual IR of CLE and the risk of receiving an additional diagnosis of SLE to be lower than previously described, continued monitoring and thorough information for patients with CLE is important due to the inherent risk of SLE.

Abstract P2-09-09: Polyligand profiling differentiates cancer patients according to their benefit of treatment

Introduction: Deconvolution of multi-nodal perturbations in cancer network architecture demands highly multiplexed profiling assays. We demonstrate the value of polyligand profiling of tumor systems states using libraries of single stranded oligodeoxynucleotides (ssODN) to distinguish between tumor tissue from breast cancer patients who did or did not derive benefit from treatment regimens containing trastuzumab.

Methods: This study included cases from women with invasive breast cancer who received chemotherapy+ trastuzumab (C+T) or trastuzumab monotherapy with available retrospective data on the time to next treatment (TTNT). A library of 2x1012 unique ssODN was exposed to FFPE tissues from patients who benefited (B) or not (NB) from trastuzumab-based regimens in several rounds of positive and negative selection. Two enriched libraries were screened on independent set of 42 B and 19 NB cases using a modified IHC protocol for detection of bound ssODNs. Poly-Ligand Profiles (PLP) were scored by a blinded pathologist. Two libraries, EL-NB and EL-B, showed significant p-values between groups of responders and non-responders. A Cox-PH model was fitted using either tumors' HER2 status or PLP test results as the independent variable. Median survival time was calculated from the Kaplan-Meier estimate. A separate group of 63 cases with TTNT data from chemotherapy without trastuzumab was used as a control to distinguish prognostic from predictive performance.

Results: The PLP scores of EL-NB and EL-B were assessed by receiver operating characteristic (ROC) curves and resulted in a combined AUC value of 0.81. EL-NB and EL-B were able to effectively classify B and NB patients with either HER2-negative/equivocal (AUC = 0.73) or HER2-positive cancers (AUC = 0.84). In contrast, HER2 status alone yielded an AUC value of 0.47. The combined PLP scores for the independent set of 63 patients treated with C excluding trastuzumab resulted in an AUC value of 0.53, indicating that the assay was predictive and not simply prognostic. Kaplan-Meier curves analysis shows that PLP+ cases have 429 days median TTNT, while PLP- cases have 129 days (HR = 0.38, log-rank p = 0.001). Analysis based on HER2 status showed no significant difference in TTNT between patients that were HER2+ (280 days) or HER2-negative/equivocal (336 days, HR = 1.27, log-rank p =0.45).

Summary: Performance of the PLP assay in differentiating patients who did or did not benefit from trastuzumab therapy outperforms the standard IHC assay for HER2 status. These results represent a promising step towards the development of a CDx to identify the 50-70% of HER2+ patients who will not benefit from trastuzumab. In addition, PLP also has the potential to identify the HER2-negative/equivocal patients who may benefit from trastuzumab-containing regimens.

Citation Format: Domenyuk V, Gatalica Z, Santhanam R, Wei X, Stark A, Kennedy P, Toussaint B, Levenberg S, Wang R, Xiao N, Greil R, Rinnerthaler G, Gampenrieder S, Heimberger AB, Berry DJ, Barker A, Demetri GD, Quackenbush J, Marshall JL, Poste G, Vacirca JL, Vidal GA, Schwartzberg LS, Halbert DD, Voss A, Miglarese MR, Famulok M, Mayer G, Spetzler D. Polyligand profiling differentiates cancer patients according to their benefit of treatment [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P2-09-09.

Working IT Out in Medical Practice: IT Systems Design and Development as Co-Realisation

Objectives: The paper explores possibilities for situating IT design and development work within the context of use so as to support the co-realisation of technology and ‘design in use’. The aim is to build a new understanding between IT professionals and users which is grounded upon what happens as the latter grapple with the problems of applying IT, appropriating its functionalities and affordances into their work practices and relations.

Methods: Following a discussion of participatory design and ethnomethodology, a novel method called co-realisation, which aims to provide a synthesis of the preceding methods, is suggested as an alternative. Through a discussion of findings from a case study of IT systems design and development in healthcare we show how the co-realisation approach might provide work-affording systems and how user-designer relations might be reformulated. We suggest that work-affording systems can be developed through the deployment of an engaged facilitator who works with the users to unpack the work site-specific potentialities of technology.

Results: The case study shows how risk of non-adoption might be minimised through the development of partnerships, and how the presence of the facilitator in the workplace capitalises on the mundane work undertaken therein and how the facilitator might work with the users to develop artefacts that support this work as opposed to reconfiguring it.

Conclusions: The case study illustrates co-realisation in action and how it might be seen to reconfigure relations between users and designers in a way that appears productive. Co-realisation can help address the widely observed problem of IT systems failures in healthcare.

Estimating Respiratory Pattern Variability by Symbolic Dynamics

Objectives: The traditional techniques of data analysis are often not sufficient to characterize the complex dynamics of respiration. In this study the respiratory pattern variability was analyzed using symbolic dynamics.

Methods: A group of 20 patients on weaning trials from mechanical ventilation were studied at two different pressure support ventilation levels. Breath duration (TTOT) time series and the relation TI/TTOT, that contains the influence of inspiratory time (TI), were considered. Length-3 words and 3 different symbols were proposed. The incidence of the overlapping τ and the parameter α were analyzed.

Results: From the breath duration time series, the distribution of words with probability of occurrence higher than 6% was concentrated on one word for low respiratory variability, whereas high variability was characterized by 4 words, presenting a statistically significant difference (p ≤ 0.0005). The probability occurrence of words “110” and “111” was also significantly different (p ≤ .0005) when comparing both variabilities.

Conclusion: The analysis carried out obtained discriminant functions able to correctly classify all the testing set series. These results permit the consideration of symbolic dynamics as a promising methodology to study the respiratory pattern variability.

Forecasting of Life Threatening Arrhythmias Using the Compression Entropy of Heart Rate

Objectives: Ventricular tachycardia (VT) provoking sudden cardiac death (SCD) are a major cause of mortality in the developed countries. The most efficient therapy for SCD prevention are implantable cardioverter defibrillators (ICD). In this study heart rate variability (HRV) measures were analyzed for short-term forecasting of VT in order to improve VT sensing and to enable a patient warning of forthcoming shocks.

Methods: The last 1000 normal beat-to-beat intervals before 50 VT episodes stored by the ICD were analyzed and compared to individually acquired control time series (CON). HRV analysis was performed with standard parameters of time and frequency domain as suggested by the HRV Task Force and furthermore with a newly developed and optimized nonlinear parameter that assesses the compression entropy of heart rate (Hc).

Results: Except of meanNN (p = 0.02) we found no significant differences in standard HRV parameters. In contrast, Hc revealed highly significant (p = 0.007) alterations in VT compared with CON suggesting a decreased complexity before the onset of VT.

Conclusion: Compression entropy might be a suitable parameter for short-term forecasting of life-threatening tachycardia in ICD.

Segmented Poincaré Plot Analysis for Risk Stratification in Patients with Dilated Cardiomyopathy

Background: The prognostic value of heart rate variability in patients with dilated cardiomyopathy (DCM) is limited and does not contribute to risk stratification although the dynamics of ventricular repolarization differs considerably between DCM patients and healthy subjects. Neither linear nor nonlinear methods of heart rate variability analysis could discriminate between patients at high and low risk for sudden cardiac death.

Objective: The aim of this study was to analyze the suitability of the new developed segmented Poincaré plot analysis (SPPA) to enhance risk stratification in DCM.

Methods: In contrast to the usual applied Poincaré plot analysis the SPPA retains nonlinear features from investigated beat-to-beat interval time series. Main features of SPPA are the rotation of cloud of points and their succeeded variability depended segmentation.

Results: Significant row and column probabilities were calculated from the segments and led to discrimination (up to p < 0.005) between low and high risk in DCM patients.

Conclusion: For the first time an index from Poincaré plot analysis of heart rate variability was able to contribute to risk stratification in patients suffering from DCM.

Infection prevention and control measures and tools for the prevention of entry of carbapenem-resistant Enterobacteriaceae into healthcare settings: guidance from the European Centre for Disease Prevention and Control

Background

Infections with carbapenem-resistant Enterobacteriaceae (CRE) are increasingly being reported from patients in healthcare settings. They are associated with high patient morbidity, attributable mortality and hospital costs. Patients who are “at-risk” may be carriers of these multidrug-resistant Enterobacteriaceae (MDR-E).

The purpose of this guidance is to raise awareness and identify the “at-risk” patient when admitted to a healthcare setting and to outline effective infection prevention and control measures to halt the entry and spread of CRE.

Methods

The guidance was created by a group of experts who were functioning independently of their organisations, during two meetings hosted by the European Centre for Disease Prevention and Control. A list of epidemiological risk factors placing patients “at-risk” for carriage with CRE was created by the experts. The conclusions of a systematic review on the prevention of spread of CRE, with the addition of expert opinion, were used to construct lists of core and supplemental infection prevention and control measures to be implemented for “at-risk” patients upon admission to healthcare settings.

Results

Individuals with the following profile are “at-risk” for carriage of CRE: a) a history of an overnight stay in a healthcare setting in the last 12 months, b) dialysis-dependent or cancer chemotherapy in the last 12 months, c) known previous carriage of CRE in the last 12 months and d) epidemiological linkage to a known carrier of a CRE.

Core infection prevention and control measures that should be considered for all patients in healthcare settings were compiled. Preliminary supplemental measures to be implemented for “at-risk” patients on admission are: pre-emptive isolation, active screening for CRE, and contact precautions. Patients who are confirmed positive for CRE will need additional supplemental measures.

Conclusions

Strengthening the microbiological capacity, surveillance and reporting of new cases of CRE in healthcare settings and countries is necessary to monitor the epidemiological situation so that, if necessary, the implemented CRE prevention strategies can be refined in a timely manner. Creating a large communication network to exchange this information would be helpful to understand the extent of the CRE reservoir and to prevent infections in healthcare settings, by applying the principles outlined here.

This guidance document offers suggestions for best practices, but is in no way prescriptive for all healthcare settings and all countries. Successful implementation will result if there is local commitment and accountability. The options for intervention can be adopted or adapted to local needs, depending on the availability of financial and structural resources.

Electronic supplementary material

The online version of this article (10.1186/s13756-017-0259-z) contains supplementary material, which is available to authorized users.

Hospitalizations among Danish SLE patients: a prospective study on incidence, causes of admission and risk factors in a population-based cohort

Objective To determine the incidence, duration and cause of hospitalization in a cohort of Danish patients with systemic lupus erythematosus (SLE). In addition, we investigated risk factors for admission and prolonged hospital stay. Methods A total of 155 SLE patients from a population-based cohort were included in the study during a period of 70 months, from January 2007 to October 2012. Data on frequency, cause and duration of hospitalizations were obtained by review of medical charts. Data on disease manifestations, organ damage and treatment were collected prospectively. Results A total of 101 of the 155 SLE patients (65%) had one or more hospitalization during the study period. The incidence rate of all hospitalizations was 0.50 per year. Leading causes of admission were complications to SLE or its treatment, but infections were also common. Mean duration of hospital stay was 6.4 ± 10.5 days, and SLE Disease Activity Index 2000 (SLEDAI-2K) on admission emerged as a risk factor for prolonged hospital stay. Conclusion Danish SLE patients experience frequent admissions to hospital. Complications to SLE or its treatment, as well as infections, are leading causes of admission. High SLEDAI-2K on admission is a risk factor for prolonged hospital stay.

The methodology of surveillance for antimicrobial resistance and healthcare-associated infections in Europe (SUSPIRE): a systematic review of publicly available information

OBJECTIVES

Surveillance is a key component of any control strategy for healthcare-associated infections (HAIs) and antimicrobial resistance (AMR), and public availability of methodologic aspects is crucial for the interpretation of the data. We sought to systematically review publicly available information for HAIs and/or AMR surveillance systems organized by public institutions or scientific societies in European countries.

METHODS

A systematic review of scientific and grey literature following the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines was performed. Information on HAIs and/or AMR surveillance systems published until 31 October 2016 were included.

RESULTS

A total of 112 surveillance systems were detected; 56 from 20 countries were finally included. Most exclusions were due to lack of publicly available information. Regarding AMR, the most frequent indicator was the proportion of resistant isolates (27 of 34 providing information, 79.42%); only 18 (52.9%) included incidence rates; the data were only laboratory based in 33 (78.5%) of the 42 providing this information. Regarding HAIs in intensive care units, all 22 of the systems providing data included central line-associated bloodstream infections, and 19 (86.3%) included ventilator-associated pneumonia and catheter-associated urinary tract infections; incidence density was the most frequent indicator. Regarding surgical site infections, the most frequent procedures included were hip prosthesis, colon surgery and caesarean section (21/22, 95.5%).

CONCLUSIONS

Publicly available information about the methods and indicators of the surveillance system is frequently lacking. Despite the efforts of European Centre for Disease Control and Prevention (ECDC) and other organizations, wide heterogeneity in procedures and indicators still exists.

Multivariate symbolic dynamics for analysis of respiratory-cardiovascular interactions

In this work, a nonlinear method to study multivariate interactions, called multivariate symbolic dynamics (MSD), was introduced. The usefulness of this technique was studied on respiratory-cardiovascular data from young women with vasovagal syncope (VVS) and from healthy subjects. The study included 16 female patients diagnosed with VVS and 24 age-matched healthy subjects (12 women). All subjects were enrolled in a head-up tilt (HUT) test, breathing normally, including 5 min of supine position and 18 to 28 min of 70° orthostatic phase. The MSD parameters were dynamically obtained for 5-min windows shifted by 1 min during HUT test. In supine position there were no considerable differences. During orthostatic phase, parameters from MSD showed a highly significantly (p=0.00005) increased occurrence of impaired respiratory-cardiovascular interactions in female patients susceptible to vasovagal syncope. This study provided promising results for a new multivariate method to investigate respiratory-cardiovascular interactions.

Neuronal desynchronization as marker of an impaired brain network

Synchronization is a central key feature of neural information processing and communication between different brain areas. Disturbance of oscillatory brain rhythms and decreased synchronization have been associated with different disorders including schizophrenia. The aim of this study was to investigate whether synchronization (in relaxed conditions with no stimuli) between different brain areas within the delta, theta, alpha (alpha1, alpha2), beta (beta1, beta2), and gamma bands is altered in patients with a neurological disorder in order to generate significant cortical enhancements. To achieve this, we investigated schizophrenic patients (SZO; N=17, 37.5±10.4 years, 15 males) and compared them to healthy subjects (CON; N=21, 36.7±13.4 years, 15 males) applying the phase locking value (PLV). We found significant differences between SZO and CON in different brain areas of the theta, alpha1, beta2 and gamma bands. These areas are related to the central and parietal lobes for the theta band, the parietal lobe for the alpha1, the parietal and frontal for the beta2 and the frontal-central for the gamma band. The gamma band revealed the most significant differences between CON and SZO. PLV were 61.7% higher on average in SZO in most of the clusters when compared to CON. The related brain areas are directly related to cognition skills which are proved to be impaired in SZO. The results of this study suggest that synchronization in SZO is also altered when the patients were not asked to perform a task that requires their cognitive skills (i.e., no stimuli are applied - in contrast to other findings).

Patient engagement with surgical site infection prevention: an expert panel perspective

Despite remarkable developments in the use of surgical techniques, ergonomic advancements in the operating room, and implementation of bundles, surgical site infections (SSIs) remain a substantial burden, associated with increased morbidity, mortality and healthcare costs. National and international recommendations to prevent SSIs have been published, including recent guidelines by the World Health Organization, but implementation into clinical practice remains an unresolved issue. SSI improvement programs require an integrative approach with measures taken during the pre-, intra- and postoperative care from the numerous stakeholders involved. The current SSI prevention strategies have focused mainly on the role of healthcare workers (HCWs) and procedure related risk factors. The importance and influence of patient participation is becoming an increasingly important concept and advocated as a means to improve patient safety. Novel interventions supporting an active participative role within SSI prevention programs have not been assessed. Empowering patients with information they require to engage in the process of SSI prevention could play a major role for the implementation of recommendations. Based on available scientific evidence, a panel of experts evaluated options for patient involvement in order to provide pragmatic recommendations for pre-, intra- and postoperative activities for the prevention of SSIs. Recommendations were based on existing guidelines and expert opinion. As a result, 9 recommendations for the surgical patient are presented here, including a practice brief in the form of a patient information leaflet. HCWs can use this information to educate patients and allow patient engagement.

Delta space plot analysis of cardiovascular coupling in vasovagal syncope during orthostatic challenge

In this work, a graphical method to study cardiovascular coupling, called delta space plot analysis (DSPA), was introduced. The graphical representation is susceptible to be parameterized in shape and orientation. The usefulness of this technique was studied on cardiovascular data from patients with vasovagal syncope (VVS) and from controls. The study included 15 female patients diagnosed with VVS and 11 age-matched healthy female subjects. All subjects were enrolled in a head-up tilt (HUT) test, breathing normally, including 5 minutes of supine position (baseline) and 18 minutes of 70° orthostatic phase. The DSPA parameters were obtained at different times during the HUT test, i.e., at baseline, early (first 5 min) and late (10-15 min) orthostatic phases. In baseline there were no considerable differences between female controls and female patients. During the late orthostatic phase, parameters from DSPA showed highly significantly (p=0.000003) reduced cardiovascular coupling in patients. Findings indicated a loss of control on cardiovascular coupling in female patients susceptible to vasovagal syncope during orthostatic challenge. In addition, this study provided promising results for a new graphical method to investigate cardiovascular coupling.