Leveraging inter-individual transcriptional correlation structure to infer discrete signaling mechanisms across metabolic tissues

Inter-organ communication is a vital process to maintain physiologic homeostasis, and its dysregulation contributes to many human diseases. Beginning with the discovery of insulin over a century ago, characterization of molecules responsible for signal between tissues has required careful and elegant experimentation where these observations have been integral to deciphering physiology and disease. Given that circulating bioactive factors are stable in serum, occur naturally, and are easily assayed from blood, they present obvious focal molecules for therapeutic intervention and biomarker development. For example, physiologic dissection of the actions of soluble proteins such as proprotein convertase subtilisin/kexin type 9 (PCSK9) and glucagon-like peptide 1 (GLP1) have yielded among the most promising therapeutics to treat cardiovascular disease and obesity, respectively1–4. A major obstacle in the characterization of such soluble factors is that defining their tissues and pathways of action requires extensive experimental testing in cells and animal models. Recently, studies have shown that secreted proteins mediating inter-tissue signaling could be identified by “brute-force” surveys of all genes within RNA-sequencing measures across tissues within a population5–9. Expanding on this intuition, we reasoned that parallel strategies could be used to understand how individual genes mediate signaling across metabolic tissues through correlative analyses of gene variation between individuals. Thus, comparison of quantitative levels of gene expression relationships between organs in a population could aid in understanding cross-organ signaling. Here, we surveyed gene-gene correlation structure across 18 metabolic tissues in 310 human individuals and 7 tissues in 103 diverse strains of mice fed a normal chow or HFHS diet. Variation of genes such asFGF21, ADIPOQ, GCGandIL6showed enrichments which recapitulate experimental observations. Further, similar analyses were applied to explore both within-tissue signaling mechanisms (liverPCSK9) as well as genes encoding enzymes producing metabolites (adiposePNPLA2), where inter-individual correlation structure aligned with known roles for these critical metabolic pathways. Examination of sex hormone receptor correlations in mice highlighted the difference of tissue-specific variation in relationships with metabolic traits. We refer to this resource asGene-DerivedCorrelationsAcrossTissues (GD-CAT) where all tools and data are built into a web portal enabling users to perform these analyses without a single line of code (gdcat.org). This resource enables querying of any gene in any tissue to find correlated patterns of genes, cell types, pathways and network architectures across metabolic organs.

Predictors of British Isles Lupus Assessment Group-based outcomes in patients with systemic lupus erythematosus: Analysis from the Systemic Lupus International Collaborating Clinics Inception Cohort

BACKGROUND

We aimed to identify factors associated with a significant reduction in SLE disease activity over 12 months assessed by the BILAG Index.

METHODS

In an international SLE cohort, we studied patients from their 'inception enrolment' visit. We also defined an 'active disease' cohort of patients who had active disease similar to that needed for enrolment into clinical trials. Outcomes at 12 months were; Major Clinical Response (MCR: reduction to classic BILAG C in all domains, steroid dose of ≤7.5 mg and SLEDAI ≤ 4) and 'Improvement' (reduction to ≤1B score in previously active organs; no new BILAG A/B; stable or reduced steroid dose; no increase in SLEDAI). Univariate and multivariate logistic regression with Least Absolute Shrinkage and Selection Operator (LASSO) and cross-validation in randomly split samples were used to build prediction models.

RESULTS

'Inception enrolment' (n = 1492) and 'active disease' (n = 924) patients were studied. Models for MCR performed well (ROC AUC = .777 and .732 in the inception enrolment and active disease cohorts, respectively). Models for Improvement performed poorly (ROC AUC = .574 in the active disease cohort). MCR in both cohorts was associated with anti-malarial use and inversely associated with active disease at baseline (BILAG or SLEDAI) scores, BILAG haematological A/B scores, higher steroid dose and immunosuppressive use.

CONCLUSION

Baseline predictors of response in SLE can help identify patients in clinic who are less likely to respond to standard therapy. They are also important as stratification factors when designing clinical trials in order to better standardize overall usual care response rates.

Genetic architecture of heart mitochondrial proteome influencing cardiac hypertrophy

Mitochondria play an important role in both normal heart function and disease etiology. We report analysis of common genetic variations contributing to mitochondrial and heart functions using an integrative proteomics approach in a panel of inbred mouse strains called the Hybrid Mouse Diversity Panel (HMDP). We performed a whole heart proteome study in the HMDP (72 strains, n=2-3 mice) and retrieved 848 mitochondrial proteins (quantified in ≥50 strains). High-resolution association mapping on their relative abundance levels revealed three trans-acting genetic loci on chromosomes (chr) 7, 13 and 17 that regulate distinct classes of mitochondrial proteins as well as cardiac hypertrophy. DAVID enrichment analyses of genes regulated by each of the loci revealed that the chr13 locus was highly enriched for complex-I proteins (24 proteins, P=2.2E-61), the chr17 locus for mitochondrial ribonucleoprotein complex (17 proteins, P=3.1E-25) and the chr7 locus for ubiquinone biosynthesis (3 proteins, P=6.9E-05). Follow-up high resolution regional mapping identified NDUFS4, LRPPRC and COQ7 as the candidate genes for chr13, chr17 and chr7 loci, respectively, and both experimental and statistical analyses supported their causal roles. Furthermore, a large cohort of Diversity Outbred mice was used to corroborate Lrpprc gene as a driver of mitochondrial DNA (mtDNA)-encoded gene regulation, and to show that the chr17 locus is specific to heart. Variations in all three loci were associated with heart mass in at least one of two independent heart stress models, namely, isoproterenol-induced heart failure and diet-induced obesity. These findings suggest that common variations in certain mitochondrial proteins can act in trans to influence tissue-specific mitochondrial functions and contribute to heart hypertrophy, elucidating mechanisms that may underlie genetic susceptibility to heart failure in human populations.

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.

A111 CLINICAL AND PATHOLOGICAL OUTCOMES BETWEEN WATER EXCHANGE AND AIR INSUFFLATION USING NON-SEDATED EXTENDED FLEXIBLE SIGMOIDOSCOPY FOR AVERAGE RISK COLORECTAL CANCER SCREENING: PRELIMINARY FINDINGS FROM A RANDOMIZED CONTROL TRIAL

Background

Colorectal cancer (CRC) is Canada's third most common cancer type and represents approximately 11% of all cancer deaths. While sedated colonoscopy or flexible sigmoidoscopy (FS) continues to be considered for CRC screening, these modalities have limitations and risks. Another unevaluated screening modality, known as an extended FS (EFS), attempts to capitalize on the benefits of a FS while minimizing the risks involved with a sedated colonoscopy. EFS provides a scope-based examination up to the splenic flexure and then attempts to examine beyond, often to the point of the caecum. Providing the option for EFS may produce improvements in the patient experience and performance, which may improve the feasibility of using scope-based screening more broadly in screening programs.

Purpose

To determine the extent non-sedated EFS using the water exchange method (WE) is associated with a complete colon examination compared to the traditional air insufflation (AI) method using CO2 in an average-risk screening population.

Method

This randomized control trial included 90 non-sedated participants, screened by trained general surgery and gastroenterology clinicians at Kelowna General Hospital, British Columbia, Canada, using two different scope insufflation techniques, WE and AI. The primary outcome of interest was the cecal intubation rates (CIR), while secondary outcomes included the adenoma detection rate (ADR) and reported pain scores. Other metrics, such as patient satisfaction rates, sessile serrated adenoma detection rates (SSADR), and serrated lesion detection rates (SLDR) were also recorded.

Result(s)

The demographic characteristics between the WE and AI groups were statistically similar, with the mean age of participants being 58 and 57, respectively. During the study period, four endoscopists performed the EFS. There were higher initial satisfaction rates in the WE group vs the AI (95% vs 77%, satisfaction of ≥ 9/10 p = 0.028). CIR and ADR were similar between the WE and AI group (CIR = 93% vs 91%, p = 0.710), (ADR = 40% vs 34%, p = 0.660). The SSADR and SLDR were also similar between the WE and AI group (SSADR = 21% vs 14%, p = 0.408), (SLDR = 42% vs 36%, p = 0.528).

Conclusion(s)

EFS without sedation using either technique exceeds quality benchmarks recommended for sedated screening colonoscopy while maintaining adequate patient safety and comfort. The WE method optimizes a patient's overall experience making a strategy of average risk colorectal cancer screening with non-sedated WE EFS feasible.

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Kelowna General Hospital, Interior Health

Disclosure of Interest

None Declared

AB0513 COVID-19 PREVENTION IN PATIENTS WITH MODERATE-TO-SEVERE LUPUS DURING THE PANDEMIC: RESULTS FROM THE BILAG-BIOLOGICS REGISTER (BILAG-BR)

Background

There have been concerns over the susceptibility of SLE patients to severe COVID-19 illness since the beginning of the pandemic, and many patients were assigned ‘clinically extremely vulnerable’ according to the UK’s shielding guidance issued in March 2020. Here we report on vaccination and shielding behaviours of a moderate-to-severe SLE cohort with high immunosuppressant burden.

Objectives

To review the shielding behaviours, and the safety and tolerability of COVID-19 vaccines in a real-world cohort of patients with moderate to severe SLE.

Methods

The British Isles Lupus Assessment Group Biologics Registry (BILAG-BR) is a national prospective registry of lupus patients from the UK (2010-21). Patients from the BILAG-BR were invited to complete a paper or online questionnaire which consisted of 17 questions to assess their self-reported shielding behaviour, vaccination status, and any adverse responses following COVID-19 vaccination. Questionnaires were completed between 9th Oct 2021 and 7th Jan 2022. Responses were linked with data collected in the BILAG-BR.

Results

Data were collected from the first 202/1268 patients (186 [92.1%] women) to respond, with a median age of 51 (IQR 38-61) years from 37 UK centres. The majority of patients were Caucasian (78.1%, 150/192). Previous therapy included rituximab (165, 81.7%), belimumab (33, 16.3%) and cyclophosphamide (54, 26.7%). In the past 12 months, over two thirds of patients (138, 68.3%) had received oral prednisolone (current dose median 5mg [IQR 5-8mg, range 2-40mg] daily), and almost a third had received parental steroids (60, 29.7%).

Shielding was reported in the first national lockdown (March-June 2020) by 93.6% (189/202) of patients, and of those in employment at the time, over half (58/100) were unable to work from home. The vast majority of patients complied with the UK government guidance (97.0%, 196/202) and did not socialise with other households indoors during this time period. Fifty-four percent of patients (109/202) reported attending a hospital or GP appointment during the first lockdown, and 24/202 (11.9%) reported regular appointments. During the first lockdown, 13/109 (11.9%) patients reported receiving rituximab infusions and 9/109 (8.3%) belimumab infusions.

Ninety-seven percent (196/202) had received at least 1 COVID-19 vaccination (Oxford AstraZeneca 95/146, 65.1%; Pfizer/ BioNtech 50/146, 34.3%). Approximately half of patients (54.2%, 104/192) reported an adverse reaction to the vaccine (both vaccine doses in 45 (23.9%) patients). The majority of these included lethargy/ flu-like symptoms (82, 78.8%) or local site reactions (32, 30.8%). Six (3.0%) patients reported a lupus flare and 3 (1.5%) patients reported a hospital attendance due to vaccine side effects.

Conclusion

In this cohort of moderate-to-severe SLE patients there was strong engagement with UK shielding guidance, however only half of patients attended a GP or hospital appointment during the earliest peak of the pandemic, highlighting disruptions to routine clinical care. There was high uptake of COVID-19 vaccination, which whilst generally well tolerated in this cohort, may be temporally associated with a flare, albeit in only a small number of patients. We recognise it may be difficult to distinguish between vaccine adverse events and lupus flares in patients with SLE, therefore this may be an overestimation. Of note, three patients reported a hospital attendance post-vaccination which warrants further investigation.

Acknowledgements

Submitted on behalf of the BILAG-biologics register

Disclosure of Interests

Sarah Dyball Grant/research support from: UCB and Eli Lilly, Mia Rodziewicz Grant/research support from: UCB, Emily Sutton: None declared, Ben Parker Speakers bureau: Eli Lilly and Roche, Consultant of: Fresenius-Kabi and AbbVie, Grant/research support from: Genzyme/Sanofi and GSK, Ian N. Bruce Speakers bureau: AstraZeneca, GSK and UCB, Consultant of: AstraZeneca, Eli Lilly, GSK, Merck Serono, UCB and ILTOO, Grant/research support from: Genzyme/Sanofi, GSK, Roche and UCB

POS0756 DETERMINANTS OF HEALTH-RELATED QUALITY OF LIFE (HR-QoL) ACROSS THE SPECTRUM OF SYSTEMIC AUTOIMMUNE RHEUMATIC DISEASES: RESULTS FROM THE LEAP COHORT

Background

Poor health-related quality of life (HR-QoL) is recognised in patients with established connective tissue diseases (CTDs), however it is not clear how it affects patients with undifferentiated CTD (UCTD) which has traditionally been associated with a mild or more benign profile.

Objectives

To investigate HR-QoL in patients affected with a variety of CTDs (including UCTD) using the SF-36 questionnaire; and secondly, to review demographic and clinical factors predictive of a poor HR-QoL

Methods

The Lupus Extended Autoimmune Phenotype (LEAP) cohort is a multicentre prospective study of patients with a CTD. Rheumatologist diagnosis was used to classify patients into four groups: systemic lupus erythematosus (SLE), primary Sjögren’s syndrome (pSS), UCTD, and (combined because of low numbers) those with an idiopathic inflammatory myopathy (IIM), systemic sclerosis (SSc) or overlap syndrome. The SF-36 quality of life questionnaire was completed at enrolment and includes eight domains: physical function (PF), role physical (RP), bodily pain (BP), general health (GH), vitality (VT), social functioning (SF), role emotional (RE) and mental health (MH) which range from 0 to 100, with higher scores reflecting better HR-QoL. Physical (PCS) and mental component score (MCS) were calculated for each group, with a score below 50 representing a worse HR-QoL compared to the general UK population. Predictors for poor HR-QoL was chosen a priori, then tested using linear regression adjusted for age, gender and ethnicity. All statistical analysis was performed using STATA v14, with results expressed as beta coefficients with 95% confidence intervals (95%CI).

Results

Data were collected from 309 patients (280 [90.6%] women, with a mean [SD] age of 48.9 [12.9] years) from three UK rheumatology centres. The majority of patients were Caucasian (n=235, 76.1%). By rheumatologist diagnosis, 115 (37.2%) had SLE, 56 (18.1%) pSS, 72 (23.3%) UCTD and 66 (21.4%) SSc, IIM or an overlap syndrome. Patients with UCTD, pSS and SSc/IIM spectrum disorders had a shorter median disease duration (3.8, 3.7 and 6.1 years respectively) compared with patients with those with SLE (11.0 years), p<0.001. Previous steroid and immunosuppressant use was highest in patients with SLE and SSc/IIM spectrum disorders (p<0.001). The most affected domains include VT, GH and BP (Figure 1), and the PCS is more impaired compared with the MCS, with similar scores across disease groups. Agnostic of disease group, factors associated with a lower PCS include increasing age (beta -0.15 [95%CI -0.26, -0.06], p=0.008), prednisolone use (-3.1 [-6.05, -0.19], p=0.037), c-reactive protein (-0.09 [-0.62, -0.10], p=0.007), fatigue (-2.00 [-3.79, -0.22], p=0.028), and sicca syndrome (-4.70 [-7.66, -1.74] p=0.002), and these remained significant in a multivariate model.

Figure 1.

radar diagrams of eight SF-36 domains, and MCS and PCS boxplots. SLE; systemic lupus erythematosus; UCTD, undifferentiated CTD; pSS, primary Sjögren’s syndrome; IIM, idiopathic inflammatory myopathy; SSc, systemic sclerosis; PF, physical function; RP, role physical; BP, bodily pain; GH, general health; VT, vitality; SF, social functioning; RE, role emotional; MH, mental health

Conclusion

Patients with UCTD exhibit similar impairment in physical components of HR-QoL compared with other established CTDs, despite perceived differences in disease severity. This study highlights sicca syndrome, fatigue, and steroid burden as key targets for improving HR-QoL in patients across the spectrum of CTDs.

Disclosure of Interests

Sarah Dyball Grant/research support from: UCB and Eli Lilly, John Reynolds: None declared, Ariane Herrick Speakers bureau: Janssen, Consultant of: Arena, Boehringer-Ingelheim, Camurus, CSL-Behring, and Gesynta, Grant/research support from: Gesynta, Hector Chinoy Speakers bureau: UCB, Biogen, Consultant of: Novartis, Eli Lilly, Orphazyme, Astra Zeneca, Grant/research support from: Eli Lilly and UCB, Sahena Haque: None declared, Sophia Naz: None declared, Ellen Bruce: None declared, Ian N. Bruce Speakers bureau: AstraZeneca, GSK and UCB, Consultant of: AstraZeneca, Eli Lilly, GSK, Merck Serono, UCB and ILTOO, Grant/research support from: Genzyme/Sanofi, GSK, Roche and UCB, Ben Parker Speakers bureau: Eli Lilly and Roche, Consultant of: Fresenius-Kabi and AbbVie, Grant/research support from: Genzyme/Sanofi and GSK

POS0757 COVID-19 INFECTION AND RECOVERY AMONGST PATIENTS WITH MODERATE-TO-SEVERE LUPUS DURING THE PANDEMIC: RESULTS FROM THE BILAG-BIOLOGICS REGISTER (BILAG-BR)

Background

Patients with systemic lupus erythematosus (SLE) are thought to be at greater risk of severe COVID-19 illness and associated complications due to a combination of inherent aberrant immune responses, immunosuppressive medications and co-morbidities.

Objectives

To review COVID-19 infections, hospitalisation and recovery in a real-world cohort of patients with moderate to severe SLE and high immunosuppressant use.

Methods

The British Isles Lupus Assessment Group Biologics Registry (BILAG-BR) is a national prospective registry of lupus patients from the UK (2010-21) requiring significant immunosuppressive therapies. Patients from the BILAG-BR were invited to complete a paper or online questionnaire which consisted of 17 questions to assess prior COVID-19 infection and their recovery during the COVID-19 pandemic. Questionnaires were completed between 9th Oct 2021 and 7th Jan 2022. Responses were linked with data collected in the BILAG-BR. Mortality data were collected from study centres and the Office of National Statistics from Dec 2019-Jan 2022.

Results

Data were collected from the first 202/1268 patients to respond. Patients were predominately female (186, 92.1%), had a median age of 51 (IQR 38-61) years and were from 37 UK centres. Previous therapy included rituximab (165, 81.7%), belimumab (33, 16.3%) and cyclophosphamide (54, 26.7%). In the past 12 months, over two thirds of patients (138, 68.3%) had received oral prednisolone (current median dose 5mg [IQR 5-8mg] daily), and almost a third had received parental steroids (60, 29.7%).

Self-reported COVID-19 diagnosis occurred in 48 (23.8%) patients, of whom 20 reported a positive test. Eleven (55%) patients reported testing positive for COVID-19 after being vaccinated. Median reported recovery was 80% (IQR 60-100%), with subjective full recovery reported in 30% of patients (6/20) who had received a positive test. Of the 20 patients who tested positive for COVID-19, 5 were receiving belimumab, 1 tocilizumab, and in the prior 12 months, 2 had received cyclophosphamide and 4 rituximab.

Of all respondents, three individuals were hospitalised with COVID-19, and one required an ICU admission. Of those hospitalised, two patients were unvaccinated prior to COVID-19 infection, and the other patient had received rituximab and cyclophosphamide prior to vaccination. Four/1387 patients registered in the BILAG-BR were confirmed to have died from COVID-19 since the beginning of the pandemic.

Conclusion

In this cohort of moderate-to-severe SLE patients there was a low incidence of COVID-19 infection. Despite this, full recovery from PCR or lateral flow test proven COVID-19 infection was seen in only a third of patients. This raises concerns over the potential risk of long COVID in patients with SLE and warrants further investigation.

Acknowledgements

Submitted on behalf of the BILAG-biologics register

Disclosure of Interests

Sarah Dyball Grant/research support from: UCB and Eli Lilly, Mia Rodziewicz Grant/research support from: UCB, Emily Sutton: None declared, Ben Parker Speakers bureau: Eli Lilly and Roche, Consultant of: Fresenius-Kabi and AbbVie, Grant/research support from: Genzyme/Sanofi and GSK, Ian N. Bruce Speakers bureau: AstraZeneca, GSK and UCB, Consultant of: AstraZeneca, Eli Lilly, GSK, Merck Serono, UCB and ILTOO, Grant/research support from: Genzyme/Sanofi, GSK, Roche and UCB

P019 Rheumatology Referrals to Tertiary Care Hospital over a Three Month Period During Covid-19 Pandemic: a Quality Improvement Project

Background/Aims

During the COVID-19 pandemic, waiting times for routine new referrals to our tertiary rheumatology department was >20 weeks. Therefore, a quality improvement project (QIP) was undertaken to understand the nature of these referrals and develop an alternative option to rheumatology review. Our aim was to reduce waiting times and improve patient experience by better integrating primary, secondary and therapy services, as well as provide additional triage options.

Methods

We conducted a retrospective analysis of all routine referrals over a 3-month period (1^st April to 30^th June 2020). Urgent referrals including GCA, CTD and EIA were excluded.

Results

A total of 92/143 (64%) patients were referred, a more significant reduction than normal due to the pandemic. Median age [IQR] was 39.5 [28-66.25] years and most referrals (79%) were from primary care. Table 1 represents information included in the referrals. Thirty-one patients had previously undergone a rheumatology review, of which 11 (35%) were seen in our department. Of these, 18/31 (58%) patients had a diagnosis of Hypermobility Spectrum Disorder (HSD) or fibromyalgia. The commonest reason for re-referral was worsening of existing symptoms (n = 11, 35%), with no suggestive of an alternative diagnosis.

Conclusion

Our QIP identified a variation in the quality of referrals and that a high proportion of referrals concerned HSD and fibromyalgia, with many re-referred due to exacerbation of their existing disease. Based on this, we conducted a regional GP trainee educational session and highlighted: i) key features in investigation and management of common rheumatological conditions ii) vital information to include in referrals based on presenting complaint(s) and working diagnosis. We developed a pathway for patients previously diagnosed with fibromyalgia or HSD in our department and re-referred with worsening symptoms, to be triaged into a newly set up weekly specialist MSK physiotherapy-led clinic with rheumatology supervision. Future work will involve re-assessing routine new-referral waiting times and evaluating pre- and post-physiotherapy intervention MSK and quality of life scores, with the aim of formulating a business case to conduct this clinic on a permanent basis. We hope incorporating this pathway will lead to improved patient outcomes and ease some departmental management decisions.

Disclosure

B. Khan: None. T. David: None. C. Clegg: None. B. Parker: None.

A95 OUTCOMES OF ERCP UNDER CONSCIOUS SEDATION COMPARED TO GENERAL ANESTHESIA: A PRE-POST RETROSPECTIVE COHORT REVIEW

Background

Endoscopic retrograde cholangiopancreatography (ERCP) is a diagnostic and therapeutic procedure used to address pathologies of the pancreatic and biliary systems. ERCP performed under conscious sedation (CS) is the current standard of care but is limited by patient movement and agitation, especially in the context of lengthy or technically complex cases. Recent literature suggests that general anesthesia (GA) may optimize patient comfort and safety while reducing complications such as pancreatitis, perforation, and mortality. In October 2017, Kelowna General Hospital (KGH) transitioned the standard anesthesia modality for ERCP from CS to GA.

Aims

To investigate differences in complications and patient outcomes for ERCP performed under CS (n=1334) before the practice change compared to GA (n=899) after the practice change.

Methods

Our study is a pre-post retrospective chart review of 2,233 patients who underwent ERCP between 2015 and 2020 at KGH. Demographic, clinical, procedural and outcome data were extracted from patient charts, and the data in CS and GA groups were compared using univariate statistical analysis.

Results

Preliminary results show rates of post-ERCP pancreatitis (6% vs. 4%; p=0.018) and rates of procedure failure (8% vs. 3%; p&lt;0.001) were statistically significant and higher under CS before the practice change compared to under GA afterwards, respectively. The 30-day mortality rates, ICU transfer rates, return rates post-discharge, and rates of cholangitis were similar.

Our study showed improvements in several patient safety outcomes, including lower procedure failure rates and lower post-ERCP pancreatitis rates with ERCP performed under GA compared to CS.

Conclusions

Performing ERCP under GA rather than under CS is a valuable practice change that should be considered by ERCP-related programs across all health authorities due to its potential to optimize both patient comfort and safety significantly. The reduction in complication rates may have implications for net cost savings in the long term.

Funding Agencies

Kelowna General Hospital Foundation, Interior Health

Search for magnetic monopoles produced via the Schwinger mechanism

Electrically charged particles can be created by the decay of strong enough electric fields, a phenomenon known as the Schwinger mechanism¹. By electromagnetic duality, a sufficiently strong magnetic field would similarly produce magnetic monopoles, if they exist². Magnetic monopoles are hypothetical fundamental particles that are predicted by several theories beyond the standard model^3-7 but have never been experimentally detected. Searching for the existence of magnetic monopoles via the Schwinger mechanism has not yet been attempted, but it is advantageous, owing to the possibility of calculating its rate through semi-classical techniques without perturbation theory, as well as that the production of the magnetic monopoles should be enhanced by their finite size^8,9 and strong coupling to photons^2,10. Here we present a search for magnetic monopole production by the Schwinger mechanism in Pb-Pb heavy ion collisions at the Large Hadron Collider, producing the strongest known magnetic fields in the current Universe¹¹. It was conducted by the MoEDAL experiment, whose trapping detectors were exposed to 0.235 per nanobarn, or approximately 1.8 × 10⁹, of Pb-Pb collisions with 5.02-teraelectronvolt center-of-mass energy per collision in November 2018. A superconducting quantum interference device (SQUID) magnetometer scanned the trapping detectors of MoEDAL for the presence of magnetic charge, which would induce a persistent current in the SQUID. Magnetic monopoles with integer Dirac charges of 1, 2 and 3 and masses up to 75 gigaelectronvolts per speed of light squared were excluded by the analysis at the 95% confidence level. This provides a lower mass limit for finite-size magnetic monopoles from a collider search and greatly extends previous mass bounds.

A Safe, Fibrosis-Mitigating, and Scalable Encapsulation Device Supports Long-Term Function of Insulin-Producing Cells

Encapsulation and transplantation of insulin-producing cells offer a promising curative treatment for type 1 diabetes (T1D) without immunosuppression. However, biomaterials used to encapsulate cells often elicit foreign body responses, leading to cellular overgrowth and deposition of fibrotic tissue, which in turn diminishes mass transfer to and from transplanted cells. Meanwhile, the encapsulation device must be safe, scalable, and ideally retrievable to meet clinical requirements. Here, a durable and safe nanofibrous device coated with a thin and uniform, fibrosis-mitigating, zwitterionically modified alginate hydrogel for encapsulation of islets and stem cell-derived beta (SC-β) cells is reported. The device with a configuration that has cells encapsulated within the cylindrical wall, allowing scale-up in both radial and longitudinal directions without sacrificing mass transfer, is designed. Due to its facile mass transfer and low level of fibrotic reactions, the device supports long-term cell engraftment, correcting diabetes in C57BL6/J mice with rat islets for up to 399 days and SCID-beige mice with human SC-β cells for up to 238 days. The scalability and retrievability in dogs are further demonstrated. These results suggest the potential of this new device for cell therapies to treat T1D and other diseases.

AB0291 PROGNOSTIC VALUE OF LATE GADOLINIUM ENHANCEMENT ON CARDIAC MAGNETIC RESONANCE IMAGING IN SYSTEMIC LUPUS ERYTHEMATOSUS

Background:

Cardiac Magnetic Resonance Imaging (CMRI) with Late Gadolinium Enhancement (LGE) has an established value in the diagnostic and prognostic assessment of ischaemic and non-ischaemic cardiomyopathies. Although CMRI is widely used for the detection of myocardial involvement in subclinical Systemic Lupus Erythematosus (SLE), its prognostic value has not been determined.

Objectives:

To determine the prognostic value of CMRI with LGE for major adverse cardiovascular events (MACE) in patients with SLE, and investigate its correlation with the severity of systemic inflammation.

Methods:

A retrospective tertiary single-centre review of patients with SLE who underwent a CMRI study at Manchester Foundation Trust between 2009-2020 was conducted. Patients were categorized into two groups; those who experienced a MACE (cardiac death, myocardial infarction (MI), stroke/TIA or heart failure) and those who did not. We compared cardiovascular (CV) risk factors, CMRI findings, SLE risk scores and biochemistry between the 2 groups.

Results:

We identified 20 female patients who underwent a CMRI, with a mean age of 46 years at the time of the scan. Indications for CMRI were assessment for worsening dyspnoea and new onset left ventricular systolic dysfunction. Table 1 demonstrates the clinical, laboratory and CMRI characteristics of the two groups. There were no significant differences in the clinical background and traditional CV risk factors between the 2 groups. 5/20 (25%) patients experienced a MACE. The SLEDAI-2K score was >12 in 2/5 (40%) of patients who suffered a MACE and they presented with a stroke within a year of CMRI study, suggesting that systemic inflammation contributes to poor vascular outcomes. 3/5 (60%) patients who reported a MACE demonstrated LGE on their CMRI study compared to 3/15 (20%) of those who did not (p-0.045). The LGE was predominantly diffuse, mid myocardial in distribution and not ischaemic in pattern, signifying a complex pathophysiological substrate in the development of myocardial pathology in SLE. Additionally, an increase in left ventricular end-diastolic, end-systolic volumes and left atrial diameter was noted in patients who had a MACE (p<0.05). Patients who had a MACE showed a higher incidence of valvular abnormalities and pericardial disease in their CMRI studies. On looking at the medications around the CMRI, the majority of MACE positive patients 4/5 (80%) were on conventional Disease Modifying Anti-Rheumatic Drugs (DMARDs) such as Mycophenolate, Tacrolimus, Cyclophosphamide, Methotrexate or hydroxychloroquine and none on biologics like Rituximab or Belimumab. While 9/15 of the MACE negative patients were on DMARDs and 4/15 were on biologics.

Table 1.

clinical, laboratory and CMRI characteristics of SLE patients with and without MACE. LVEDV-left ventricular end-diastolic volume, LVESV-left ventricular end-systolic volume, LA-left atrial, LVEF-Left ventricular ejection fraction, SLEDAI- SLE Disease Activity Index, +ve-positive.

MACE+ (n = 5)MACE- (n = 15)Mean age of SLE diagnosis (years)35.634.4Mean duration to CMRI (years)8.811.71Lupus nephritis 20%20%Raynaud’s 40%27%Previous CV involvement02 SLEDAI-2K > 122(40%)11(73%)Lupus anticoagulant +ve20%27%Anticardiolipin +ve2(40%)2(14%)anti-dsDNA (iu/ml)+ve3(60%)6(40%)Low C3 (g/L)2(40%)6(40%)Mean prednisolone dose28.338.21 Conventional DMARDs4/5(80%)9/15(60%)Biologics0/54/15Mean LVEF (%)47.456.7CMR LGE3(60%)3(20%)Valvular abnormalities 2(40%) 4(27%)Mean LA area (cm2) 29.620.6Pericardial effusion 40%27%

Conclusion:

In our small SLE cohort, we add to existing knowledge that CMRI with LGE is an indispensable tool to investigate cardiac involvement in SLE and may indeed add important prognostic information. Larger scaled studies are required to confirm the use of CMRI with LGE as a predictor of MACE in patients with SLE.

Disclosure of Interests:

None declared

O17 Effectiveness of rituximab in the treatment of neuro-psychiatric SLE: results from the British Isles Lupus Assessment Group Biologics Register

Background/Aims 

Neuro-psychiatric (NP) involvement in systemic lupus erythematosus (SLE) can occur in 56.3% cases. Rituximab (RTX) has been demonstrated to be safe and efficacious in the treatment of refractory SLE although there is limited evidence for its use in NP-SLE. We aim to describe the baseline characteristics and short-term effectiveness of RTX in patients treated for NP-SLE within the British Isles Lupus Assessment Group Biologics Register (BILAG-BR).

Methods 

Patients with active NP involvement; scoring BILAG A or B and/or on SLEDAI-2K were included. Baseline characteristics, disease activity and oral steroid dose pre and 5 - 9 months post-treatment were analysed. Paired Wilcoxon-Signed-Ranked Test was used to determine changes in disease activity scores and steroid dose.

Results 

We identified 74 patients of whom 61 (82%) were female and 48 (74%) Caucasian. Median age [interquartile range (IQR)] was 45.5 years [37 - 58] and disease duration 11.5 years [7 - 18.8]. 68 patients had active disease on BILAG (A = 34, B = 34) with 6 scoring on SLEDAI-2K only. The majority (n = 71/74, 96%) had at least one other organ involved. Central nervous system (CNS) disease occurred in 45/65 (69%) cases, 12/65 (18%) had peripheral nervous system (PNS) disease and 8/65 (12%) CNS/PNS overlap. Anti-Ro was the commonest identified antibody (n = 26/57, 46%) and 42 of 59 (71%) patients had a raised anti-dsDNA and/or low complement. The majority (n = 64/74, 86%) were taking glucocorticoids and median prednisolone dose was 15mg [IQR 10 - 20]. Pre and post-RTX BILAG, total SLEDAI-2K and oral steroid dose were available in 50, 57 and 27 patients respectively. Following RTX, patients with NP BILAG A or B reduced from 50 to 11 (p &lt; 0.0001). 4 of the 6 patients with NP-SLE on SLEDAI-2K alone, improved. Total median SLEDAI-2K score reduced from 12 [IQR 14 - 18] to 2 [IQR 0 - 4] (p &lt; 0.0001). Median steroid dose reduced from 15mg [IQR 11.3 - 25] to 10mg [IQR 6.9 - 18.8] (p = 0.009). For 53 patients, active CNS, PNS and overlap disease reduced from 37 (70%) to 6 (11%), 10 (19%) to 3 (6%) and 6 (11%) to 4 (8%) respectively. In 9 patients treated with concomitant CYC, none had persistent NP disease. In contrast, 11 of 41 patients who had RTX alone had persistent NP disease.

Conclusion 

RTX use is associated with improvement in NP-SLE with reduction in oral steroid dose. Concomitant CYC may enhance the level of improvement seen with RTX. Large scale studies are therefore warranted to establish the effectiveness of RTX alone or in combination with CYC in the treatment of NP-SLE.

Disclosure 

T. David: None. R. Hum: None. E. Sutton: None. B. Parker: None. E. McCarthy: None. I. Bruce: None.

A122 WATER EXCHANGE FACILITATES HIGH CECAL INTUBATION RATE FOLLOWING INCOMPLETE COLONOSCOPY

Background

Incomplete colonoscopy is a complex problem that negatively affects the success of colon cancer screening programs. Failure to intubate the cecum is associated with a significant risk of missed colorectal cancer and increases costs through missed diagnoses and salvage investigations. Water exchange (WE) colonoscopy is associated with a high rate of patient comfort and cecal intubation (CI) and may be of value in preventing and following up on incomplete colonoscopy.

Aims

To estimate effectiveness of WE colonoscopy as initial salvage of incomplete colonoscopy.

Methods

All patients referred to the Kelowna Gastroenterology group for incomplete colonoscopy between Jan 2010 to Dec 2019 were included. Demographic, clinical, procedural, and pathological information were collected via retrospective chart review. Patients underwent WE colonoscopy by a single endoscopist. The outcomes evaluated were CI rate, sedation requirements, and adenoma detection.

Results

116 patients met study criteria and underwent WE colonoscopy after a previously failed or incomplete colonoscopy for technical reasons. The mean age was 66 years (range 21–89). 83 (72%) patients were female. 53 (46%) patients had previous abdominal surgery, and 42 (36%) had previous pelvic surgery. 65 (56%) patients had previous bowel disease. 81 (70%) patients had previously incomplete conventional air insufflation (AI) colonoscopy, 9 (8%) patients had previously incomplete WE colonoscopy, and 5 (4%) patients underwent unsuccessful combination of WE and AI colonoscopy. 17 (15%) patients had previously incomplete flexible sigmoidoscopy, and 4 (3%) patients had previously incomplete water immersion colonoscopy. The most common cause of unsuccessful CI was redundant colon (n=39, 34%) followed by strictures/angulations (n=16, 14%). 105 (91%) patients underwent repeat WE colonoscopy only, while 7 (6%) patients had combination WE and AI colonoscopy and 4 (3%) patients had concurrent gastroscopy. CI was successful in 114 (98%) patients and unsuccessful in 2 (2%) patients. 87 (75%) study patients received conscious sedation, 16 (14%) opted for no sedation, and 7 (6%) attempted no sedation then switched to conscious sedation. 5 patients (4%) required general anesthesia. CI was achieved in all 16 unsedated patients. 236 polyps were identified in 79 (68%) patients, 2 (1%) of which were malignant.

Conclusions

There is no standardized approach to incomplete colonoscopy. In this cohort of patients with previous failed attempt at colonoscopy, WE as a primary technique was associated with a high success rate with minimal need for general anesthesia and a high rate of polyp detection. A significant rate of colon cancer was identified, similar to that seen in general screening populations.

Funding Agencies

None

First Search for Dyons with the Full MoEDAL Trapping Detector in 13 TeV pp Collisions

The MoEDAL trapping detector consists of approximately 800 kg of aluminum volumes. It was exposed during run 2 of the LHC program to 6.46  fb^{-1} of 13 TeV proton-proton collisions at the LHCb interaction point. Evidence for dyons (particles with electric and magnetic charge) captured in the trapping detector was sought by passing the aluminum volumes comprising the detector through a superconducting quantum interference device (SQUID) magnetometer. The presence of a trapped dyon would be signaled by a persistent current induced in the SQUID magnetometer. On the basis of a Drell-Yan production model, we exclude dyons with a magnetic charge ranging up to five Dirac charges (5g_{D}) and an electric charge up to 200 times the fundamental electric charge for mass limits in the range 870-3120 GeV and also monopoles with magnetic charge up to and including 5g_{D} with mass limits in the range 870-2040 GeV.

Invasive central venous monitoring during hepatic resection: unnecessary for most patients

BACKGROUND

Low central venous pressure (LCVP) anesthesia reduces blood loss during hepatic resection and historically has required a central venous catheter (CVC) for intra-operative monitoring. The aim of this study was to assess the effect of an evolution of practice to CVP monitoring without CVC on the perioperative outcomes after liver resection.

METHODS

A retrospective study of partial hepatectomy patients from 2007 to 2016 who were over 18 years of age was performed.

RESULTS

Of 3903 patients having partial hepatectomy, 2445 (62%) met inclusion criteria, and 404 (16%) had a CVC. Overall morbidity (33% non-CVC vs 38% CVC P = 0.076), major morbidity (16% vs 20% P = 0.067), and infective complications (superficial wound infection) 3% vs 4% P = 0.429; deep wound infection (5% vs 6% P = 0.720) did not differ between the two groups. In multivariate analysis, superficial wound infection, deep wound infection, and major complications were not associated with the presence of a CVC. All-cause mortality at 90 days was associated with CVC presence (OR 3.45, CI 1.74-6.85, P = 0.001) and age (OR 1.05, CI 1.02-1.08, P < 0.001).

CONCLUSION

Since the adoption of non-invasive CVP monitoring, there has been no increase in adverse peri-operative outcomes.

SAT0168 ONLY ONE THIRD OF REAL WORLD LUPUS PATIENTS MEET ELIGIBILITY CRITERIA FOR CLINICAL TRIALS: IMPLICATIONS FOR TRIAL VALIDITY AND GENERALISABILITY

Background:

Despite unprecedented drug development in SLE, the paucity of approved therapies remains a significant challenge. Recent trials have highlighted the need for minimising heterogeneity within SLE populations; however, there is concern this results in the recruitment of patients that are not representative of the SLE population.

Objectives:

Our aim was to apply published trial eligibility criteria to patients with non-renal SLE in a large UK-wide register to quantify how accurately these clinical trials represent a real-world cohort.

Methods:

A literature review of all major published double-blinded randomised phase III trials in non-renal SLE was performed (n=12). Inclusion and exclusion criteria common across the majority of clinical trials were applied to all patients recruited to the BILAG-BR (BILAG biologics register) starting either biological therapy or standard of care (SOC). We applied available data to common inclusion criteria including age ≥18 years, ACR 1997 SLE classification criteria, positive anti-dsDNA or ANA antibodies, active disease (defined as a BILAG A in 1 domain or a BILAG B in ≥2 domains, or a SLEDAI ≥6); and common exclusion criteria including restricted medication rules, active renal or neurological SLE (defined as a BILAG A in either domain), a history of hepatitis B or C, a history of malignancy (excluding basal cell carcinoma), CKD stage 4 or 5, a UPCR ≥100mg/mmol, and cytopenias (defined as neutrophils <1.0 x109/L, platelets <10 x109/L or Hb <70g/L). Baseline variables were compared using chi-squared test.

Results:

As of July 2018, 837 patients were recruited to the BILAG-BR starting either SOC (n=125) or a biologic therapy (n=712). The commonest biologic and SOC therapy was rituximab (n=662, 93%) and mycophenolate (n=64, 51%) respectively. Patients taking SOC were more likely to have inactive disease, as well as having higher steroid doses and less exposure to previous cyclophosphamide or B cell therapy. In the biologic and SOC groups, 476 (67%) and 71 (57%) respectively met all inclusion criteria (table 1). One or more exclusion criteria were met by 324 (46%) of the biologics group and 46 (37%) of the SOC group. As such, 562 (67%) patients were not eligible to enrol in a clinical trial. The patients not eligible to participate were similar in age (P=1.0), gender (P=0.7) and ethnicity (p=0.5) to those who were eligible. Median disease duration was longer in patients eligible to participate (2.9 vs. 5.1 years, p<0.01).

Table 1.

Patients from the BILAG-BR who meet eligibility criteria for major SLE clinical trials

Inclusion criteriaBiologic (n=712)SOC (n=125)P valueAge ≥18 years7061220.1Meet ACR criteria for SLE6751160.4Antibody positive567990.9Active disease62697<0.01Total meeting all inclusion criteria476710.03Exclusion criteriaBiologic (n=712)SOC (n=125)P valueSteroids >40mg prednisolone98<0.001Active CNS SLE3971.0Active renal SLE138280.4Hepatitis B or C2010.2Malignancy5250.2Cyclophosphamide <90 days before entry370<0.01B cell therapy <1 year before entry500<0.01CKD 4/ 52230.7UPCR ≥100mg/mmol92201.0Low blood counts2510.1Pregnancy310.6Total number of patients excluded324460.1TotalNOT*eligible for clinical trial(n)562/837 (67%)1.0

Conclusion:

In a large national register of SLE patients, we found that two thirds of patients would not be eligible for recruitment to clinical trials using published inclusion and exclusion criteria. These results suggest that clinical trial recruits are not fully representative of the target disease population. This limits the generalisability of clinical trial results and supports the need for evidence from real world studies to fully understand the effectiveness of new therapies.

Disclosure of Interests: :

Sarah Dyball: None declared, Sophie Collinson: None declared, Emily Sutton: None declared, Eoghan McCarthy: None declared, Ben Parker Grant/research support from: GSK and Sanofi Genzyme, Consultant of: GSK, AstraZenaca, UCV, Abbvie, Pfizer, BMS, Celltrion, Ian N. Bruce Grant/research support from: Genzyme Sanofi, GSK, and UCB, Consultant of: Eli Lilly, AstraZeneca, UCB, Iltoo, and Merck Serono, Speakers bureau: UCB

AB0402 DISEASE ACTIVITY AND OBSESSIVE-COMPULSIVE DISORDER IN SYSTEMIC LUPUS ERYTHEMATOSUS

Background:

Obsessive-compulsive disorder (OCD) is more prevalent in systemic autoimmune diseases when compared to healthy controls. This is in part due to inflammatory mechanisms, common across both conditions. Neuroinflammation and specifically problems within the basal ganglia are associated with OCD.

Objectives:

The primary objective of this analysis was to investigate the effects of disease activity in systemic lupus erythematosus (SLE) on OCD. Other variables investigated included psychiatric aspects, inflammatory biomarkers and structural brain abnormalities.

Methods:

SLE patients who met ACR or SLICC criteria were recruited. Demographic and clinical data were collected and data measuring disease activity (BILAG and SLEDAI-2K), disease damage (SLICC-DI), depression (MADRS, BDI-II, HADS), anxiety (HADS, STAI), fatigue (FSMC), quality of life (LupusQoL and EQ5D), inflammatory and endothelial activation (EA) biomarkers (IL-6, ESR, TNF-α, MCP-1, hsCRP, BLyS, VCAM-1, VEGF, EMVs) and OCD (OCI-R). MRI FLAIR structural scans were also used to examine signal hyperintensities in the brain. Participants with active disease (SLE-F) also had a 2ndvisit approx. 4 months later. Non-parametric correlations with the OCI-R were undertaken for all SLE participants and for the change over time scores for the SLE-F participants (n=11).

Results:

39 participants were included in the analysis and were typical for a SLE population. 6 (23%) patients had scores above the threshold for OCD. OCI-R significantly correlated with disease activity, quality of life, fatigue, depression and anxiety measures for all the SLE participants. Change in monocyte chemoattractant protein-1 (MCP-1) correlated with the OCI-R for the within SLE-F group analysis (Table 1). No significant correlations were found with the full SLE group for inflammatory or EA biomarkers or with either group for the structural brain analysis.

Table 1.

Significant correlations with the OCI-R for: a) all SLE participants; b) the SLE-F group only (visit 1 minus visit 2).

Variablersp-valuea)All SLE participants, n=39Disease activity: BILAG global score0.4080.01Quality of life: LupusQoL – Physical-0.4950.001  – Pain-0.535<0.001  – Planning-0.586<0.001  – Intimate-0.3420.03  – Burden-0.5040.001  – Emotion-0.3970.01  – Fatigue-0.4710.002 EQ5D: VAS-0.4180.01  total-0.3590.03Fatigue measures (FSMC): Cognitive0.5210.001 Motor0.4480.004Depression measures: MADRS0.4670.003 HADS – D0.545<0.001Anxiety measure: HADS-A0.3750.02b)SLE-F group (v1-v2), n=11Inflammatory marker: MCP-10.7710.006

BILAG The British Isles Lupus Assessment Group index, LupusQoL Lupus quality of life, EQ5D European quality of life, VAS visual analogue scale, FSMC Fatigue scale for motor and cognitive function, MADRS Montgomery Asberg depression rating scale, HADS Hospital anxiety and depression scale, D-depression, A-anxiety score, MCP-1 monocyte chemoattractant protein-1

Conclusion:

OCD in lupus is strongly related to other psychological co-morbidities, fatigue and quality of life. Our results also support a role for inflammatory pathways in mediating some of these changes and so obsessive-compulsive features should be assessed in SLE patients who flare. A larger study is underway to better understand the mechanisms underlying these associations.

Acknowledgments:

This study was partially funded by an unrestricted grant from Sanofi Genzyme and supported by the NIHR Manchester Biomedical Research Centre.

Disclosure of Interests: :

Michelle Barraclough Grant/research support from: This study was partially funded by an unrestricted grant from Sanofi Genzyme., Ben Parker Grant/research support from: GSK and Sanofi Genzyme, Consultant of: GSK, AstraZenaca, UCV, Abbvie, Pfizer, BMS, Celltrion, Shane McKie: None declared, Philip Pemberton: None declared, Alan Jackson: None declared, Rebecca Elliott: None declared, Ian N. Bruce Grant/research support from: Genzyme Sanofi, GSK, and UCB, Consultant of: Eli Lilly, AstraZeneca, UCB, Iltoo, and Merck Serono, Speakers bureau: UCB

OP0094 EULAR-ACR 2019 CLASSIFICATION CRITERIA FOR SLE: CAN WE CLASSIFY USING LABORATORY TESTS ALONE?

Background:

The EULAR-ACR 2019 (EULAR19) classification criteria for systemic lupus erythematosus (SLE) were developed to improve the sensitivity and specificity of previous criteria. Notably, both the EULAR19 and existing SLICC-SLE 2012 (SLICC12) criteria can classify patients as having SLE by the presence of immunology and haematological abnormalities in the absence of any signs or symptoms.

Objectives:

To validate the EULAR19 criteria, with comparison to existing criteria, in a large cohort of patients with an established systemic autoimmune rheumatic disease (SARD).

Methods:

We recruited 227 adult patients who were ANA positive with ≥1 clinical feature suggestive of a SARD, from three hospitals in the North West of England. Clinician diagnosis was used as gold standard; we then applied the EULAR19, SLICC12 and the ACR-SLE 1997 (ACR97) criteria.

Results:

Of the 227 patients recruited, by clinician diagnosis, 89 patients (36%) had SLE, 43 (17%) primary Sjögren’s (pSS), 62 (25%) undifferentiated CTD (UCTD), 25 (10%) systemic sclerosis (SSc) and 8 (3%) an inflammatory myositis. The characteristics of these patients and the breakdown of the EULAR19 criteria are outlined in figure 1.

Figure 1.

Baseline characteristics and classification criteria compared across five SARD diagnoses.

The sensitivity and specificity of the EULAR19 is similar to ACR97 (sensitivity 84% (95% CI 75-91%) vs. 87% (95% CI 78-93%) and specificity 78% (95% CI 70-84%) vs. 76% (95% CI 68-83%) respectively). The SLICC12 criteria by contrast are more sensitive (94% (95% CI 87-98%)) and less specific (61% (95% CI 52-69%)) in this cohort.

Figure 2 illustrates patients with a clinician diagnosis of SLE or UCTD who meet each of the classification criteria. Of the 89 patients with a clinician diagnosis of SLE, 39 (44%) patients would have sufficient points to meet EULAR19 criteria on blood test results alone in the absence of clinical symptoms. Four pSS patients and 4 UCTD patients would also meet EULAR19 criteria from positive blood results alone.

Figure 2.

Venn diagrams illustrating patients with SLE and UCTD who meet the EULAR19, ACR97 and SLICC12 classification criteria. No criteria refers to the patients not meeting any of the three SLE classification criteria.

Conclusion:

These results suggest that the EULAR19 criteria perform comparably to the ACR97 criteria when applied to an established cohort of SARDs. Similar to SLICC12, it is possible to classify patients as having SLE using the EULAR19 criteria by haematological and other laboratory tests. To what extent haematological abnormalities can be potentially used as the sole ‘clinical criteria’ needs consideration.

SLE n=89pSS n=43UCTD n=62SSc n=25Myositis n=8Female N (%)82 (92)42 (98)53 (85)24 (96)8 (100)Age, mean (SD) /years44 (13)52 (12)47 (13)60 (9)53 (7)Disease duration, mean (SD) /years12 (10)6 (5)5 (7)9 (11)3 (3)SLE classification criteriaEULAR SLE 2019, N (%)75 (84)10 (23)20 (32)1 (4)0ACR SLE 1997, N (%)77 (87)9 (21)21 (34)2 (8)1 (13)SLICC SLE 2012, N (%)84 (94)15 (35)33 (53)4 (16)2 (25)EULAR-ACR 2019 criteriaConstitutional, N (%)10 (11)2 (5)1 (2)01 (13)Neuropsychiatric, N (%)3 (3)01 (2)1 (4)0Mucocutaneous, N (%)71 (80)13 (30)27 (44)2 (8)2 (25)Serosal, N (%)13 (15)1 (2)2 (3)00Musculoskeletal, N (%)52 (58)14 (33)22 (35)3 (12)3 (38)Renal, N (%)30 (34)001 (4)0Haematological, N (%)44 (49)12 (28)10 (16)3 (12)0Antiphospholipid antibodies, N (%)43 (48)7 (16)17 (27)4 (16)0Low complement, N (%)48 (54)10 (23)10 (16)3 (12)1 (13)Anti-Sm, N (%)19 (21)2 (5)4 (6)1 (4)0Anti-dsDNA, N (%)50 (56)8 (19)12 (19)01 (13)

Disclosure of Interests:

Sarah Dyball: None declared, John Reynolds: None declared, Eoghan McCarthy: None declared, Sahena Haque: None declared, Ariane Herrick: None declared, Hector Chinoy: None declared, Ellen Bruce: None declared, Ben Parker Grant/research support from: GSK and Sanofi Genzyme, Consultant of: GSK, AstraZenaca, UCV, Abbvie, Pfizer, BMS, Celltrion, Ian N. Bruce Grant/research support from: Genzyme Sanofi, GSK, and UCB, Consultant of: Eli Lilly, AstraZeneca, UCB, Iltoo, and Merck Serono, Speakers bureau: UCB

A273 ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY IN A TERTIARY CANADIAN HOSPITAL: OPTIMIZING TISSUE SAMPLING TECHNIQUES

Background

Pancreatic and biliary cancer can be difficult to definitively diagnose, and tissue diagnosis defines clinical management in both early and late disease. The majority of patients with pancreaticobiliary malignancy present with late disease and only 30% have resectable tumours, contributing to poor prognosis and outcome. Endoscopic retrograde cholangiopancreatography (ERCP) is a mainstay for diagnosing and treating conditions of the bile and pancreatic duct.

Aims

This study aimed to provide data on the diagnostic performance of ERCP utilizing conventional methods for tissue acquisition particularly in the setting of an indeterminate stricture. In particular, this was a quality assurance review to determine our centre’s baseline performance as a reference so new methods of tissue acquisition such as SpyglassTM can be benchmarked against.

Methods

In a tertiary care hospital, 3723 ERCP procedures were performed between 2013 and 2017. Demographic and clinical information was retrospectively collected. Demographic and clinical information was collected. Three ERCP techniques of tissue sampling were analyzed: brushing alone (BiA), biopsy alone (BrA), and brushing and biopsy dual-modality approach (BrBi). The diagnostic performances (sensitivity, specificity, and accuracy) were calculated with data from post-sampling clinical reports, surgical pathological reports, and diagnostic imaging reports.

Results

222 patients (285 ERCP procedure) met the study criteria and received fluoroscopy-guided ERCP sampling with cytology brushing and/or tissue biopsies. 36 (13%) patients had BiA, 85 (29%) patients had BrA, and 164 (58%) patients had BrBi. The sensitivities, specificities, and accuracies of the three sampling techniques respectively were: 56%, 93%, and 85% for BiA; 73%, 96%, and 83% for BrA; and 79%, 94%, and 86% for BrBi.

Conclusions

Our retrospective analysis of fluoroscopic-guided tissue acquisition shows accuracy as high as current published data on direct visualization cholangiosopy guided techniques. A prospective study looking not only at clinical yield but a cost analysis should be put in place prior to a commitment to purchase new equipment such as the SpyglassTM.

Funding Agencies

None

Cost-effectiveness of negative-pressure wound therapy in adults with severe open fractures of the lower limb: evidence from the WOLLF randomized controlled trial

Aims

The aim of this study was to estimate the cost-effectiveness of negative-pressure wound therapy (NPWT) in comparison with standard wound management after initial surgical wound debridement in adults with severe open fractures of the lower limb.

Patients and Methods

An economic evaluation was conducted from the perspective of the United Kingdom NHS and Personal Social Services, based on evidence from the 460 participants in the Wound Management of Open Lower Limb Fractures (WOLLF) trial. Economic outcomes were collected prospectively over the 12-month follow-up period using trial case report forms and participant-completed questionnaires. Bivariate regression of costs (given in £, 2014 to 2015 prices) and quality-adjusted life-years (QALYs), with multiple imputation of missing data, was conducted to estimate the incremental cost per QALY gained associated with NPWT dressings. Sensitivity and subgroup analyses were undertaken to assess the impacts of uncertainty and heterogeneity, respectively, surrounding aspects of the economic evaluation.

Results

The base case analysis produced an incremental cost-effectiveness ratio of £267 910 per QALY gained, reflecting higher costs on average (£678; 95% confidence interval (CI) -£1082 to £2438) and only marginally higher QALYS (0.002; 95% CI -0.054 to 0.059) in the NPWT group. The probability that NPWT is cost-effective in this patient population did not exceed 27% regardless of the value of the cost-effectiveness threshold. This result remained robust to several sensitivity and subgroup analyses.

Conclusion

This trial-based economic evaluation suggests that NPWT is unlikely to be a cost-effective strategy for improving outcomes in adult patients with severe open fractures of the lower limb. Cite this article: Bone Joint J 2019;101-B:1392–1401.

Magnetic Monopole Search with the Full MoEDAL Trapping Detector in 13 TeV pp Collisions Interpreted in Photon-Fusion and Drell-Yan Production

MoEDAL is designed to identify new physics in the form of stable or pseudostable highly ionizing particles produced in high-energy Large Hadron Collider (LHC) collisions. Here we update our previous search for magnetic monopoles in Run 2 using the full trapping detector with almost four times more material and almost twice more integrated luminosity. For the first time at the LHC, the data were interpreted in terms of photon-fusion monopole direct production in addition to the Drell-Yan-like mechanism. The MoEDAL trapping detector, consisting of 794 kg of aluminum samples installed in the forward and lateral regions, was exposed to 4.0  fb^{-1} of 13 TeV proton-proton collisions at the LHCb interaction point and analyzed by searching for induced persistent currents after passage through a superconducting magnetometer. Magnetic charges equal to or above the Dirac charge are excluded in all samples. Monopole spins 0, ½, and 1 are considered and both velocity-independent and-dependent couplings are assumed. This search provides the best current laboratory constraints for monopoles with magnetic charges ranging from two to five times the Dirac charge.

Economic outcomes associated with deep surgical site infection in patients with an open fracture of the lower limb

Aims

The aim of this study was to estimate economic outcomes associated with deep surgical site infection (SSI) in patients with an open fracture of the lower limb.

Patients and Methods

A total of 460 patients were recruited from 24 specialist trauma hospitals in the United Kingdom Major Trauma Network. Preference-based health-related quality-of-life outcomes, assessed using the EuroQol EQ-5D-3L and the 6-Item Short-Form Health Survey questionnaire (SF-6D), and economic costs (£, 2014/2015 prices) were measured using participant-completed questionnaires over the 12 months following injury. Descriptive statistics and multivariate regression analysis were used to explore the relationship between deep SSI and health utility scores, quality-adjusted life-years (QALYs), and health and personal social service (PSS) costs.

Results

Deep SSI was associated with lower EQ-5D-3L derived QALYs (adjusted mean difference -0.102, 95% confidence interval (CI) -0.202 to 0.001, p = 0.047) and increased health and social care costs (adjusted mean difference £1950; 95% CI £1383 to £5285, p = 0.250) versus patients without deep SSI over the 12 months following injury.

Conclusion

Deep SSI may lead to significantly impaired health-related quality of life and increased economic costs. Our economic estimates can be used to inform clinical and budgetary service planning and can act as reference data for future economic evaluations of preventive or treatment interventions. Cite this article: Bone Joint J 2018;100-B:1506–10.

Abstract PD2-14: Participation in a personalized breast cancer screening trial does not increase anxiety at baseline

Introduction: The purpose of this study is to examine whether participation in a personalized screening trial is associated with anxiety or breast cancer worry. The Patient Centered Outcomes Research Institute recently funded WISDOM (Women Informed to Screen Depending On Measures of risk), which is a randomized trial that tests the safety and efficacy of basing starting age, stopping age, frequency and modality of breast cancer screening on individual risk (Clinical Trials Identifier NCT02620852).

Methods: In WISDOM, participants can be randomized to annual screening or personalized screening arm, or self-select an arm an observational cohort. This interim analysis examined the first 1817 participants to determine if the personalized risk arm is acceptable and to explore whether baseline anxiety was associated with study arm. For acceptability our target was to have &gt;60% of participants agree to randomization. Participants completed questions about their Risk Perception, the PROMIS Anxiety short form 8a (total scores 8-40 with higher scores indicating more anxiety), and Breast Cancer Risk Worry (BCRW) survey (total scores 5-20) with higher scores indicating more worry) at baseline and before they were given information on their personal risk or study assignment. For the purposes of these analyses, we defined high anxiety to be the percentage of participants scoring =&gt;22 on the PROMIS and &gt;8 on the BCRW.

Results: The participants were recruited from three sites (UCSD, UCSF, Sanford Health). Of the 1817 initial participants, 1643 completed the baseline questionnaire. Participants has a mean age of 57 years (SD 9). 15.8% felt their chances of developing breast cancer was high, 19.5% felt their chance of developing breast cancer was greater than the average women, and 56.6% felt their lifetime risk of developing breast cancer was &gt;25. Risk perception was not significantly different between women who opted to be randomized versus the observational arm.

The majority of participants were willing to be randomly assigned to an arm (1071/1643, 65.1%). Of those who joined the observational cohort, the majority selected personalized risk arm (474/572, 82.9%). Overall, PROMIS anxiety scores were low at baseline (14.0 MEAN (SD 4.6)) as were the Breast Cancer Risk Worry scores (5.7 MEAN (SD 1.05)). Less than 8% of participants had PROMIS scores &gt;22 and that did not vary across the randomized or observational groups (P=0.2)). About 2% of participants had a BCRW scores &gt;8. Women who worried with breast cancer were more likely to select to be in the observational (3.5%) than randomized (1.7%) arm of the study (P=0.02).

Conclusions: For the women approached to participate in Wisdom, personalized screening was acceptable alternative to annual mammography. Participants in general overestimated their lifetime risk of breast cancer, had very low anxiety and low breast cancer worry. Those who were worried about breast cancer opted more often for the observational arm of the study to allow them to choose between the personalized versus annual arm. Future analyses will follow participants prospectively to determine adherence to assigned or selected arm, and whether anxiety changes after receipt of their personalized risk information.

Citation Format: Naeim A, Sepucha K, Wenger N, Eklund M, Annette S, Madlensky L, van't Veer L, Parker B, Yau C, Cink T, Anton-Culver H, Borowsky A, Petruse A, Sarrafan S, Stover-Fiscalini A, LaCroix A, Adduci K, Wisdom Advocate Partners, Laura E. Participation in a personalized breast cancer screening trial does not increase anxiety at baseline [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 PD2-14.

Abstract OT3-03-01: Preference-Tolerant randomized trial of risk-based vs. annual breast cancer screening: WISDOM study in progress

Purpose: Women Informed to Screen Depending on Measures of risk (WISDOM) trial is a pragmatic study comparing two real world approaches to clinical care for breast screening: annual screening versus personalized screening. The novelty of the personalized arm of the study is that we are combining known risk factors (age, family history, history of breast disease, ethnicity, BIRADS breast density, and genetics) into a single risk assessment model. All components of the model have been tested and established, but have never been used jointly.

The goal of the WISDOM study is to examine the effectiveness of personalized breast cancer screening and to bring objective recommendations to the current mammography screening debate.

Methods: The WISDOM trial will enroll 100,000 women with a preference-tolerant design that will determine if risk-based screening vs. annual screening, is as safe, less morbid, enables prevention, and is preferred by women. Women 40 - 74 years of age with no history of breast cancer or DCIS, and no previous double mastectomy can join the study from the WISDOM Study website (wisdomstudy.org). All participants sign up, elect randomization or self-select the study arm, provide electronic consent using DocuSign (eConsent), and sign a Medical Release Form. For all participants, 5-year risk of developing breast cancer is calculated according to the Breast Cancer Screening Consortium (BCSC) model. For participants in the personalized arm, the overall 5-year risk BCSC score is combined with a Polygenic Risk Score, based on a genetic test including mutations in 9 genes (BRCA1, BRCA2, TP53, PTEN, STK11, CDH1, ATM, PALB2, and CHEK2) and a panel of 75 common single nucleotide polymorphisms known to increase breast cancer risk. Risk stratification will determine frequency of screening. The study is registered on ClinicalTrials.gov as NCT02620852.

Results: As of June 12th 2017, the WISDOM study is live at all UC medical centers and recruitment is open to all eligible women in California. Up to date 4,769 eligible women registered at all sites. 2,823 women have consented in the trial. 64% were randomized and 36% chose their screening arm. A pilot was conducted to test the logistics of online participation and examine the acceptance of the study design and approach. We are partnering with health insurance companies and self-insured companies to reach our recruitment goal.

Conclusions: Enrollment will be completed by end of 2018.

Acknowledgment: support by the Patient-Centered Outcomes Research Institute (PCORI), PCS-1402-10749 to L.J.E.

(*) Authors equally contributed to this work.

Citation Format: Acerbi I, Abihider K, Ling J, Layton T, DeRosa D, Madlensky L, Tice J, Shieh Y, Ziv E, Sarrafan S, Firouzian R, Tong B, Blanco A, Lee V, Heditsian D, Brain S, Kaplan C, Borowsky A, Anton-Culver H, Naeim A, Cink T, Stover Fiscalini A, Parker B, van 't Veer L, Wisdom Study and Athena Breast Health Network Investigators and Advocate Partners, LaCroix A, Esserman L. Preference-Tolerant randomized trial of risk-based vs. annual breast cancer screening: WISDOM study in progress [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 OT3-03-01.

Abstract P3-09-02: Risk stratification using clinical risk factors and genetic variants in a personalized screening trial

Introduction: Tailoring breast cancer screening according to individual risk may represent an improvement over the current practice of age-based screening. WISDOM (Women Informed to Screen Depending on Measures of Risk) is an ongoing randomized trial comparing the safety, efficacy, cost, and patient acceptability of personalized versus annual screening. Women in the personalized arm receive screening recommendations based on sequencing of 9 genes associated with hereditary breast cancer and a 5-year risk estimate from the Breast Cancer Surveillance Consortium (BCSC) risk model modified by a polygenic risk score (PRS) comprised of 75 single nucleotide polymorphisms. WISDOM represents the first-ever use of a PRS to prospectively modify risk estimates and allows comparison of risk model performance in a population-based setting. Thus, we evaluated the risk estimates generated by: 1) the Breast Cancer Risk Assessment Tool (BCRAT) based on the Gail model, 2) the BCSC model, and 3) the BCSC model modified by the PRS (BCSC-PRS).

Methods: We analyzed participants in the personalized screening arm of the WISDOM Study (NCT02620852). The trial opened in October 2016 and is enrolling participants aged 40-74 years. Participants' self-reported demographic and risk factor information were collected through an online portal. Genotyping of participants in the personalized arm was done using a custom panel from Color Genomics. 5-year risk estimates were generated using the BCRAT (2011 version), BCSC, and BCSC-PRS models. In the latter, the PRS was used as a Bayesian likelihood ratio to modify the BCSC 5-year risk estimate. We compared the distributions of BCRAT, BCSC, and BCSC-PRS risk estimates around a low-risk (&lt;1%) and moderately high-risk (≥3%) threshold using a paired statistical test (McNemar).

Results: To date, WISDOM has enrolled 2,065 participants, of whom 1,157 are in the personalized arm and 830 have completed risk assessment. The median age was 57 years (interquartile range, IQR 49-64). 83% were Caucasian, 2% African-American, and 7% Asian. 8% self-reported as Hispanic. The median 5-year risk was 1.7% (IQR 1.1-2.3%) using the BCRAT, 1.6% (IQR 1.1-2.3%) using the BCSC model, and 1.5% (IQR 0.9-2.7%) using the BCSC-PRS model. The BCSC-PRS model classified more women into the low (&lt;1%) and moderately high (≥3%) risk categories compared with the BCRAT (p &lt; 0.001) and BCSC model (p &lt; 0.001), Table.

5-year risk classification according to the BCRAT, BCSC and BCSC-PRS models &lt;1%1-3%≥3% n (%)n (%)n (%)Gail161 (19)556 (67)113 (14)BCSC159 (19)568 (68)103 (12)BCSC-PRS275 (33)379 (46)176 (21)

Discussion: Adding a PRS to the BCSC model categorized significantly more women below the low-risk threshold and above the moderately high-risk threshold compared with the BCSC model and BCRAT. Furthermore, the BCSC and BCRAT generated similar distributions of risk estimates. Follow-up with incident breast cancer data is needed to determine whether the reclassification provided by the PRS improves risk stratification and clinical outcomes. However, our preliminary findings suggest that incorporating genetic variants into a validated clinical model is feasible and could enhance risk prediction.

Citation Format: Shieh Y, Ziv E, Eklund M, Sabacan L, Firouzian R, Madlensky L, Anton-Culver H, Borowsky A, LaCroix A, Naeim A, Parker B, van't Veer L, Esserman L, Tice J, WISDOM Study and Athena Network Investigators WS. Risk stratification using clinical risk factors and genetic variants in a personalized screening trial [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 P3-09-02.

A High-Resolution Minimicroscope System for Wireless Real-Time Monitoring

OBJECTIVE

Compact, cost-effective, and high-performance microscope that enables the real-time imaging of cells and lab-on-a-chip devices is highly demanded for cell biology and biomedical engineering. This paper aims to present the design and application of an inexpensive wireless minimicroscope with resolution up to 2592 × 1944 pixels and speed up to 90 f/s.

METHODS

The minimicroscope system was built on a commercial embedded system (Raspberry Pi). We modified a camera module and adopted an inverse dual lens system to obtain the clear field of view and appropriate magnification for tens of micrometer objects.

RESULTS

The system was capable of capturing time-lapse images and transferring image data wirelessly. The entire system can be operated wirelessly and cordlessly in a conventional cell culturing incubator. The developed minimicroscope was used to monitor the attachment and proliferation of NIH-3T3 and HEK 293 cells inside an incubator for 50 h. In addition, the minimicroscope was used to monitor a droplet generation process in a microfluidic device. The high-quality images captured by the minimicroscope enabled us an automated analysis of experimental parameters.

CONCLUSION

The successful applications prove the great potential of the developed minimicroscope for monitoring various biological samples and microfluidic devices.

SIGNIFICANCE

This paper presents the design of a high-resolution minimicroscope system that enables the wireless real-time imaging of cells inside the incubator. This system has been verified to be a useful tool to obtain high-quality images and videos for the automated quantitative analysis of biological samples and lab-on-a-chip devices in the long term.

Clinicians approaches to management of background treatment in patients with SLE in clinical remission: results of an international observational survey

Background

The definition of remission in systemic lupus erythematosus (SLE) remains unclear, especially how background treatment should be interpreted.

Objective

To determine preferences of clinicians in treatment of patients in clinical remission from SLE and to assess how previous severity, duration of remission and serology influence changes in treatment.

Methods

We undertook an internet-based survey of clinicians managing patients with SLE. Case scenarios were constructed to reflect different remission states, previous organ involvement, serological abnormalities, duration of remission and current treatment (hydroxychloroquine (HCQ), steroids and/or immunosuppressive (ISS) agents).

Results

130 clinicians from 30 countries were surveyed. The median (range) duration of practice and number of patients with SLE seen each month was 13 (2–42) years and 30 (2–200), respectively. Management decisions in all scenarios varied with greater caution in treatment reduction with shorter duration of remission, extent of serological abnormalities and previous disease severity. Even with mild disease, normal serology and a 5-year clinical remission, 113 (86.9%) clinicians continue to prescribe HCQ. Persistent abnormal serology in any scenario led to a reluctance to reduce or discontinue medications. Prescribing in remission, particularly of steroids and HCQ, varied significantly according to geographical location.

Conclusions

Clinicians preferences in withdrawing or reducing treatment in patients with SLE in clinical remission vary considerably. Serological abnormalities, previous disease severity and duration of remission all influence the decision to reduce treatment. It is unusual for clinicians to stop HCQ even after prolonged periods of clinical remission. Any definition(s) of remission needs to take into consideration such evidence on how maintenance treatments are managed.

Isolevuglandins as a gauge of lipid peroxidation in human tumors

The cellular production of free radicals or reactive oxygen species (ROS) can lead to protein, lipid or DNA modifications and tumor formation. The cellular lipids undergo structural changes through the actions of enzymes (e.g. cyclooxygenases) or free radicals to form a class of compounds called Isolevuglandins (IsoLGs). The recruitment and continued exposure of tissue to ROS and IsoLGs causes increased cell proliferation, mutagenesis, loss of normal cell function and angiogenesis. The elevated concentration of ROS in cancerous tissues suggests that these mediators play an important role in cancer development. We hypothesized that tumors with elevated ROS levels would similarly possess an increased concentration of IsoLGs when compared with normal tissue. Using D11, an ScFv recombinant antibody specific for IsoLGs, we utilized immunohistochemistry to visualize the presence of IsoLG in human tumors compared to normal adjacent tissue (NAT) to the same tumor. We found that IsoLG concentrations were elevated in human breast, colon, kidney, liver, lung, pancreatic and tongue tumor cells when compared to NAT and believe that IsoLGs can be used as a gauge indicative of lipid peroxidation in tumors.

QT Interval Shortening With Isavuconazole: In Vitro and In Vivo Effects on Cardiac Repolarization

The effects of isavuconazole (active moiety of isavuconazonium sulfate) on cardiac ion channels in vitro and cardiac repolarization clinically were assessed in a phase I, randomized, double‐blind study in healthy individuals who received isavuconazole (after 2‐day loading dose), at therapeutic or supratherapeutic doses daily for 11 days, moxifloxacin (400 mg q.d.), or placebo. A post‐hoc analysis of the phase III SECURE trial assessed effects on cardiac safety. L‐type Ca²⁺ channels were most sensitive to inhibition by isavuconazole. The 50% inhibitory concentrations for ion channels were higher than maximum serum concentrations of nonprotein‐bound isavuconazole in vivo. In the phase I study (n = 161), isavuconazole shortened the QT interval in a dose‐ and plasma concentration‐related manner. There were no serious treatment‐emergent adverse events; palpitations and tachycardia were observed in placebo and supratherapeutic isavuconazole groups; no cardiac safety signals were detected in the SECURE study (n = 257). Isavuconazole was associated with a shortened cardiac QT interval.

Search for Magnetic Monopoles with the MoEDAL Forward Trapping Detector in 13 TeV Proton-Proton Collisions at the LHC

MoEDAL is designed to identify new physics in the form of long-lived highly ionizing particles produced in high-energy LHC collisions. Its arrays of plastic nuclear-track detectors and aluminium trapping volumes provide two independent passive detection techniques. We present here the results of a first search for magnetic monopole production in 13 TeV proton-proton collisions using the trapping technique, extending a previous publication with 8 TeV data during LHC Run 1. A total of 222 kg of MoEDAL trapping detector samples was exposed in the forward region and analyzed by searching for induced persistent currents after passage through a superconducting magnetometer. Magnetic charges exceeding half the Dirac charge are excluded in all samples and limits are placed for the first time on the production of magnetic monopoles in 13 TeV pp collisions. The search probes mass ranges previously inaccessible to collider experiments for up to five times the Dirac charge.

Bacterial contamination of saline used for epidural procedures in an obstetric setting: a randomised comparison of two drawing-up techniques

BACKGROUND

There is little evidence to inform practice regarding the optimum aseptic technique of drawing up saline for epidural insertion. Our regional practice is to draw up saline from a non-sterile packaged plastic ampoule, therefore introducing the risk of bacterial contamination. Usually, the anaesthetist draws up saline directly from the vial held by an assistant using a needle (needle technique). Alternatively, the saline vial is emptied onto a sterile tray by an assistant and then drawn up by the anaesthetist (tray technique). We hypothesised that the latter will lead to an increase in the number of contaminated saline samples as they are exposed to the environment.

METHODS

In labour rooms and before epidural catheter insertion, 110 samples of saline 20mL were randomly drawn up using our hospital's recommended epidural aseptic precautions, using either the needle or the tray technique. Equal amounts of saline were inoculated into aerobic and anaerobic blood culture bottles.

RESULTS

Eleven percent of samples in the needle arm and 24% of samples in the tray arm grew commensal micro-organisms including coagulase-negative Staphylococcus, Micrococcus luteus and Streptococcus viridans. A two-sided Fisher's exact test for categorical unpaired data showed no statistical difference between the two arms of the trial (P=0.13).

CONCLUSION

The difference in the saline contamination rate between the two techniques did not reach statistical significance. As bacterial contamination occurred with both techniques, we recommend using sterile saline pre-packaged in the epidural tray or individually wrapped sterile glass saline ampoules.

Microparticle subpopulations are potential markers of disease progression and vascular dysfunction across a spectrum of connective tissue disease

Objective

Microparticles (MPs) are membrane-bound vesicles derived from vascular and intravascular cells such as endothelial cells (EMPs) and platelets (PMPs). We investigated EMP and PMP numbers across a spectrum of autoimmune rheumatic diseases (AIRDs) with the aim of comparing the levels of, and relationship between, EMPs and PMPs.

Methods

Patients with Systemic Lupus Erythematosus (SLE) (n = 24), Systemic Sclerosis (SSc) (n = 24), Primary Raynauds Phenomenon (RP) (n = 17) and “other CTD” (n = 15) (Primary Sjogrens Syndrome, UCTD or MCTD) as well as 15 healthy controls were recruited. EMPs and PMPs were quantified using flow cytometry. Associations between MP levels and objective functional vascular assessments were evaluated.

Results

SLE patients had significantly higher EMPs compared with healthy controls and SSc patients. Higher PMP levels were noted in SSc and primary RP when compared to healthy controls and ‘other CTD’ patients. A modest correlation was noted between EMP and PMP levels in healthy controls (Spearman r = 0.6, p = 0.017). This relationship appeared stronger in SLE (r = 0.72, p < 0.0001) and other CTD patients (r = 0.75, p < 0.0001). The association between EMPs and PMPs was notably less strong in SSc (r = 0.45, p = 0.014) and RP (r = 0.37, p = 0.15). A significantly lower EMP/PMP ratio was detected in SSc/RP patients in comparison to both healthy controls and SLE/other CTD patients. Higher EMP and PMP levels were associated with higher digital perfusion following cold challenge in SSc. In contrast, higher PMP (but not EMP) levels were associated with lower digital perfusion at both baseline and following cold challenge in primary RP. Higher PMP levels were associated with greater endothelial-independent dilation in patients with SLE.

Conclusion

MP populations differ across the spectrum of AIRDS, possibly reflecting differences in vascular cell injury and activation. MP levels are associated with functional assessments of vascular function and might have a role as novel vascular biomarkers in AIRDs.

Significance and innovations

Levels of circulating endothelial and platelet microparticles differ between SSc/primary RP compared with SLE and other CTDs (UCTD, MCTD and Primary Sjogrens). MP release may occur within different vascular sites across these disease groups (macrovascular and microvascular).

The association between circulating MP levels and objective assessment of macro- and microvascular dysfunction within these disease areas suggests that MPs might have a useful role as novel circulating biomarkers of vascular disease within the CTDs.

•

Levels of circulating EMPs and PMPs differ between SSc/primary RP compared with other CTDs including SLE.

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Circulating MP levels are associated with objective assessments of macro- and microvascular dysfunction.

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MPs may have a useful role as novel circulating biomarkers of vascular disease within the CTDs.