Adjuvant-dependent effects on the safety and efficacy of inactivated SARS-CoV-2 vaccines during heterologous infection by a SARS-related coronavirus

Inactivated whole virus SARS-CoV-2 vaccines adjuvanted with aluminum hydroxide (Alum) are among the most widely used COVID-19 vaccines globally and have been critical to the COVID-19 pandemic response. Although these vaccines are protective against homologous virus infection in healthy recipients, the emergence of novel SARS-CoV-2 variants and the presence of large zoonotic reservoirs provide significant opportunities for vaccine breakthrough, which raises the risk of adverse outcomes including vaccine-associated enhanced respiratory disease (VAERD). To evaluate this possibility, we tested the performance of an inactivated SARS-CoV-2 vaccine (iCoV2) in combination with Alum against either homologous or heterologous coronavirus challenge in a mouse model of coronavirus-induced pulmonary disease. Consistent with human results, iCoV2 + Alum protected against homologous challenge. However, challenge with a heterologous SARS-related coronavirus, Rs-SHC014-CoV (SHC014), up to at least 10 months post-vaccination, resulted in VAERD in iCoV2 + Alum-vaccinated animals, characterized by pulmonary eosinophilic infiltrates, enhanced pulmonary pathology, delayed viral clearance, and decreased pulmonary function. In contrast, vaccination with iCoV2 in combination with an alternative adjuvant (RIBI) did not induce VAERD and promoted enhanced SHC014 clearance. Further characterization of iCoV2 + Alum-induced immunity suggested that CD4+ T cells were a major driver of VAERD, and these responses were partially reversed by re-boosting with recombinant Spike protein + RIBI adjuvant. These results highlight potential risks associated with vaccine breakthrough in recipients of Alum-adjuvanted inactivated vaccines and provide important insights into factors affecting both the safety and efficacy of coronavirus vaccines in the face of heterologous virus infections.

Comparing post-traumatic stress severity in professional and volunteer Australian firefighters

BACKGROUND

While extensive research has highlighted increased risk for post-traumatic stress disorder (PTSD) in firefighters, previous research has yielded mixed results regarding the role of work status (professional versus volunteer) in the development of psychopathological symptoms.

AIMS

To explore the predictive strength of work status on PTSD or post-traumatic stress symptom severity in a large sample of professional (PFFs) and volunteer (VFFs) Australian firefighters exposed to operational work-related trauma.

METHODS

The stratified random sample comprised 1317 PFFs (n = 1148 (87%) males and 13%, n = 169 (13%) females) and 898 VFFs (n = 744 (83%) males and n = 154 (17%) females) who reported having experienced trauma while working or volunteering. Participants completed demographic, health and work-related questions and mental health measures of stress, trauma, PTSD, social support and use of mental health prevention programmes.

RESULTS

The results revealed a significant relationship between work status and PTSD, with PFFs reporting higher levels of PTSD symptom severity compared to VFFs. This association persisted after controlling for demographics, health, stress away from work, social support and use of organizational mental health support programmes (debriefing and face-to-face training for mental and physical self-care).

CONCLUSIONS

This study suggests the importance of work status in PTSD amongst Australian firefighters exposed to operational trauma. Future research is needed to substantiate our findings and examine why PFFs may be more prone to developing PTSD. Implications for the provision of mental health programmes offered by fire organizations to their members are discussed.

Volumetric response and pattern of failure of histone altered high grade glioma in adults following management with radiation therapy

PURPOSE

H3K27M- and H3G34R-mutant gliomas are recently-classified subgroups of high-grade gliomas (HGGs) affecting younger adults. This study aimed to describe patterns of infiltration and failure, and the volumetric response of these tumours to radiotherapy.

METHODS

Patients with histone-mutant gliomas aged 16-50 years, managed from 2009 to 2021 were identified and clinical, radiological and histopathological characteristics collected. Tumour volume was assessed on MRI at diagnosis, pre-radiotherapy, month + 1, + 3 and + 5 post-radiation and at relapse.

RESULTS

Of 538 IDH1/2 wild-type HGGs, 18(15%) had a histone alteration. Eleven were H3K27M- and 7 H3G34R-mutant respectively. Median age at diagnosis was 20 years (range17-48 years). Median overall survival was 20 months (95%CI 14-29 months). Both H3K27M- and H3G34R-mutant tumours exhibited extensive T2F infiltration involving a median of 4 neuroanatomical subsites at diagnosis. Median volume of disease pre-radiotherapy on T1gd and T2F respectively was 0.5cm³ (IQR:0-1.7cm³) and 11.9 cm³ (IQR:7.5-29.6cm³) for H3K27M and 0.9cm³ (IQR:0-8.4cm³) and 43.8cm³ (IQR:25.2-86.6 cm³) for H3G34R tumours. T2F volume reduction > 50% was observed 3-months post-IMRT in 7(64%) patients with H3K27M and 1(14%) with H3G34R tumours. Fourteen patients had relapsed. Relapse was local-only, distant-only and both in 4(44%), 3(33%) and 2(22%) H3K27M-mutant and 1(20%), 2(40%), and 2(40%) H3G34R-mutant tumours. On last scan before death, leptomeningeal spread was present in 4/8(50%) and 1/5(20%) and subependymal spread in 4/8 (50%) and 0/5 H3K27M- and G34R-mutant cases respectively.

CONCLUSION

H3K27M-mutant gliomas are highly responsive to radiotherapy but exhibit high propensity for subsequent leptomeningeal and subependymal spread. H3G34R-mutant tumours exhibit lesser early volumetric response to radiotherapy and propensity for distant in-brain failure.

In-person versus virtual administration of the American College of Radiology gold standard cognitive battery in systemic lupus erythematosus: Are they interchangeable?

OBJECTIVE

During the COVID-19 pandemic, many research studies were adapted, including our longitudinal study examining cognitive impairment (CI) in systemic lupus erythematosus (SLE). Cognitive testing was switched from in-person to virtual. This analysis aimed to determine if the administration method (in-person vs. virtual) of the ACR-neuropsychological battery (ACR-NB) affected participant cognitive performance and classification.

METHODS

Data from our multi-visit, SLE CI study included demographic, clinical, and psychiatric characteristics, and the modified ACR-NB. Three analyses were undertaken for cognitive performance: (1) all visits, (2) non-CI group visits only and (3) intra-individual comparisons. A retrospective preferences questionnaire was given to participants who completed the ACR-NB both in-person and virtually.

RESULTS

We analysed 328 SLE participants who had 801 visits (696 in-person and 105 virtual). Demographic, clinical, and psychiatric characteristics were comparable except for ethnicity, anxiety and disease-related damage. Across all three comparisons, six tests were consistently statistically significantly different. CI classification changed in 11/71 (15%) participants. 45% of participants preferred the virtual administration method and 33% preferred in-person.

CONCLUSIONS

Of the 19 tests in the ACR-NB, we identified one or more problems with eight (42%) tests when moving from in-person to virtual administration. As the use of virtual cognitive testing will likely increase, these issues need to be addressed - potentially by validating a virtual version of the ACR-NB. Until then, caution must be taken when directly comparing virtual to in-person test results. If future studies use a mixed administration approach, this should be accounted for during analysis.

Cohort profile: the ESC EURObservational Research Programme Non-ST-segment elevation myocardial infraction (NSTEMI) Registry

AIMS

The European Society of Cardiology (ESC) EURObservational Research Programme (EORP) Non-ST-segment elevation myocardial infarction (NSTEMI) Registry aims to identify international patterns in NSTEMI management in clinical practice and outcomes against the 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without ST-segment-elevation.

METHODS AND RESULTS

Consecutively hospitalised adult NSTEMI patients (n = 3620) were enrolled between 11 March 2019 and 6 March 2021, and individual patient data prospectively collected at 287 centres in 59 participating countries during a two-week enrolment period per centre. The registry collected data relating to baseline characteristics, major outcomes (in-hospital death, acute heart failure, cardiogenic shock, bleeding, stroke/transient ischaemic attack, and 30-day mortality) and guideline-recommended NSTEMI care interventions: electrocardiogram pre- or in-hospital, pre-hospitalization receipt of aspirin, echocardiography, coronary angiography, referral to cardiac rehabilitation, smoking cessation advice, dietary advice, and prescription on discharge of aspirin, P2Y12 inhibition, angiotensin converting enzyme inhibitor (ACEi)/angiotensin receptor blocker (ARB), beta-blocker, and statin.

CONCLUSION

The EORP NSTEMI Registry is an international, prospective registry of care and outcomes of patients treated for NSTEMI, which will provide unique insights into the contemporary management of hospitalised NSTEMI patients, compliance with ESC 2015 NSTEMI Guidelines, and identify potential barriers to optimal management of this common clinical presentation associated with significant morbidity and mortality.

Risks and treatment related aspects of COVID-19 infection in patients with ANCA-associated vasculitis

OBJECTIVE

Patients with anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) require immunosuppressive therapy for disease control and relapse prevention and may be at risk for severe coronavirus disease 2019 (COVID-19). The study objective was to analyse risk factors and outcomes of COVID-19 in well-characterized AAV patients.

METHOD

Data were retrieved from March 2020 to May 2021 from medical records of AAV cohorts in Stockholm and Uppsala, Sweden. COVID-19 was confirmed by positive PCR test or by ELISA. Severe COVID-19 was defined as need for non-invasive ventilation, intensive care unit care, and/or death. Age, gender, ANCA antibody type, ongoing immunosuppressive medication, and estimated glomerular filtration rate were recorded.

RESULTS

The cohort comprised 310 AAV patients, of whom 29 (9%) were diagnosed with COVID-19. Four deaths were attributed to COVID-19. Fifteen patients (52%) were on prednisolone in the COVID-19 group and 130 (46%) in the non-COVID group, with significantly higher doses in COVID-19 patients (p < 0.01). Ongoing induction therapy was more prevalent in the COVID-19 group (p < 0.01). Severe COVID-19 was diagnosed in 9/29 (31%). Significant risk factors for severe COVID-19 were impaired kidney function (p = 0.01) and more intense immunosuppressive therapy (p = 0.02), with a trend for age (p = 0.07). Maintenance therapy with rituximab was not associated with severe COVID-19.

CONCLUSIONS

Our findings highlight risks and suggest that more attention should be given to optimal AAV treatment in a pandemic situation. They also emphasize the need for continued shielding, mitigation strategies, and effective vaccination of AAV patients.

In Silico Finite Element Analysis of the Foot Ankle Complex Biomechanics: A Literature Review

Computational approaches, especially finite element analysis (FEA), have been rapidly growing in both academia and industry during the last few decades. FEA serves as a powerful and efficient approach for simulating real-life experiments, including industrial product development, machine design, and biomedical research, particularly in biomechanics and biomaterials. Accordingly, FEA has been a "go-to" high biofidelic software tool to simulate and quantify the biomechanics of the foot-ankle complex, as well as to predict the risk of foot and ankle injuries, which are one of the most common musculoskeletal injuries among physically active individuals. This paper provides a review of the in silico FEA of the foot-ankle complex. First, a brief history of computational modeling methods and finite element (FE) simulations for foot-ankle models is introduced. Second, a general approach to build an FE foot and ankle model is presented, including a detailed procedure to accurately construct, calibrate, verify, and validate an FE model in its appropriate simulation environment. Third, current applications, as well as future improvements of the foot and ankle FE models, especially in the biomedical field, are discussed. Finally, a conclusion is made on the efficiency and development of FEA as a computational approach in investigating the biomechanics of the foot-ankle complex. Overall, this review integrates insightful information for biomedical engineers, medical professionals, and researchers to conduct more accurate research on the foot-ankle FE models in the future.

P–314 Serum Stem Cell Factor as a predictor of top quality blasotcysts formation in women with endometriosis

Study question

To evaluate the correlation between the serum level of stem cell factor (s-SCF) during the stimulation and results of embryo culture.

Summary answer

The serum SCF concentration at the stimulation stage may be a potential predictor of IVF outcome in endometriosis patients.

What is known already

Stem cell factor (SCF) is a pleiotropic cytokine that affects the target cells via the c-kit receptor, a tyrosine kinase receptor. Recent evidence indicates that SCF and c-kit may play a role in regulation and growth of ovarian follicular function. It is unclear whether endometriosis primarily affects in vitro fertilization outcomes via oocyte quality. SCF is produced during the human follicular phase, immediately before the ovulatory phase, and may play an important role in folliculogenesis and in the mechanism of ovulation. It may reflect a successful stimulation with ample follicle maturation.

Study design, size, duration

This was a prospective case-control study and consisted four group of patients: 10 with endometriosis, 24 PCOs, 20 with normal (AMH 1.2–4.0 ng/ml) and 11 with lower (AMH&lt;1.2 ng/ml) ovary reserve who were undergoing IVF treatment with the assessment of serum SCF concentration between August 2019 and March 2020 at INVICTA Fertility Centre, Poland. The age of the patients ranged from 22 to 42 years (median 34 years).

Participants/materials, setting, methods

s-SCF was measured in duplicate by enzyme-linked immunosorbent assay (ELISA) kit in 195 serum samples collected during ovarian stimulation on days 1 and 8 and on the day of oocyte retrieval. We analysed correlation between s-SCF level and formation of top quality (TQ) blastocysts on day 5 formation in the study groups.

Main results and the role of chance

We have compared mean level of s-SCF within each group dividing the patients into two subgroups – those with at least one TQ blastocyst (TQ) on day 5 vs. those with no TQ blastocysts (no-TQ). There were no significant differences in mean s-SCF level on day 1 of stimulation between no-TQ and TQ patients in PCOs, normal and lower ovary reserve groups (41.1 pg/ml vs. 40.9 pg/ml; 34.8 pg/ml vs. 38.9 pg/ml and 32.3pg/ml vs. 28.7 pg/ml respectively). The mean level of s-SCF in endometriosis patients was higher in case of no-TQ compared to the TQ subgroup and were 41.1 pg/ml and 29.1 pg/ml respectively. Also no significant differences were also observed in the mean level of s-SCF in the no-TQ and TQ subgroups on the 8 day of stimulation and pick-up in PCOs, normal and lower ovary reserve patients. However, again in the case of endometriosis patients, the mean level of s-SCF was significantly lower on the 8 day of stimulation (28.1 pg/ml vs. 49.1 pg/ml; p &lt; 0.05) and pick-up day (33.4 pg/ml vs. 50.4 pg/ml; p &lt; 0.005) in samples from patients who had at least one TQ blastocysts on day 5 of culture.

Limitations, reasons for caution

More data are required to confirm the corelation of s-SCF level and presence of top quality blastocysts in patients with endometriosis.

Wider implications of the findings: Our study suggests that the level of serum SCF during ovarian stimulation in patients with endometriosis of less 30 pg/ml may potentially be a predictor for the chance of obtaining at least one top quality blastocyst on day 5 and thus a chance to successful treatment.

Trial registration number

Not applicable

Addressing low consumption of fruit and vegetables in England: a cost-effectiveness analysis

Background

Most adults do not meet the recommended intake of five portions per day of fruit and vegetables (F&V) in England, but economic analyses of structural policies to change diet are sparse. This study aimed to estimate (1) the health and economic burden attributable to the low intake of fruit and vegetables (F&V) by English adults, and (2) the cost-effectiveness of three policies promoting consumption of F&V in England - a universal 10% subsidy, a targeted 30% subsidy for low-income households, and a nationwide social marketing campaign (SMC).

Methods

Using published data from official statistics and meta-epidemiological studies, we estimated the deaths, years-of-life lost (YLL), and the healthcare costs attributable to consumption of F&V below the recommended five portions per day by English adults. Then, we estimated the cost-effectiveness from governmental and societal perspectives of three policies.

Results

Low consumption of F&V accounted for 16,321 [10,091-23,516] deaths and 238,767 [170,350-311,651] YLL due to cardiovascular diseases, type 2 diabetes and cancer in England in 2017, alongside £705,951 [398,761-1,061,559] million in healthcare costs. From a societal perspective, the incremental cost-effectiveness ratios were £22,891 [22,300-25,079], £16,860 [15,589-19,763], and £25,683 [25,237-28,671] per life-year saved for the universal subsidy, targeted subsidy and SMC, respectively. At a threshold of £20,000 per life-year saved, the likelihood that the universal subsidy, the targeted subsidy and the SMC were cost-effective was 84%, 19% and 5%, respectively. The targeted subsidy was the only policy that would also reduce inequalities.

Conclusions

Both a SMC and subsidies can significantly increase consumption of F&V and reduce the attributable burden of disease and healthcare costs, but their cost-effectiveness varies substantially. A targeted subsidy to low-income households is most likely cost-effective and can additionally reduce inequalities.

Key messages

Low intake of fruit and vegetables accounts for a substantial number of deaths and years of life lost and represents a heavy burden for the healthcare system in England. From a societal perspective, a targeted subsidy to low-income households was most likely cost-effective and it would reduce inequalities.

OP0010 EFFECTIVENESS OF THE MAKING IT WORK™ PROGRAM AT IMPROVING PRESENTEEISM AND WORK CESSATION IN WORKERS WITH INFLAMMATORY ARTHRITIS – RESULTS OF A RANDOMIZED CONTROLLED TRIAL

Background:

Arthritis often leads to presenteeism (decreased at-work productivity), missed days from work and permanent work disability, leading to reduced quality of life and high costs to individuals and society. Yet, health services addressing the employment needs of people with arthritis are lacking.

Objectives:

We evaluated the effectiveness of the Making-it-WorkTM(MiW) program, an online self-management program developed to help people with inflammatory arthritis (IA) deal with employment issues.

Methods:

A multi-center RCT evaluated the effectiveness of MiW at improving presenteeism and preventing work cessation (WC) over two years. Participants were recruited from rheumatologist practices, consumer organizations and arthritis programs, in three Canadian provinces. Eligibility criteria: diagnosis of IA, employed, age 18-59, and concerned about ability to work. Participants were randomized 1:1 to MiW or usual care plus printed material on workplace tips. MiW consists of five online self-learning modules and group meetings, and individual vocational counselling and ergonomic consultations. Questionnaires were administered every 6 months. Outcomes were presenteeism [Rheumatoid Arthritis Work Instability Scale (RA-WIS)], time to WC ≥ 6 months, and time to WC ≥ 2 months (secondary outcome). Baseline characteristics (age, gender, ethnicity, occupation, education, disease duration and self-employment) were collected. Intention-to-treat (ITT) longitudinal analysis of RA-WIS using linear mixed effect regression models with 2-year comparison as primary endpoint and survival analysis for time to WC using Kaplan-Meier and Cox Proportional Hazard models were performed. Robustness analyses were conducted by using various missing values imputation methods like last observation carried forward, imputation using worse possible outcomes and model-based multiple imputations; using square root transformation of RA-WIS outcome; and adjusting for baseline covariates. SAS version 9.4 was used.

Results:

A total of 564 participants were recruited, with 478 (84.75%) completing 2-year follow-up. Baseline characteristics were similar between groups. Mean RA-WIS scores were significantly lower in the intervention group from 6 months onwards, with the greatest difference observed at 2 years (-1.78, 95%CI: -2.7, -0.9, p < .0001), yielding a standardized effect size of 32%. Satisfactory robustness was observed. Work cessation occurred less often in intervention than control groups, but only reached statistical significance for WC ≥ 2 months (WC ≥ 6 months: 31 versus 44 events, aHR 0.70, 95%CI: 0.44, 1.11, p = 0.13; WC ≥ 2 months: 39 versus 61 events, aHR: 0.65, 95%CI: 0.43, 0.98, p = 0.04).

Conclusion:

Results of the RCT reveal the program was effective at improving presenteeism and preventing short-term WC. Effectiveness at preventing long-term work disability will be assessed at 5 years. This program fills one of the most important and costly unmet needs for people with inflammatory arthritis.

References:

[1]Carruthers EC, Rogers P, Backman CL, et al. “Employment and arthritis: making it work” a randomized controlled trial evaluating an online program to help people with inflammatory arthritis maintain employment (study protocol).BMC Med Inform Decis Mak. 2014;14:59. Published 2014 Jul 21. doi:10.1186/1472-6947-14-59

Disclosure of Interests:

Andre Luquini: None declared, Yufei Zheng: None declared, Hui Xie: None declared, Catherine Backman: None declared, Pamela Rogers: None declared, Alex Kwok: None declared, Astrid Knight: None declared, Monique Gignac: None declared, Dianne Mosher: None declared, Linda Li: None declared, John Esdaile: None declared, Carter Thorne Consultant of: Abbvie, Centocor, Janssen, Lilly, Medexus/Medac, Pfizer, Speakers bureau: Medexus/Medac, Diane Lacaille: None declared

THU0303 TREATMENT OF GIANT CELL ARTERITIS WITH TOCILIZUMAB IN CLINICAL PRACTICE IN SWEDEN

Background:

Giant cell arteritis (GCA) is the most common form of systemic vasculitis in adults. GCA is often associated with comorbidities related to the disease itself or caused by its treatment, here: mainly glucocorticosteroids. Since 2017, tocilizumab (TCZ) is approved for the treatment of GCA, but its uptake and treatment outcomes in clinical practice remain to be characterized.

Objectives:

To describe characteristics of GCA patients treated with tocilizumab (TCZ) in clinical practice, to evaluate the use of prednisolone up until and following TCZ treatment start, and to describe the TCZ treatment duration.

Methods:

We linked together the Swedish Rheumatology Quality Register (SRQ), the national Prescribed Drug register, and national Patient register, covering data from July 2009 until July 2019. Through these linkages, we identified GCA patients treated with TCZ including start and discontinuation, their comorbidities and use of other medications. TCZ treatment durations were evaluated through survival probability curves.

Results:

We identified 468 patients with GCA treated with TCZ, before and after its formal approval for GCA, Table 1. Over calendar time, the proportion who started TCZ as first ever bDMARD increased, as did the mean age at start of TCZ. The pattern of co-morbidities and health care utilisation demonstrated substantial burden from, e.g., diabetes and infections (Table). Patients starting treatment with TCZ were characterized by an increasing average dose of prednisolone during the last 1.5 years before TCZ start. Thereafter, prednisolone use declined substantially, from a mean of 15 mg/day in the six months before the start of TCZ to 6 mg/day 1 year after its start (Figure 1). Analysis of the duration of TCZ treatment (from start until discontinuation) suggested that at one year, two thirds of patients were still on treatment (Figure 2).

Table.

Swedish GCA patients starting treatment with tocilizumab July 2009 - Nov 2019.

July 2009 -July 2015July 2016 - July 2017July 2017 -July 2018July 2018 - Nov 2019Patients8914014099Female64%77%73%71%Age, mean (sd)67 (7.9)68 (8.8)69 (8)70 (7.8)Previous use of bDMARDs27%21%11%11%Hospitalisations most recent 5 years, mean (sd)3.9 (4.2)3.2 (2.6)2.9 (2.5)3.3 (3)Co-morbidities, most recent 5 years:Chronic obstructive pulmonary disease6%2%4%3%Ischemic heart disease12%7%14%11%Diabetes mellitus, type 1&234%26%26%26%Fractures (any location)15%14%11%10%Knee/hip replacement7%10%7%8%Myocardial infarction2%1%4%3%Stroke2%4%2%5%Hospitalisation listing infection39%40%39%37%Figure 1.

Average daily dose of prednisolone before and after* start of tocilizumab, based on cumulative dose every 6 months. *The average daily dose of prednisolone after the start of TCZ is calculated only among patients who were still on treatment at the end of each period (351 patients in the first 6 months, 251 in 6m-1y, 161 in 1 – 1.5 y, 95 in 1.5 – 2y).

Figure 2.

Kaplan-Meier curve for tocilizumab in GCA by time since treatment start.

Conclusion:

Patients treated with TCZ for GCA in clinical practice are characterized by a significant burden of co-morbidities, many of which may be related to prolonged use of glucocorticosteroids. This study confirms a marked reduction in the use of oral prednisolone following treatment with TCZ, and demonstrates that in a majority of patients in clinical practice, treatment with TCZ for GCA is extended beyond one year. Future analyses will evaluate the association of these observed treatment patterns with the level of GCA disease control, co-morbidities and quality of life, over time.

Acknowledgments:

These analyses was partly funded through an agreement between Roche and Karolinska Institutet.

Disclosure of Interests:

Daniela Di Giuseppe: None declared, Ann Knight: None declared, Aladdin J Mohammad Speakers bureau: lecture fees from Roche and Elli Lilly Sweden, PI (GiACTA study), Carl Turesson Grant/research support from: Unrestricted grant from Bristol-Myers Squibb, Consultant of: Roche, Speakers bureau: Abbvie, Bristol Myers-Squibb, Pfizer, Roche, Johan Askling Grant/research support from: JA acts or has acted as PI for agreements between Karolinska Institutet and the following entities, mainly in the context of the ARTIS national safety monitoring programme of immunomodulators in rheumatology: Abbvie, BMS, Eli Lilly, Merck, MSD, Pfizer, Roche, Samsung Bioepis, Sanofi, and UCB Pharma

Search for Electron Antineutrino Appearance in a Long-Baseline Muon Antineutrino Beam

Electron antineutrino appearance is measured by the T2K experiment in an accelerator-produced antineutrino beam, using additional neutrino beam operation to constrain parameters of the Pontecorvo-Maki-Nakagawa-Sakata (PMNS) mixing matrix. T2K observes 15 candidate electron antineutrino events with a background expectation of 9.3 events. Including information from the kinematic distribution of observed events, the hypothesis of no electron antineutrino appearance is disfavored with a significance of 2.40σ and no discrepancy between data and PMNS predictions is found. A complementary analysis that introduces an additional free parameter which allows non-PMNS values of electron neutrino and antineutrino appearance also finds no discrepancy between data and PMNS predictions.

Search for CP Violation in Neutrino and Antineutrino Oscillations by the T2K Experiment with 2.2×10^{21} Protons on Target

The T2K experiment measures muon neutrino disappearance and electron neutrino appearance in accelerator-produced neutrino and antineutrino beams. With an exposure of 14.7(7.6)×10^{20} protons on target in the neutrino (antineutrino) mode, 89 ν_{e} candidates and seven anti-ν_{e} candidates are observed, while 67.5 and 9.0 are expected for δ_{CP}=0 and normal mass ordering. The obtained 2σ confidence interval for the CP-violating phase, δ_{CP}, does not include the CP-conserving cases (δ_{CP}=0, π). The best-fit values of other parameters are sin^{2}θ_{23}=0.526_{-0.036}^{+0.032} and Δm_{32}^{2}=2.463_{-0.070}^{+0.071}×10^{-3}  eV^{2}/c^{4}.

Wastewater recycling in Antarctica: Performance assessment of an advanced water treatment plant in removing trace organic chemicals

The Australian Antarctic Division (AAD) operates Australia's Davis Station in the Antarctic. In 2005, Davis Station's wastewater treatment plant failed and since then untreated, macerated effluent has been discharged to the ocean. The objectives of this study were to determine whether an advanced water treatment plant (AWTP) commissioned by the AAD and featuring a multi-barrier process involving ozonation, ceramic microfiltration, biologically activated carbon filtration, reverse osmosis, ultraviolet disinfection and chlorination was capable of producing potable water and a non-toxic brine concentrate that can be discharged with minimal environmental impact. The AWTP was tested using water from a municipal wastewater treatment plant in Tasmania, Australia. We used spot water and passive sampling combined with two multi-residue chromatographic-mass spectrometric methods and a range of recombinant receptor-reporter gene bioassays to screen trace organic chemicals (TrOCs), toxicity and receptor activity in the Feed water, in the environmental discharge (reject water), and product water from the AWTP for six months during 2014-15, and then again for three months in 2016. Across the two surveys we unambiguously detected 109 different TrOCs in the feed water, 39 chemicals in the reject water, and 34 chemicals in the product water. Sample toxicity and receptor activity in the feed water samples was almost totally removed in both testing periods, confirming that the vast majority of the receptor active TrOCs were removed by the treatment process. All the NDMA entering the AWTP in the feed and/or produced in the plant (typically < 50 ng/L), was retained into the reject water with no NDMA observed in the product water. In conclusion, the AWTP was working to design, and releases of TrOCs at the concentrations observed in this study would be unlikely cause adverse effects on populations of aquatic organisms in the receiving environment or users of the potable product water.

Randomised controlled trial of early detection and cognitive therapy for preventing transition to psychosis in high-risk individuals

Background

There is interest in the possibility of indicated prevention of psychosis. There is a strong case for using psychological approaches to prevent transition to psychosis in high-risk patients.

Aims

To identify individuals at high risk of transition to psychosis, and psychological characteristics relevant to the development of psychosis in this group.

Method

The design of a randomised controlled trial of cognitive therapy for the prevention of psychosis in people at high risk (meeting operational criteria of brief or attenuated psychotic symptoms, or first-degree family history with functional decline) is outlined. The first patients recruited are compared with non-patient samples on cognitive and personality factors; an interim analysis of transition rate is reported.

Results

Cases (n=31) were recruited mainly from primary care. Of the 23 high-risk patients monitored for 6–12 months, 5 (22%) made the transition to psychosis. The high-risk group scored significantly higher than non-patients on measures of schizotypy, metacognitive beliefs and dysfunctional self-schemas (sociotropy).

Conclusions

The findings validate the methods of identifying individuals at high risk of experiencing a psychotic episode. Compared with non-patient controls, the cases showed dysfunctional metacognitive beliefs and self-schemas.

Combined Analysis of Neutrino and Antineutrino Oscillations at T2K

T2K reports its first results in the search for CP violation in neutrino oscillations using appearance and disappearance channels for neutrino- and antineutrino-mode beams. The data include all runs from January 2010 to May 2016 and comprise 7.482×10^{20} protons on target in neutrino mode, which yielded in the far detector 32 e-like and 135  μ-like events, and 7.471×10^{20} protons on target in antineutrino mode, which yielded 4 e-like and 66  μ-like events. Reactor measurements of sin^{2}2θ_{13} have been used as an additional constraint. The one-dimensional confidence interval at 90% for the phase δ_{CP} spans the range (-3.13, -0.39) for normal mass ordering. The CP conservation hypothesis (δ_{CP}=0, π) is excluded at 90% C.L.

Pentraxin 3 in serum and synovial fluid of patients with rheumatoid arthritis with and without autoantibodies

OBJECTIVES

Pentraxin 3 (PTX3) is a locally produced multifunctional protein involved in inflammation, matrix deposition, and immunity. As patients with seropositive rheumatoid arthritis (RA) have a more severe disease course and higher risk of joint destruction than seronegative patients, the aim of the present study was to examine differences in PTX3 in synovial fluid (SF) (and serum) in seropositive compared to seronegative RA, and other local markers of inflammation and destruction.

METHOD

Ninety-seven RA patients with knee effusion were included. Serum and SF levels of PTX3, as well as serum levels of anti-citrullinated protein antibody and rheumatoid factor of immunoglobulin A and M subclasses, and markers of inflammation and potential destruction in SF: white blood cell counts, tumour necrosis factor, interleukin-6, vascular endothelial growth factor, metalloproteinase 3, and cartilage oligomeric matrix protein, were analysed. In addition, a radiographic knee examination was performed.

RESULTS

Seropositive patients had significantly higher PTX3 levels in SF than seronegative patients, whereas there was no difference for serum levels. SF-PTX3 levels correlated with disease activity and with local inflammatory markers, especially polymorphonuclear cells, and with autoantibody levels. There was no correlation between PTX3 levels in serum and SF.

CONCLUSION

The correlation of disease activity and autoantibody levels with SF-PTX3 levels in antibody-positive patients suggests a role for PTX3 in the inflammatory process specifically in seropositive RA joints, and supports the hypothesis that seropositive and seronegative RA are different disease entities. Polymorphonuclear granulocytes may be an important source of PTX3 in RA SF.

Measurement of Coherent π^{+} Production in Low Energy Neutrino-Carbon Scattering

We report the first measurement of the flux-averaged cross section for charged current coherent π^{+} production on carbon for neutrino energies less than 1.5 GeV, and with a restriction on the final state phase space volume in the T2K near detector, ND280. Comparisons are made with predictions from the Rein-Sehgal coherent production model and the model by Alvarez-Ruso et al., the latter representing the first implementation of an instance of the new class of microscopic coherent models in a neutrino interaction Monte Carlo event generator. We observe a clear event excess above background, disagreeing with the null results reported by K2K and SciBooNE in a similar neutrino energy region. The measured flux-averaged cross sections are below those predicted by both the Rein-Sehgal and Alvarez-Ruso et al.

Measurement of Muon Antineutrino Oscillations with an Accelerator-Produced Off-Axis Beam

T2K reports its first measurements of the parameters governing the disappearance of ν[over ¯]_{μ} in an off-axis beam due to flavor change induced by neutrino oscillations. The quasimonochromatic ν[over ¯]_{μ} beam, produced with a peak energy of 0.6 GeV at J-PARC, is observed at the far detector Super-Kamiokande, 295 km away, where the ν[over ¯]_{μ} survival probability is expected to be minimal. Using a data set corresponding to 4.01×10^{20} protons on target, 34 fully contained μ-like events were observed. The best-fit oscillation parameters are sin^{2}(θ[over ¯]_{23})=0.45 and |Δm[over ¯]_{32}^{2}|=2.51×10^{-3}  eV^{2} with 68% confidence intervals of 0.38-0.64 and 2.26-2.80×10^{-3}  eV^{2}, respectively. These results are in agreement with existing antineutrino parameter measurements and also with the ν_{μ} disappearance parameters measured by T2K.

The illness experience of youth with lupus/mixed connective tissue disease: a mixed methods analysis of patient and parent perspectives

OBJECTIVE

We aimed to develop a model of the illness experience for youth with systemic lupus erythematosus (SLE)/mixed connective tissue disease (MCTD).

METHODS

We conducted 32 semi-structured interviews with 16 outpatient youth with SLE/MCTD, age 11 to 22 years, and their parents. We qualitatively defined key features of illness for families and distinguished profiles of youth adapting well vs poorly to SLE/MCTD. We then related these profiles to features of illness, patient-level attributes and outcomes.

RESULTS

Experiences with SLE/MCTD grouped into five themes: managing disease, limitations, stigma, illness uncertainty and psychological coping. Youth adapting well experienced minimal challenges in these areas. Youth adapting poorly (4/16) experienced significant challenges in >1 thematic area, and were older with lower socioeconomic status, quality of life and psychosocial functioning, and increased disease-related morbidity. They also described suboptimal treatment adherence, healthcare utilization and transition to adult care. These findings support a dynamic model in which illness adaptation and outcomes are shaped by patient characteristics and five central illness-related challenges.

CONCLUSION

Further testing of our model of illness experience may help guide comprehensive and personalized care of youth with SLE/MCTD, with targeted supports for youth at risk for negative adaptation to illness and poor outcomes.

The effect of carbohydrate mouth rinse on a 30-minute arm cranking performance

The aim of this study was to examine the effect of carbohydrate mouth rinse on 30-min arm cranking performance. Twelve healthy, active males (age 21.6, standard deviation (SD)=3.1 years; mass 76.2, SD=12.2 kg) volunteered in a single-blind, randomised crossover design. Firstly they completed an incremental exercise test to exhaustion (VO2max test) on an arm crank (50W for 2 min, increasing by 10W every min). During visit 2 and 3 they arm cranked for maximal distance over 30 min at a resistance equivalent to 50% of their peak power, mouth rinsing for 5 s with either 25 ml of a tasteless 6.4% maltodextrin solution (CHO) or 25 ml of water (placebo) every 6 min. A letter cancellation test was performed pre and post exercise to measure cognitive function. The result showed that cognitive function was not significantly different between trials (P=0.874). There was no significant difference in distance arm cranked between trials (P=0.164) even though 9 out of 12 participants had improved performance on the CHO trial. In conclusion, further research is needed to determine the ergogenic effect of CHO mouth rinsing on upper body exercise performance.

Late-onset neutropenia after rituximab in ANCA-associated vasculitis

BACKGROUND

Rituximab (RTX) is being used increasingly in anti-neutrophil cytoplasmatic antibody (ANCA)-associated vasculitis (AAV). Late-onset neutropenia (LON) and risks of infections have been observed following RTX therapy in rheumatological diseases including granulomatosis with polyangiitis (GPA) but data on microscopic polyangiitis (MPA) are lacking.

METHOD

We studied the occurrence of LON in 59 AAV (47 GPA/12 MPA) patients treated with RTX. Patient charts were retrospectively reviewed for the occurrence of LON and clinical data were extracted and included in the analysis.

RESULTS

Seven of the total 59 patients (11.9%) developed LON after a median time of 86 days (range 56-168 days) since their latest RTX treatment. Of these seven LON patients, 5/47 (10.6%) had a diagnosis of GPA and 2/12 (16.7%) of MPA. Three of the patients developed LON after the first RTX treatment and four had received repeated courses. Five LON patients developed infectious symptoms. Six of the patients were hospitalized. Retreatment with RTX was given in three cases without further LON episodes.

CONCLUSIONS

LON is a potentially severe side-effect of RTX occurring in both GPA and MPA and may develop after both single and repeated treatment courses. As infections are commonly seen, the condition requires an increased awareness. No predisposing factors for LON were identified.

Lifetime Physical Activity and Breast Cancer: a Case-Control Study in Kelantan, Malaysia

BACKGROUND

Physical inactivity has been identified as the fourth leading risk factor for global mortality and is associated with increased breast cancer diagnosis and recurrence.

PURPOSE

To examine the association between adult lifetime physical activity and breast cancer risk in a case-control analysis.

MATERIALS AND METHODS

This study involved 122 cases of breast cancer and 121 controls in the state of Kelantan in Malaysia. A comprehensive measure of lifetime physical activity was used to assess occupational, household, and recreational/sports activity. For every type of activity, a metabolic equivalent (MET) score was assigned using the compendium of physical activities. MET-hours/week per year for all types of activities at different levels of intensities for different age groups were calculated. Logistic regression analysis was used to estimate odds ratios between various measures of physical activity and breast cancer risk.

CONCLUSIONS

The mean MET-hours/week per year for all activities were 120.0 and 132.9 of MET-hours/week per year for cases and controls respectively. Household activities accounted for about 70% of the total lifetime physical activities. Only about 2.5% of the total lifetime physical activities were in the form of recreational/sports. This study found no association between lifetime occupational and recreational/sports physical activities with breast cancer risk among Kelantanese women. However, higher intensity lifetime household activities seemed to significantly reduce risk of breast cancer.

What drives junior doctors to use clinical practice guidelines? A national cross-sectional survey of foundation doctors in England & Wales

BACKGROUND

Clinical practice guidelines (CPGs) aim to improve patient care, but their use remains variable. We explored attitudes that influence CPG use amongst newly qualified doctors.

METHODS

A self-completed, anonymous questionnaire was sent to all Foundation Doctors in England and Wales between December 2012 and May 2013. We included questions designed to measure the 11 domains of the validated Theoretical Domains Framework (TDF). We correlated these responses to questions assessing current and future intention to use CPGs.

RESULTS

A total of 13,138 doctors were invited of which 1693 [corrected] (13 %) responded. 1,035 (62.5 %) reported regular CPG use with 575 (34.4 %) applying CPGs 2-3 times per week. A significant minority of 606 (36.6 %) declared an inability to critically appraise evidence. Despite efforts to design a questionnaire that captured the domains of the TDF, the domain scales created had low internal reliability. Using previously published studies and input from an expert statistical group, an alternative model was sought using exploratory factor analysis. Five alternative domains were identified. These were judged to represent: "confidence", "familiarity", "commitment and duty", "time" and "perceived benefits". Using regression analyses, the first three were noted as consistent predictors of both current and future intentions to use CPGs in decreasing strength order.

CONCLUSIONS

In this large survey of newly qualified doctors, "confidence", "familiarity" and "commitment and duty" were identified as domains that influence use of CPGs in frontline practice. Additionally, a significant minority were not confident in critically appraising evidence. Our findings suggest a number of approaches that may be taken to improve junior doctors' commitment to CPGs through processes that increase their confidence and familiarity in using CPGs. Despite limitations of a self-reported survey and potential non-response bias, these findings are from a large representative sample and a review of existing implementation strategies may be warranted based on these findings.

Access to oncology consultation in a cancer cohort in northeastern Ontario

BACKGROUND

To enhance cancer symptom management for residents of Sudbury-Manitoulin District, an ambulatory palliative clinic (pac) was established at the Northeast Cancer Centre of Health Sciences North. The pac is accessed from a medical or radiation oncology consultation. The primary purpose of the present population-based retrospective study was to estimate the percentage of cancer patients who died without ever having a medical or radiation oncology consultation. A secondary purpose was to determine factors associated with never having received one of those specialized consultations.

METHODS

Administrative data was obtained through the Ontario Cancer Data Linkage Project. For each index case, we constructed a timeline, in days, of all Ontario Health Insurance Plan billing codes and associated service dates starting with the primary cancer diagnosis and ending with death.

RESULTS

Within the 5-year study period (2004-2008), 6683 people in the area of interest with a valid record of primary cancer diagnosis died from any cause. Most (n = 5988, 89.6%) had 1 primary cancer diagnosis. For that subgroup, excluding those with a disease duration of 0 days (n = 67), about 18.4% (n = 1088) never had a consultation with a medical or radiation oncologist throughout their disease trajectory. Patients who were older or who resided in a rural area were significantly less likely to have had a consultation.

CONCLUSIONS

Specific strategies directed toward older and rural patients might help to address this important access-to-care issue.

Efficacy and safety of rituximab as maintenance therapy for relapsing granulomatosis with polyangiitis—a case series

The objective of this work was to study the efficacy and safety of pre-emptive rituximab (RTX) in a series of patients with severe relapsing granulomatosis with polyangiitis (GPA). GPA is a systemic vasculitis with a high relapse rate despite successful remission induction. Drug toxicity with repeated induction treatments and long-standing immunosuppression poses a problem. Based on the findings in reports on RTX for rheumatoid arthritis, we treated patients with severe relapsing GPA with pre-emptive RTX, 1,000 mg 2 weeks apart every 6 months, aiming at achieving sustainable remission. All patients at one centre with relapsing GPA in spite of traditional maintenance treatment, who had received more than or equal to three cycles of RTX as regularly repeated pre-emptive maintenance therapy every 6 months, were included in this retrospective study. Information on disease manifestations and activity, treatments, lab parameters and adverse events was extracted from the medical files. Of the 12 included patients, all with a positive proteinase 3–anti-neutrophil cytoplasmic antibodies, generalised disease and a median disease duration of 35 months (21–270), 92 % (11/12) achieved sustainable remission during a median follow-up time of 32 months (range 21–111) from first RTX treatment. Concomitant immunosuppressants were reduced. Infections were the most common adverse events, but infections were an issue also before the start of RTX. RTX administered every 6 months seems to be an effective maintenance treatment in a population with severe, relapsing long-standing GPA. Granulomatous as well as vasculitic manifestations responded equally well. Infections are a problem in this patient group but no new safety problems were identified.

The relationship between socio-economic status and access to eye health services in the UK: a systematic review

OBJECTIVES

Lower socio-economic status has been shown to adversely affect access to general health care. This study aims to determine the existence and nature of an association between socio-economic status and access to eye health services in the UK.

STUDY DESIGN

Systematic review.

METHODS

Search terms were run in four databases and reviewed against a pre-agreed set of inclusion and exclusion criteria by two independent reviewers. Quality of studies was assessed according to calculations of statistical significance, size of effect, primary research question and a quality score against an adapted STROBE checklist.

RESULTS

Good quality studies included in the review most commonly concluded that lower socio-economic groups had less access to eye health services than higher socio-economic groups. However there were a comparable number of studies that concluded that there was no association. This discrepancy was largely attributed to different ways of measuring socio-economic status, access, and types of eye health services, and so studies did not compare the same thing. The evidence base was of low quality, limiting the ability of this review to make definitive conclusions.

CONCLUSIONS

The review concluded that there is equal and weak evidence of lower socio-economic groups having reduced access to eye health services in the UK, and there being no association. This subject would benefit from further research to improve the quality of the evidence base.

Impact of early incentive spirometry in an enhanced recovery program after laparoscopic donor nephrectomy

BACKGROUND

This study aimed to assess the impact of early incentive spirometry on the incidence of chest infection in patients undergoing laparoscopic donor nephrectomy.

METHODS

A retrospective review on all consecutive laparoscopic donor nephrectomies (LDN) performed at a single institution from January 2008 to August 2012 was performed. We performed 84 LDN. Seventy patients had epidural analgesia continued for 48 hours postoperatively and 14 had a combination of spinal followed by oral analgesia. Incentive spirometry was introduced from July 2010 and 45 of the 84 donors used the spirometer as taught, both pre- and postoperatively.

RESULTS

We performed 84 LDN; 39 patients did not receive incentive spirometers and had postoperative chest physiotherapy started on postoperative day 1. Of the 45 patients given incentive spirometers, 44 started using their spirometers as taught, after recovery once they were settled in the ward, 1 patient started the exercises the following day. In the group who received no spirometer, 5 patients had a chest infection. In the group of patients who started using their spirometers in the early perioperative period (44/45), no patient developed a chest infection. One patient in this group was excluded from the analysis because he started spirometer exercises on postoperative day 1. This patient did develop a chest infection.

CONCLUSIONS

Our results suggest that early introduction of incentive spirometry after LDN significantly reduces the incidence of chest infection (P < .05); however, this benefit may be lost if the introduction of spirometry is delayed.

Development and testing of models of tuberculosis contact tracing in rural southern Africa

SETTING

A regional hospital in rural Swaziland.

OBJECTIVES

To evaluate a hospital-based contact screening programme and test approaches to improve its effectiveness.

DESIGN

An evaluation and quality improvement study of tuberculosis (TB) contact tracing services.

RESULTS

Hospital-based TB contact tracing led to screening of 157 (24%) of 658 contacts; of these, 4 (2.5%) were diagnosed with TB. Of 68 contacts eligible for human immunodeficiency virus (HIV) testing and counselling, 45 (66%) were tested and 7/45 (16%) were identified as HIV-positive. Twelve (50%) of 24 screened contacts aged <5 years were provided isoniazid prophylaxis. Three enhanced models of TB contact tracing were piloted to screen contacts in the community. Although some enhanced models screened large numbers of contacts, no contacts were diagnosed with TB.

CONCLUSION

Contact tracing of household members conducted in TB clinics within hospital settings is effective in high-burden, low-income settings, and can be provided using current resources. Enhanced household contact tracing models that followed up contacts in the community were not found to be effective. Additional resources would be required to provide household TB contact tracing in the community.

Well-being: its influence and local impact on public health

OBJECTIVES

To explore the emergence of the concept of well-being and examine its influences on the modernization of the public health structure at the local level.

STUDY DESIGN

The article applies a theoretical and policy orientated approach.

METHODS

The article assesses the concept of well-being and applies its uses to local policy and practice.

RESULTS

The concept of well-being has implications for the development of local public health structures, policy making and delivery.

CONCLUSIONS

In terms of local policy making, it enables public health professionals to develop locally based concepts and uses of well-being, engage communities, make links to social capital and consider wider determinants within them. In terms of delivery, it focuses attention on the need for collaboration between local statutory and voluntary organizations in applying local concepts of well-being to public health policy; and engaging with healthcare interventions grounded within local context and needs.

Social media use by orthodontic patients

Internet-based social media sites have recently surged in popularity and are often used to share thoughts and seek support about health issues.

OBJECTIVES

The aim of this study was to investigate how orthodontic patients use Internet-based social media sites to share their treatment-related experiences and attitudes towards braces. A secondary objective was to investigate whether an online or mobile application would be considered helpful in improving co-operation with the use of orthodontic appliances.

METHOD

Patients visiting the orthodontic clinic at the University of Otago were asked to participate in a cross-sectional survey that sought details of their Internet-based social media use and their thoughts about the development of a reminder application.

RESULTS

The sample comprised 130 orthodontic patients, with a mean age of 17.2 (SD 6.9) and a nearly equal sex distribution (52.3% were female). Internet-based social media sites were used by 80.8%, with Facebook being the most popular. Some 13.3% of the sample had posted comments about braces on these social media sites. Only 6.7% had considered obtaining information about orthodontic treatment from Internet-based social media sites, with the majority (81%) preferring to seek this information directly from their orthodontist. Nearly two-thirds of those who had difficulty remembering to wear their orthodontic appliances reported that a reminder application on their phone would be beneficial.

CONCLUSIONS

A large proportion of orthodontic patients use Internet-based social media sites, although only a few currently use them to post about treatment-related topics. Social media sites may provide a useful channel of communication for patients seeking support. Further research is needed to evaluate the use of phone reminder applications in orthodontics.