Defining remission in childhood-onset lupus: PReS-endorsed consensus definitions by an international task force

OBJECTIVE

To derive childhood-onset SLE (cSLE) specific remission definitions for future treat-to-target (T2T) trials, observational studies, and clinical practice.

METHODS

The cSLE International T2T Task Force conducted Delphi surveys exploring paediatric perspectives on adult-onset SLE remission targets. A modified nominal group technique was used to discuss, refine, and agree on the cSLE remission target criteria.

RESULTS

The Task Force proposed two definitions of remission: 'cSLE clinical remission on steroids (cCR)' and 'cSLE clinical remission off steroids (cCR-0)'. The common criteria are: (1) Clinical-SLEDAI-2 K = 0; (2) PGA score < 0.5 (0-3 scale); (4) stable antimalarials, immunosuppressive, and biologic therapy (changes due to side-effects, adherence, weight, or when building up to target dose allowed). Criterion (3) in cCR is the prednisolone dose ≤0.1 mg/kg/day (maximum 5 mg/day), whereas in cCR-0 it is zero.

CONCLUSIONS

cSLE definitions of remission have been proposed, maintaining sufficient alignment with the adult-SLE definition to facilitate life-course research.

Evidence for the earliest structural use of wood at least 476,000 years ago

Wood artefacts rarely survive from the Early Stone Age since they require exceptional conditions for preservation; consequently, we have limited information about when and how hominins used this basic raw material1. We report here on the earliest evidence for structural use of wood in the archaeological record. Waterlogged deposits at the archaeological site of Kalambo Falls, Zambia, dated by luminescence to at least 476 ± 23 kyr ago (ka), preserved two interlocking logs joined transversely by an intentionally cut notch. This construction has no known parallels in the African or Eurasian Palaeolithic. The earliest known wood artefact is a fragment of polished plank from the Acheulean site of Gesher Benot Ya'aqov, Israel, more than 780 ka (refs. 2,3). Wooden tools for foraging and hunting appear 400 ka in Europe4-8, China9 and possibly Africa10. At Kalambo we also recovered four wood tools from 390 ka to 324 ka, including a wedge, digging stick, cut log and notched branch. The finds show an unexpected early diversity of forms and the capacity to shape tree trunks into large combined structures. These new data not only extend the age range of woodworking in Africa but expand our understanding of the technical cognition of early hominins11, forcing re-examination of the use of trees in the history of technology12,13.

Real-World Analysis of Durvalumab after Chemoradiation in Stage III Non-Small-Cell Lung Cancer

The 2017 PACIFIC trial heralded the incorporation of routine adjuvant durvalumab following curative-intent chemoradiation for stage III non-small-cell lung cancer (NSCLC). However, carefully selected clinical trial populations can differ significantly from real-world populations, which can have implications on treatment toxicities and outcomes, making it difficult to accurately counsel patients. Consequently, we performed a real-world, retrospective analysis of outcomes and toxicities in 118 patients with stage III NSCLC treated with durvalumab after platinum-based chemoradiotherapy. The data were collected from patients who underwent treatment at a single, tertiary-level Canadian cancer centre from May 2018 to October 2020. The variables collected included patient demographics, treatment specifics, progression-free survival, overall survival, and immune-related adverse events (IRAE) from durvalumab. Descriptive statistics were used for toxicity analysis, and progression-free survival and overall survival estimates were calculated using the Kaplan-Meier method. The statistical analyses indicated a 64.4% (n = 76) toxicity rate, with a 21% (n = 25) toxicity rate of grade 3+ IRAEs. The most common documented IRAEs were pneumonitis (n = 44; 40%), followed by rash (n = 20; 18%) and thyroid dysfunction (n = 17; 15%). FEV1 and DLCO were not found to be associated predictors of pneumonitis toxicity. The median PFS and OS were estimated to be >1.7 years and >2.7 years, respectively.

PReS-endorsed international childhood lupus T2T task force definition of childhood lupus low disease activity state (cLLDAS)

OBJECTIVE

To achieve a consensus-based definition of Low Disease Activity (LDA) for use in cSLE trials.

METHODS

The International cSLE T2T Task Force, comprising of paediatric rheumatologists/nephrologists, and adult rheumatologists undertook a series of Delphi surveys/consensus meetings to discuss, refine, and vote upon cSLE LDA criteria.

RESULTS

The Task Force agreed that LDA should be based upon the adult-SLE Lupus Low Disease Activity State definition (LLDAS), with modifications to make it applicable to cSLE (cLLDAS). They agreed upon five cLLDAS criteria: (1) SLE Disease Activity Index (SLEDAI)-2 K ≤4, with no activity in major organ systems; (2) no new features of lupus disease activity compared with the last assessment; (3) Physician Global Assessment score of ≤1 (0-3 scale); (4) prednisolone dose of ≤0.15 mg/kg/day, 7.5 mg/day/maximum; while on (5) stable antimalarials, immunosuppressives, and biologics.

CONCLUSIONS

A cSLE-appropriate definition of cLLDAS has been generated, maintaining alignment with the adult-SLE definition to promote life-course research.

Environmental life cycle assessment of production of the high intensity sweetener steviol glycosides from Stevia rebaudiana leaf grown in Europe: The SWEET project

PURPOSE

There is an increasing interest in the use of non-nutritive sweeteners to replace added sugar in food and beverage products for reasons of improving consumer health. Much work has been done to understand safety of sweeteners, but very little on sustainability. To address that gap, this study presents the results of a life cycle assessment (LCA) of production of rebaudioside A 60%, 95% pure (RA60) steviol glycoside mix from Stevia rebaudiana leaf grown in Europe.

METHODS

An attributional cradle-to-factory-gate life cycle assessment was conducted on growing of stevia leaves and extraction of steviol glycosides in Europe. Primary data were used from a case study supply chain. Results are reported in impact categories from the ReCiPe 2016 (H) method, with focus given to global warming potential, freshwater eutrophication, water consumption, and land use. Impacts are expressed both in terms of production mass and sweetness equivalence, a common metric for understanding high intensity sweetener potency. Sweetness equivalence of RA60 is typically 200 to 300 times that of sugar. Comparison of environmental impact is made to sugar (sucrose) produced from both cane and beets. The research is part of the EU project SWEET (sweeteners and sweetness enhancers: impact on health, obesity, safety, and sustainability).

RESULTS AND DISCUSSION

Global warming potential for production of RA60 was found to be 20.25 kgCO₂-eq/kg_RA60 on a mass basis and 0.081 kgCO₂-eq/kg_SE on a sweetness equivalence basis. Field production of stevia leaves was found to be the main source of impact for most impact categories, and for all four focus categories. Extraction of the RA60 was the main source of impact for the others. Leaf processing and seedling propagation were minor contributors to life cycle impact. Removal of international transport from the supply chain reduced global warming potential by 18.8%. Compared with sugar on a sweetness equivalence basis, RA60 has approximately 5.7% to 10.2% the impact for global warming potential, 5.6% to 7.2% the impact for land use, and is lower across most other impact categories.

CONCLUSION

This is the first LCA of steviol glycoside mix RA60 produced from leaf in Europe. The results indicate that RA60 can be used to reduce environmental impact of providing a sweet taste by replacing sugar across all impact categories. However, it is important to note that specific formulations in which RA60 is used will have a bearing on the final environmental impact of any food or beverage products. For solid foods, this requires further research.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s11367-022-02127-9.

Molecular imaging of experimental atherosclerosis using anti-malondialdehyde-modified low-density lipoprotein humanised antibody fragment targeted nanoparticles

Introduction

Oxidative modification of low-density lipoprotein (LDL), for example by malondialdehyde (MDA) adduction with subsequent uptake by macrophages to form foam cells and later the plaque necrotic core, is a key initiating event in atherogenesis. Accordingly, a larger lipid necrotic core is a key plaque vulnerability factor, predisposing plaques to rupture and subsequent thrombosis and development of an acute coronary syndrome. Thus, MDA-LDL is an attractive focus for the molecular targeting of atherosclerotic plaques.

Purpose

To develop antibody fragment-targeted nanoparticles that can be utilised for both the molecular imaging and therapeutics of vulnerable atherosclerotic plaques.

Methods

LO1 is an IgG3k natural monoclonal murine antibody that reacts with MDA-LDL. Humanised LO1Fab fragments have been engineered to reduce immunogenicity and improve lesion penetration. These humanised LO1Fab fragments were used to functionalise fluorescent poly(lactic-co-glycolic acid) (PLGA) - polyethylene glycol (PEG) nanoparticles. Nanoparticle in vitro function was assessed, prior to fluorescence molecular tomography (FMT) co-registered with micro-CT, four-hours after iv injection in atherosclerotic LDL-receptor−/− mice fed a high-fat diet for 40-weeks.

Results

Humanised LO1Fab fragment conjugated fluorescent PLGA-PEG nanoparticles were formulated with 210nm size and polydispersity index (variability of nanoparticle size around the average) of &lt;0.2. Antibody conjugation efficiency was 30%. In vitro function was confirmed on ELISA versus the blank untargeted nanoparticles with MDA-LDL on solid phase, detecting nanoparticle presence via the conjugated LO1Fab, PEG corona or fluorescence. Fluorescence microscopy on stained aortic root cryosections from atherosclerotic mice confirmed binding to fatty lesions. Construct in vivo in half-life was 90-minutes for both the targeted and untargeted nanoparticles in a two-phase model in LDL-receptor−/− mice, based on fluorescence analysis of serial tail vein blood samples. There was greater uptake in the region-of-interest (heart and aortic arch vessels) in mice injected with LO1Fab-conjugated nanoparticles versus untargeted nanoparticles (mean ± standard deviation) (64.7±22.9 versus 25.2±26.5pmol of Cy5; n=7; p=0.02). Ex vivo analysis fluorescence reflectance imaging and quantitative FMT of the extracted aortae confirmed these findings (1.0±0.3 versus 0.5±0.2pmol of Cy5; n=7; p=0.002; Figure 1).

Conclusions

Humanised antibody Fab fragment fluorescent nanoparticles have been developed that successfully target MDA-LDL and localise to atherosclerotic plaques in murine experimental atherosclerosis. These targeted nanoparticles have the potential to amplify fluorescent signal for imaging and carry a therapeutic cargo for targeted drug delivery direct to atherosclerotic plaques.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): Wellcome Trust Clinical Research Fellowship

553 Does Patella Implant Design Affect Outcomes? Patella Resurfacing in Total Knee Arthroplasty: A Systematic Review and Meta-Analysis

Aim

To investigate whether implant design affect (1)incidence of anterior knee pain, (2)patient reported outcomes and (3)reintervention rates in a resurfaced vs non-resurfaced Total Knee Arthroplasty (TKA).

Method

MEDline, pubmed and google scholar studies were evaluated using SIGN assessment tool and data analysis was conducted using Review Manager 5.2 on only randomised controlled trials. Search terms: arthroplasty, replacement, knee (Mesh), TKA, prosthesis, patella, patellar resurfacing, patellar retaining.

Results

33 randomised controlled studies were identified. A total of 11 used the modern “patella-friendly” implants and 22 used the older “patella non-friendly” implants.

There was no significant difference in anterior knee pain rates for either surgical option. When using patella-friendly implant, patella resurfacing results in a statistically higher clinical (P 0.007, MD -0.77) and functional (P &lt; 0.0001, MD -1.87) KSS than the non-resurfaced counterparts, but scores were not clinically significant. When the patella was not resurfaced, there was a significant increased risk of reoperation with “non-patella friendly” implant (p=0.04, OR 1.42, CI 1.01, 2.00), whilst there was no significant difference between reoperation rates for the “patella friendly” implants (OR 1.17, CI 0.59,2.30).

Conclusions

Patella implant design has been shown to significantly improve KSS scores but with no clinical significance. Risk of further procedures was significantly higher in non-resurfaced patella TKAs with “non-friendly” implants, likely due to increased rates of anterior knee pain in these older generation implants leading to secondary resurfacing. However, when utilising “patella-friendly” implants, resurfacing does not lower reintervention rates. This meta-analysis finds no clinical indication to resurface the patellar whilst performing a TKA.

228 Idiopathic Intracranial Hypertension and Pregnancy: A Comprehensive Review of Management

Aim

To investigate idiopathic intracranial hypertension (IIH) and its management during pregnancy.

Method

PubMed and Embase databases were searched for studies on pregnancy and IIH, with the most recent search in July 2021. Mesh terms used were “idiopathic intracranial hypertension” or “pseudotumor cerebri” AND “pregnancy”. Papers were limited to studies with human subjects and written in the English language. There were no restrictions in study design or date of publication. The reference lists of all retrieved articles were reviewed for further identification of potentially relevant publications.

Results

Management of IIH during pregnancy is similar to those who are non-pregnant. It is recommended that pregnant women with IIH are treated in health care settings that have access to multi-specialty input. Management depends on disease severity and includes conservative management, the use of medication such as steroids and diuretics, lumbar punctures, and surgical management.

An indication for surgical management includes worsening visual deterioration despite initial management with medication or serial lumbar punctures. Surgical management includes cerebral spinal fluid diversion procedures and optic nerve sheath fenestration. These operations can be performed in all three trimesters of pregnancy.

IIH in pregnancy does not increase morbidity or mortality in the newborn and method of delivery should be based on obstetrical indication.

Conclusion

This review highlights the role of multi-disciplinary approach in the management of IIH during pregnancy.

Complex Relational Leadership: Meeting the Challenge of Postpandemic Professional Governance

Development of nursing in the postpandemic future will require active engagement of all nurses. Complex relational leadership in complex adaptive systems is explored through 3 focused areas: professional governance, equitable and inclusive relationships, and clinical practice. Pragmatic examples for each area of focus are offered as a framework for the postpandemic future. A conceptual model was developed to illustrate these relationships.

The role of endometrial staining for CD138 as a marker of chronic endometritis in predicting live birth

PURPOSE

Chronic endometritis (CE) is diagnosed via endometrial biopsy and staining for plasma cells. A threshold plasma cell count that identifies CE and predicts pregnancy outcomes has not been established, and the prevalence of plasma cells in the general infertile population is unknown. The purpose of this study was to determine the prevalence of plasma cells in the general infertile population and whether a threshold exists which predicts live birth.

METHODS

Endometrial samples were obtained prospectively from 80 women undergoing IVF, embedded in paraffin, and stained for plasma cells using mouse mono-clonal antibody for CD138. Slides were reviewed at 20× magnification and 10 random images captured. Three reviewers graded each image for plasma cells. Participants underwent single, euploid, and frozen blastocyst transfer.

RESULTS

Forty-nine percent of samples had ≥1 plasma cell across 10 HPFs, 11% had ≥5 cells across 10 HPFs, and 4% had ≥10 cells across 10 HPFs. There was no difference in prevalence between those who did and did not achieve live birth. Using thresholds of 1, 5, and 10 plasma cells per 10 HPFs, there were no differences in implantation, clinical pregnancy, clinical pregnancy loss, or live birth rates between patients with and without CE.

CONCLUSION

Endometrial plasma cells are present in half the general infertile population and do not predict implantation, clinical pregnancy, clinical pregnancy loss, or live birth rates at low levels.

P046 A review and retrospective case series of paediatric Sjögren’s syndrome from Southern Africa

Background

Paediatric Sjögren’s syndrome (pSS) is an uncommon autoimmune paediatric disease, rarely reported in children in Africa. It remains an important consideration in a child with parotid swelling. Here, we present a retrospective case-series of four patients from a paediatric rheumatology clinic in South Africa and discuss some of the difficulties of diagnosis in our context.

Methods

We performed a retrospective analysis of patients who attend the Red Cross War Memorial Hospital Paediatric Rheumatology clinic between 2010 and 2019.

Result

The four patients diagnosed with Sjögren’s all had varied presentations and disease courses. There were 3 females and 1 male and the ages at diagnosis ranged from 6 to 19 years old. The time to diagnosis was prolonged and ranged from 1 month to 10 years. Two patients with primary pSS presented with extra-articular manifestations of arthritis, abdominal pain and fatigue, followed by dry mouth, dry eyes, parotid swelling and and suggestive histopathology. The remaining 2 patients had a secondary pSS due to juvenile onset SLE and tuberculosis respectively.

Conclusion

In less resourced settings the diagnosis of pSS is often delayed. Both patients with primary pSS had preceding extra-glandular manifestations. In less resourced settings, infectious diseases may present as pSS and associated rheumatic diseases causing secondary pSS must be considered.

Emergency Laparotomy Follow-Up Study (ELFUS): prospective feasibility investigation into postoperative complications and quality of life using patient-reported outcome measures up to a year after emergency laparotomy

BACKGROUND

Emergency laparotomy carries a significant risk profile around the time of surgery. This research aimed to establish the feasibility of recruitment to a study using validated scoring tools to assess complications after surgery; and patient-reported outcome measures (PROMs) to assess quality of life and quality of recovery up to a year following emergency laparotomy (EL).

METHODS

We used our local National Emergency Laparotomy Audit (NELA) register to identify potential participants at a single NHS centre in England. Complications were assessed at 5, 10 and 30 days after EL. Patient-reported outcome measures were collected at 1, 3, 6 and 12 months after surgery using EQ5D and WHODAS 2.0 questionnaires.

RESULTS

Seventy of 129 consecutive patients (54%) agreed to take part in the study. Post-operative morbidity survey data was recorded from 63 and 37 patients at postoperative day 5 and day 10. Accordion Complication Severity Grading data was obtained from 70 patients. Patient-reported outcome measures were obtained from patients at baseline and 1, 3, 6 and 12 months after surgery from 70, 59, 51, 48, to 42 patients (100%, 87%, 77%, 75% and 69% of survivors), respectively.

CONCLUSIONS

This study affirms the feasibility of collecting PROMs and morbidity data successfully at various time points following emergency laparotomy, and is the first longitudinal study to describe quality of life up to a year after surgery. This finding is important in the design of a larger observational study into quality of life and recovery after EL.

LB0004 EFFICACY AND SAFETY OF SECUKINUMAB IN ENTHESITIS-RELATED ARTHRITIS AND JUVENILE PSORIATIC ARTHRITIS: PRIMARY RESULTS FROM A RANDOMISED, DOUBLE-BLIND, PLACEBO-CONTROLLED, TREATMENT WITHDRAWAL, PHASE 3 STUDY (JUNIPERA)

Background:

Enthesitis-related arthritis (ERA) and juvenile psoriatic arthritis (JPsA) are two ILAR categories of juvenile idiopathic arthritis (JIA) and represent paediatric correlates of axial spondyloarthritis (axSpA) and adult psoriatic arthritis (PsA), respectively.1,2 Secukinumab (SEC) has demonstrated efficacy and safety in adult patients (pts) with PsA, ankylosing spondylitis and non-radiographic axSpA.3-5

Objectives:

Evaluate efficacy and safety of SEC using a flare prevention design in pts with active ERA and JPsA.

Methods:

This 2-yr study consisted of an open-label (OL) s.c. SEC (75/150 mg in pts <50/ ≥50 kg) at baseline (BL), and at Weeks (Wk) 1, 2, 3, 4, 8 and 12 in treatment-period (TP) 1. Responder pts who achieved at least JIA ACR 30 response at Wk 12 were randomised into the double-blinded TP2 to continue SEC or placebo (PBO) q4w until a disease flare, or up to Wk 100. Pts (aged 2 to <18 yrs) classified as ERA or JPsA according to ILAR criteria of ≥6 months duration with active disease were included. Primary endpoint was time to flare in TP2 and key secondary endpoints were JIA ACR 30/50/70/90/100, inactive disease, JADAS, enthesitis count and safety. Analysis of time to flare in TP2 included proportion of disease flare, Kaplan-Meier (KM) estimate of median time to flare in days, hazard ratio (95% CI) from Cox model, and P-value for the Stratified log-rank test. KM estimates of the probability to disease flare by treatment groups in TP2 were plotted against days. Observed data were used in all analyses. Post-hoc analyses using non-responder imputation (NRI) were performed for JIA ACR 30/50/70/90/100 responses.

Results:

86/97 (89%) pts were enrolled in the OL period TP1 (mean age, 13.1 yrs; female, 33.7%; ERA, n=52; JPsA, n=34). At BL, mean JADAS-27 score was 15.1 and enthesitis count was 2.6. At the end of TP1, 90.4% (75/83) of pts achieved JIA ACR 30 and 69.9% (58/83) achieved JIA ACR 70. There were 21 and 10 flares in TP2, respectively in PBO and SEC treated pts with a significantly longer time to flare and 72% risk of flare reduction in SEC treatment vs PBO (HR: 0.28; 95% CI: 0.13–0.63; P<0.001) (Figure 1). JIA ACR responses, disease activity and enthesitis count are reported in Table 1. NRI analyses showed that 87.2%, 83.7%, 67.4%, 38.4% and 24.4% of pts achieved JIA ACR 30/50/70/90/100, respectively. Rates of adverse events (AEs; 91.7% vs 92.1%) and serious AEs (14.6% vs 10.5%) in SEC and PBO groups were comparable in the entire TP. No new safety signals were observed.

Table 1.

Efficacy of secukinumab in Treatment Periods 1 and 2 (Key secondary endpoints)

Efficacy Outcomes, %TP1TP2¥SEC (N=83)^SEC (N=37)PBO (N=37)P-valueJIA ACR 3090.489.264.90.014JIA ACR 5086.778.462.20.152JIA ACR 7069.967.643.20.042JIA ACR 9039.851.440.50.431JIA ACR 10025.343.237.80.745Inactive disease#36.147.237.80.500JADAS-27, mean (SD)15.1 (7.2)14.6 (8.1)13.3 (5.8)NAEnthesitis count, mean change from BL (SD)−1.8 (2.3)−2.1 (2.0)−1.9 (1.2)NA

P-values: Cochran-Mantel-Haenszel test, adjusted for analysis factors: JIA category (ERA/ JPsA) and MTX use at BL

¥The N numbers are values at the end of TP2

^Efficacy outcomes (%) in TP1 calculated in patients with evaluable data at Wk 12 (N=83)

#Inactive disease: Definition adapted from JIA ACR criteria of Wallace et al., 2011. N=36 for SEC at the end of TP2

JADAS, Juvenile Arthritis Disease Activity Score; N, total number of patients in the treatment group; NA, data not available

Figure 1.

Time to flare in Treatment Period 2 (Primary Endpoint)

Conclusion:

In children and adolescents with ERA and JPsA, efficacy of SEC was demonstrated with a significantly longer time to flare vs PBO with sustained improvement of signs and symptoms up to Wk 104 and a favourable safety profile.

References:

[1]Colbert RA. Nat Rev Rheumatol. 2010;6:477–85.

[2]Martini A, et al. J Rheumatol. 2019;46:190–7.

[3]McInnes IB, et al. Lancet. 2015;386:1137–46.

[4]Baeten D, et al. N Engl J Med. 2015;373:2534–48.

[5]Deodhar A, et al. Arthritis Rheumatol. 2021;73:110–20.

Disclosure of Interests:

Nicolino Ruperto Consultant of: Ablynx, Astrazeneca-Medimmune, Bayer, Biogen, Boehringer, Bristol Myers and Squibb, Celgene, Eli-Lilly, EMD Serono, Glaxo Smith and Kline, Hoffmann-La Roche, Janssen, Merck, Novartis, Pfizer, R-Pharma, Sinergie, Sobi and UCB, Grant/research support from: BMS, Eli-Lilly, GlaxoSmithKline, F Hoffmann-La Roche, Janssen, Novartis, Pfizer, Sobi, Speakers bureau: Ablynx, Astrazeneca-Medimmune, Bayer, Biogen, Boehringer, Bristol Myers and Squibb, Celgene, Eli-Lilly, EMD Serono, Glaxo Smith and Kline, Hoffmann-La Roche, Janssen, Merck, Novartis, Pfizer, R-Pharma, Sinergie, Sobi and UCB, Ivan Foeldvari Consultant of: Novartis, Speakers bureau: Novartis, Ekaterina Alexeeva Grant/research support from: Novartis, Pfizer, Sanofi, MSD, AMGEN, Eli Lilly, Roche, Speakers bureau: Novartis, Pfizer, Sanofi, MSD, AMGEN, Eli Lilly, Roche, NURAY AKTAY AYAZ: None declared, Inmaculada Calvo Consultant of: Sobi, Novartis, Abbvie, GlaxoSmithKline, Pfizer, Amgen, Clementia, Speakers bureau: Sobi, Novartis, Abbvie, GlaxoSmithKline, Pfizer, Amgen, Clementia, Ozgur KASAPCOPUR: None declared, Vyacheslav Chasnyk: None declared, Markus Hufnagel Grant/research support from: Astellas, F. Hoffmann-La Roche, Novartis, Zbigniew Żuber: None declared, Grant Schulert Consultant of: Sobi, Novartis, Seza Ozen: None declared, Artem Popov: None declared, Athimalaipet Ramanan Speakers bureau: Roche, Sobi, Eli Lilly, UCB, Novartis, Christiaan Scott: None declared, Betül Sözeri: None declared, Elena Zholobova Grant/research support from: Pfizer, Novartis, Speakers bureau: Abbvie, Pfizer, Roche, Novartis, Xuan Zhu Employee of: Novartis, sarah whelan Employee of: Novartis, Shareholder of: Novartis, Luminita Pricop Employee of: Novartis, Shareholder of: Novartis, Angelo Ravelli Consultant of: Abbvie, Bristol-Myers Squibb, Pfizer, Hoffmann-LaRoche, Novartis, Centocor, Angelini Holding, Reckitt Benckiser, Speakers bureau: Abbvie, Bristol-Myers Squibb, Pfizer, Hoffmann-LaRoche, Novartis, Centocor, Angelini Holding, Reckitt Benckiser, Alberto Martini Consultant of: Eli Lilly, EMD Serono, Janssen, Novartis, Pfizer, Abbvie, Speakers bureau: Eli Lilly, EMD Serono, Janssen, Novartis, Pfizer, Abbvie, Daniel J Lovell Consultant of: AstraZeneca, Wyeth, Amgen, Abbott, Pfizer, Hoffmann-La Roche, Novartis, UBC, Takeda, Janssen, GlaxoSmithKline, Boehringer Ingelheim, Celgene, Bristol Myers Squibb, AbbVie, Forest Research, Speakers bureau: AstraZeneca, Wyeth, Amgen, Abbott, Pfizer, Hoffmann-La Roche, Novartis, UBC, Takeda, Janssen, GlaxoSmithKline, Boehringer Ingelheim, Celgene, Bristol Myers Squibb, AbbVie, Forest Research, Hermine Brunner Consultant of: Aurina, AbbVie, Astra Zeneca-Medimmune, Biogen, Boehringer, Bristol-Myers Squibb, Celgene, Eli Lilly, EMD Serono, GlaxoSmithKline, F. Hoffmann-La Roche, Merck, Novartis, R-Pharm, Sanofi, Pfizer, Grant/research support from: Bristol-Myers Squibb, Eli Lilly, GlaxoSmithKline, F. Hoffmann-La Roche, Janssen, Novartis, and Pfizer, Speakers bureau: Pfizer, Roche and GlaxoSmithKline

441 Intravenous Tranexamic Acid Given at Femoral Fragility Fracture Surgery Reduces Blood Transfusion Requirements Four-Fold

Introduction

Tranexamic acid (TXA) is proven to reduce blood loss in several surgical fields, but its use in femoral fragility fracture (FFF) management is ill defined. This study examined the effect of intraoperative TXA on the rate of postoperative blood transfusion following FFF.

Method

A prospective non-randomized case-control study of 361 consecutive patients admitted to the study centre with FFFs over a 4-month period was performed. Intravenous TXA 1g was administered intraoperatively at the discretion of the operating team: 178 patients received TXA and 183 did not.

Results

Patients given TXA required fewer blood transfusions: 15/178 (8.4%) vs controls 58/183 (31.7%), (p &lt; 0.001). Calculated blood loss (mean difference -222ml (-337 to -106, 95%CI), p &lt; 0.001) and percentage drop in Hb (mean difference -4.3% (-6.3 to -2.3, 95%CI), p &lt; 0.001) were significantly lower in the TXA group. The difference in CBL was greatest following intramedullary nail (n = 49: mean difference -394ml, p = 0.030) and DHS (n = 101, mean difference -216ml, p = 0.032). There was no significant difference in complication rates: venous thromboembolism TXA 2/178 vs control 1/182 (p = 0.620); MI/stroke/TIA 2/178 vs 0/182 (p = 0.244)

Conclusions

Intraoperative intravenous TXA significantly reduced calculated blood loss and blood transfusion requirements following femoral fragility fracture surgery without increasing the rate of complications.

Extracting hypertrophic cardiomyopathy features from cardiac magnetic resonance reports by natural language processing

Objective

Determine if information regarding hypertrophic cardiomyopathy (HCM) can be accurately retrieved from cardiac magnetic resonance (CMR) reports using natural language processing (NLP).

Background

CMR imaging is used for diagnosis and risk stratification of HCM. Manual annotation of information from CMR is time-consuming. NLP is an artificial intelligence method for automating extraction of information from narrative text.

Methods

We identified 200 HCM patients who had CMR reports from 1998 to 2018. These patients were randomly allocated into training (100 patients with 185 CMR reports) and testing sets (100 patients with 206 reports). An NLP system with 2 tiers was developed; the first extracted information regarding HCM diagnosis while second extracted categorical or numeric concepts for HCM classification. NLP performance was compared with gold-standard manual annotation.

Results

NLP algorithms achieved very high performance across all concepts with mean positive predictive value (PPV) = 0.96. An outlier was the performance for abstracting the presence of an apical pouch from CMR reports, which had noticeably lower PPV= 0.78 which be attributed to the low number of cases with this finding.

Conclusions

The algorithms developed can be translated to clinical decision support systems to increase efficiency and contribute to improved quality of care.

Funding Acknowledgement

Type of funding source: Other. Main funding source(s): Study supported by the National Heart, Lung and Blood Institute of National Institutes of Health (K01HL124045), the Mayo Clinic Center for Clinical and Translational Science (CCaTS), and the Mayo Clinic K2R award. Content is solely the responsibility of authors and does not necessarily represent official views of the National Institutes of Health.

ABVD and BEACOPP regimens' effects on fertility in young males with Hodgkin lymphoma

Purpose

Considering the increased cancer patient survivorship, the focus is now on addressing the impacts of treatment on quality of life. In young people, altered reproductive function is a major issue and its effects in young males are largely neglected by novel research. To improve clinician awareness, we systematically reviewed side effects of chemotherapy for Hodgkin lymphoma (HL) in young males.

Methods

The review was prospectively registered (PROSPERO N. CRD42019122868). Three databases (Medline via PUBMED, SCOPUS, and Cochrane Library) were searched for studies featuring males aged 13-51-years who underwent chemotherapy for HL using ABVD (Adriamycin® (doxorubicin), bleomycin, vinblastine, and dacarbazine) or BEACOPP (bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, and prednisolone) regimens. These chemotherapy regimens were compared against each other using sperm characteristics, FSH, and inhibin B levels to measure fertility levels.

Results

Data were extracted from five studies featuring 1344 patients. 6 months post-ABVD saw marked deterioration in sperm count, further reduced by more cycles (P = 0.05). Patients treated with BEACOPP rather than ABVD were more prone to oligospermia. Receiving fewer cycles of both regimens increased the likelihood of sperm production recovering. Patients treated with 6-8 cycles of BEACOPP did not recover spermiogenesis.

Conclusions

ABVD and BEACOPP regimens significantly reduce fertility function to varying effects depending on treatment duration. ABVD temporarily causes significant reductions in male fertility, whereas BEACOPP’s effects are more permanent. Therefore, clinicians should discuss fertility preservation with male patients receiving infertility-inducing gonadotoxic therapy. Further high-quality studies are required to more adequality describe the risk to fertility by chemotherapy.

Electronic supplementary material

The online version of this article (10.1007/s12094-020-02483-8) contains supplementary material, which is available to authorized users.

Predictors of Favorable Outcome after Endovascular Thrombectomy in MRI: Selected Patients with Acute Basilar Artery Occlusion

BACKGROUND AND PURPOSE

Clinical outcomes after endovascular treatment for acute basilar artery occlusions need further investigation. Our aim was to analyze predictors of a 90-day good functional outcome defined as mRS 0-2 after endovascular treatment in MR imaging-selected patients with acute basilar artery occlusions.

MATERIALS AND METHODS

We analyzed consecutive MR imaging-selected patients with acute basilar artery occlusions endovascularly treated within the first 24 hours after symptom onset. Successful and complete reperfusion was defined as modified TICI scores 2b-3 and 3, respectively. Outcome at 90 days was analyzed in univariate and multivariate analysis regarding baseline patient treatment characteristics and periprocedural outcomes.

RESULTS

One hundred ten patients were included. In 10 patients, endovascular treatment was aborted for failed proximal/distal access. Overall, successful reperfusion was achieved in 81.8% of cases (n = 90; 95% CI, 73.3%-88.6%). At 90 days, favorable outcome was 31.8%, with a mortality rate of 40.9%; the prevalence of symptomatic intracranial hemorrhage within 24 hours was 2.7%. The median time from symptom onset to groin puncture was 410 minutes (interquartile range, 280-540 minutes). In multivariable analysis, complete reperfusion (OR = 6.59; 95% CI, 2.17-20.03), lower pretreatment NIHSS (OR = 0.77; 95% CI, 0.64-0.94), the presence of posterior communicating artery collateral flow (OR = 2.87; 95% CI, 1.05-7.84), the absence of atrial fibrillation (OR = 0.18; 95% CI, 0.03-0.99), and intravenous thrombolysis administration (OR = 2.75; 95% CI, 1.04-7.04) were associated with 90-day favorable outcome.

CONCLUSIONS

In our series of MR imaging-selected patients with acute basilar artery occlusions, complete reperfusion was the strongest predictor of a good outcome. Lower pretreatment NIHSS, the presence of posterior communicating artery collateral flow, the absence of atrial fibrillation, and intravenous thrombolysis administration were associated with favorable outcome.

Equine seminal plasma and sperm membrane: Functional proteomic assessment

During ejaculation, a large amount of seminal plasma proteins interact with the sperm membrane, leading to a series of biochemical and structural changes implicated in sperm function and gamete interaction. However, the roles of the majority of these proteins remain unknown. This study aimed to investigate the proteome and functionality of the major equine proteins of seminal plasma and the sperm membrane. Seminal plasma and enriched-membrane proteins (150 μg) were separated by two-dimensional gel electrophoresis, and the respective maps were analyzed. Protein identification was performed by in-gel digestion and tandem mass spectrometry (GeLC-MS/MS). Samples were also submitted to in-solution digestion (complex protein mixture) and identified by shotgun analysis by LC-MS/MS; bioinformatic tools were used to investigate protein functions. Seminal plasma and sperm membrane extract maps contained 91.0 ± 8.2 spots and 245.3 ± 11.3 spots, respectively, within the 3-10 pH range. In total, the most abundant proteins identified in 2D maps and in complex protein mixtures included 24 proteins for seminal plasma and 33 for sperm membrane extract, with a high degree of confidence (P < 0.05). Of these, HSP1, CRISP3 and KLK1E2 were the most abundant in seminal plasma; HSP1 was highly abundant in sperm membrane extract, in many isoforms, which is related to membrane destabilization and may compromise sperm preservation. HSP1-polybromo-1 interactions suggested a role in DNA stabilization. Prosaposin was identified in seminal plasma and may play a role in the fertilization process. IZUMO4, a member of the IgSF family involved in the prefertilization stages, was identified in 2D gel and MS/MS analysis of sperm membrane extract. Ten proteins of seminal plasma were found to interact with the sperm membrane and were related to binding and catalytic activities (clusterin, CRISP3, epididymal sperm-binding protein 1, kallikrein1E2, seminal plasma protein A3, and HSP1). Additionally, other identified proteins were associated with DNA integrity, capacitation and recognition of pregnancy. These findings indicate that the binding of specific proteins to the plasma membrane during ejaculation may influence sperm survival after cryopreservation and may play a role in decreasing the quality in stallions with toxic seminal plasma. Elucidation of these interactions is an important step in understanding the biological processes related to equine fertility and facilitates future investigations on the selection and application of low freezability semen strategies.

Investigating Conceptual Models for the Relationship Between Depression and Condomless Sex Among Gay, Bisexual, and Other Men Who have Sex with Men: Using Structural Equation Modelling to Assess Mediation

The aim of this study is to investigate five hypothesized mechanisms of causation between depression and condomless sex with ≥ 2 partners (CLS2+) among gay, bisexual, and other men who have sex with men (GBMSM), involving alternative roles of self-efficacy for sexual safety and recreational drug use. Data were from the AURAH cross-sectional study of 1340 GBMSM attending genitourinary medicine clinics in England (2013–2014). Structural equation modelling (SEM) was used to investigate which conceptual model was more consistent with the data. Twelve percent of men reported depression (PHQ-9 ≥ 10) and 32% reported CLS2+ in the past 3 months. AURAH data were more consistent with the model in which depression was considered to lead to CLS2+ indirectly via low self-efficacy for sexual safety (indirect Beta = 0.158; p < 0.001) as well as indirectly via higher levels of recreational drug use (indirect Beta = 0.158; p < 0.001). SEM assists in understanding the relationship between depression and CLS among GBMSM.

AB1078 USE OF MYOSITIS SPECIFIC AUTOANTIBODIES TEST ACROSS A LARGE NHS HOSPITAL TRUST

Background:

The immunology laboratory at Barts Health supports a large clinical myopathy service, providing blood tests for myositis-specific autoantibodies (MSA) by a commercial line immunoblot panel for Jo1, PL7, PL12, SRP, Mi2, Ku, PM-Scl and Scl-70.

As Idiopathic Inflammatory Myositis (IIM) disease subtype definitions have evolved from the 1975 Bohan & Peter criteria, the discovery of new antibodies has proven useful in the hands of neuromuscular clinicians whose patients have a high pre-test probability of disease. Ready availability of the test has led to increased demand from:

Objectives:

Determine the frequency of MSA requests from different departments.

To investigate the possibility of rejecting requests for MSAs at the laboratory in the absence of an elevated creatine kinase (CK), a hallmark of muscle damage associated with myositis (1).

Methods:

MSA were measured by a commercial line blot (Bluediver) which included Jo-1, PL-7, PL-12, Mi-2, Ku, SRP-54 and PM-Scl-100. Demographics and results for all MSA requested between September 2017 and November 2019 were pulled from laboratory records, together with CK results (if performed). CK was interpreted as low, normal or elevated according to reference ranges of 25-200 U/L (female) or 40-320 U/L (male).

Results:

597 tests were performed between 2017 and 2019. In total 59/597 (10%) were positive for the audited antibodies (Table 1). General Practitioner (GP) requests accounted for 41/597 (6.9%) tests, internal 464/597 (78%) and external 82/597 (14%). External requests were the most frequently positive at 10/82 (12%), internal requests 46/464 (10%), and GP requests only 3/41 (7%) of the time. Of all internal requesting sources, Respiratory accounted for the largest number at 108/597 (18%), followed by neurology with 85/597 (14%) (Figure 1). GPs constituted the 4thlargest source of requests.

Table 1.Positive on polymyositis screen% positivityAll tests597Total599.9%Jo-140.7%PL-720.3%PL-1250.8%SRP-54101.7%Mi-240.7%Ku30.5%PM-Scl 100254.2%Scl-7071.2%Figure 1.

MSAs had an associated CK result in 75% of internal and 12% of GP requests. A cohort of 17 patients had positive MSAs (3 x SRP, 1 x PL-7, 1 x Jo-1, 2 x Mi-2, 1 x Ku, 8 x PM-Scl100 and 1 x Scl-70) with normal CK.

Of the 41 GP requests, MSA had been requested by the lab on the basis of ANA pattern for 33 (80%) of them, 3 of which were positive (2 x Scl-70, 1 x SRP-54).

Conclusion:

Demand for MSA from the Respiratory department (screening for ILD) currently exceeds demand from Neurology and from Rheumatology. In the GP cohort, 33 requests (80% of GPs, 5% of all requests) were generated by the laboratory.

A cohort of patients with normal CK results had a positive MSA, implying CK alone cannot be used to limit test access. Interestingly, 10 positive results had no CK requested implying they were not being investigated for myositis.

Further work is needed to determine the specificity and sensitivity of these antibodies for patients with clinically defined myositis, and the appropriateness of allowing the test to be applied in the absence of any clinical evidence of IIM.

The findings of this audit need to be further extended to look at other myositis including other anti-synthetases, HMGCoAR, MDA5, TIF-1γ, NPX-2.

References:

[1]Dalakas MC, Hohlfeld R (2003) Polymyositis and dermatomyositis. Lancet 362:971–982

Disclosure of Interests:

None declared

AB1131 STATISTICAL PROCESS CONTROL AND PROCESS MAPPING QUANTIFY THE EFFECTS OF HISTORICAL CHANGES TO THE CONNECTIVE TISSUE DISEASE TESTING ALGORITHM AND IDENTIFY AREAS FOR FUTURE IMPROVEMENT IN A LARGE DIAGNOSTIC IMMUNOLOGY SERVICE

Background:

Pathology test turnaround times (TATs) are a limiting factor in patient flow through rheumatology services. Quality improvement (QI) methodologies such as Lean use tools including statistical process control (SPC) and process mapping to study the performance of the whole of a clinical pipeline, expose unnecessary complexity (non-value-adding activity), and streamline processes and staff roles.

Objectives:

Understand effects of changes made to CTD testing algorithm over last 12 years by measuring some of the effects on TATs. Model current processes and suggest changes to workflow to improve TAT.

Methods:

High-level flow diagrams of the current testing algorithm, and low-level process maps of analyser and staff processes were drawn.

Activity and TATs (working days between report and booking date) for ANA, ENA, DNA and CCP tests were plotted as XmR control charts.

Results:

Finding 1: Largest referral laboratory does not currently operate a separate DNA monitoring workstream, resulting in unnecessary ANA and ENA testing (figure 1).

Figure 1.

Current testing strategy (left) and suggested improvement (right)

Finding 2:Samples are handed off between 3 different lab benches, each of which may be staffed by a different staff member on a different day, and results processing involves handoff to a further 2 different staff members.

Finding 3:ANA demand is close to capacity, ENA demand exceeds current capacity (table 1).

Table 1.

Demand for ANA, ENA and DNA tests, compared to capacity

TestMedian Demand(tests/ day)Approx. Capacity(tests/ day)NotesANA74100Close to 80% recommended by the ILGsENA3836*Less capacity than demand!!DNA34100Plenty

Finding 4:Stopping screening DNA requests on ANA result increased the number of DNA tests performed by about 10 samples per day (30%), but decreased turnaround time by a similar proportion (3.3 to 2.3 days, figure 2). It also reduced turnaround times of ANA and ENA tests.

Figure 2.

Control chart of average TAT of dsDNA antibodies by request date

Conclusion:

Typically for a QI project, the initially simple CTD testing pipeline has accumulated many changes made without consideration of whole system performance, and is now a struggle to run.

Improvement ideas to be explored from this work include:

Disclosure of Interests:

None declared

OP0259-PARE WORLD YOUNG RHEUMATIC DISEASES (WORD) DAY: THE FIRST INTERNATIONAL AWARENESS DAY FOR PAEDIATRIC RHEUMATIC DISEASES

Background:

There is a lack of awareness of paediatric rheumatic diseases (PRDs), among the public, and certain groups of healthcare professionals, such as general practitioners [1]. To help improve awareness and understanding of PRDs, World Young Rheumatic Diseases Day (WORD Day) was established in 2019.

Objectives:

The aim of WORD Day, which took place on 18 March 2019, was to raise awareness of PRDs, while informing young people, families, healthcare professionals, teachers, and the public about the importance of timely referral plus early diagnosis and access to appropriate treatment and support.

Methods:

A steering committee was established for the inaugural campaign. An external agency was appointed to provide digital support, with an official social media campaign launching in December 2018. Social media analytics were used to measure the impact of official social media platforms. A range of branded materials were also made available (Fig 1), including an official campaign video. In addition, a specific engagement activity (#ButtonChallenge2019) was launched. This challenged participants to button up a piece of clothing while wearing gloves, to simulate the difficulties that young people with PRDs face undertaking daily activities. As part of the campaign launch, a list of suggested activities were provided, along with template press releases.

Results:

Several face-to-face and virtual events took place globally on or around WORD Day 2019, with 34 countries reporting events (Fig 2). Examples of events included lectures, social gatherings and media appearances. An official WORD Day tweet chat was also hosted. Regarding social media impact, between December 2018 and March 2019, a total of 2,585 and 660 individuals followed the official Facebook and Twitter accounts, respectively. Facebook posts were seen 646,000 times since the start of the campaign, with over 60,000 of Facebook reach from posts published on 18 March 2019 exclusively. A total of 270,800 impressions were observed on Twitter. The official #WORDDay2019 hashtag was seen by 533,955 unique accounts on 18 March 2019 alone, with 3,334,699 impressions. Posts with the hashtag were retweeted 1,112 times on WORD Day, with a total of 1,568 tweets recorded that day. With regards to the #ButtonChallenge2019, the challenge video was viewed for 6,700 minutes and received participation from across the world. Compared to the industry benchmark, the average engagements per post for WORD Day-related content was significantly higher compared to other medical and non-for-profit social media pages.

Conclusion:

WORD Day 2019 was the first international campaign focused solely on PRDs. Organic and paid social media content aided the dissemination of the WORD Day message, with Facebook proving to be the most popular social platform. Despite a wealth of different content published, authentic materials, namely video content, proved to be the most popular with users, particularly when it featured material designed by and with young people with PRDs. It was demonstrated that awareness events can often be resource-light and easily implemented across a range of diverse countries. It is anticipated that the global reach of WORD Day will increase over time as the campaign becomes more established.

References:

[1]Egert Y et al. Children and young people get rheumatic disease too. The Lancet Child & Adolescent Health. 2019;3(1):8-9.

Acknowledgments:

PReS for their financial support.

Disclosure of Interests:

Simon Stones Consultant of: I have been a paid consultant for Envision Pharma Group and Parexel. This does not relate to this abstract., Speakers bureau: I have been a paid speaker for Actelion and Janssen. These do not relate to this abstract., Eve Smith: None declared, Sammy Ainsworth: None declared, Veerle Buys: None declared, Wendy Costello: None declared, Yona Egert: None declared, Helen Foster: None declared, Lovro Lamot: None declared, Berent J. Prakken: None declared, Christiaan Scott: None declared

A158 LACK OF DIFFERENCE OF COLONIC CURVATURE IN SUPINE VERSUS PRONE PATIENT POSITIONS, IN NORMAL AND HIGH BMI INDIVIDUALS, AS ASSESSED BY QUANTITATIVE ASSESSMENT OF COMPUTED TOMOGRAPHY COLONOGRAPHY

Background

Dynamic positional changes during colonoscopy are commonly used in clinical practice, in particular moving from side to side. It has been shown to improve both adenoma detection rates as well as cecal intubation times. However, perhaps due to an additional level of inconvenience, there have been few studies comparing the anatomy and changes in colonic curvature when patients are in the prone position, which may help to prevent anterior bowing of the scope, particularly in patients with high body mass index (BMI).

Aims

To compare both the number of colonic curves and degree of change in curves with patients in supine versus prone positioning during computed tomography colonography (CTC).

Methods

75 CTC studies, obtained between January and April 2017 at Hotel Dieu Hospital in Kingston, Ontario, were screened and included based on image quality and adequacy of distention. Per standardized protocol, all patients undergoing CTC are imaged both in supine and prone positioning. Using an automated computer algorithm process developed for this study, curves were identified and measured via centerline points placed digitally through the colonic lumen, and compared between supine and prone patient positioning.

Results

75 colonographies were examined. The mean age was 68 years and 37/75 were male. BMI data was available for 56 patients, with mean BMI 29.4 (SD 5.7). There were no significant differences in total mean degrees of curvature between supine and prone positions [75.3 (SD 13.5) vs. 77.3 (SD 15.3), p=0.07], nor a significantly higher total number of curves &gt;100 degrees [4.0 (SD 2.0) vs. 4.5 (SD 2.3), p=0.14]. No significant correlation was seen between BMI and change in position (correlation factor 0.2, p=0.13).

Conclusions

No significant differences were found between the two positions during CT colonography. This certainly calls into question the strategy of starting in prone position, even in higher BMI patients. However, CT colonography doesn’t account for changes that can occur during colonoscopy, as the scope itself can dynamically affect angulations within the colon.

Funding Agencies

None

1049 High single-beat Doppler signals in low-gradient aortic stenosis are associated with higher aortic valve calcium

Funding Acknowledgements

Mayo Clinic

Background

Variability in Doppler signals is common in patients with atrial fibrillation (AF) and AF is common in low-gradient AS (LGAS). Presence of high single beat Doppler signals (peak velocity ≥4m/s or mean gradient ≥40mmHg) is not factored into decision-making in low-gradient aortic stenosis (LGAS).

Objective

Determine prevalence of at least one high Doppler signal in AF LGAS and its relationship to computed tomography aortic valve calcium score (AVCS) versus sinus rhythm (SR) high-gradient aortic stenosis (HGAS).

Methods

Consecutive patients with aortic valve area ≤1cm2 and left ventricular ejection fraction ≥50% during echo were identified (January 1, 2012-December 31, 2016). At least three consecutive Doppler signals were averaged in sinus rhythm (SR) and five in atrial fibrillation (AF).

Results

Of 1,854 patients, age 76± 11 years, male 52%, 301/1,854 (16%) were in AF and LGAS was present in 122/301 (41%). At least one high Doppler signal in AF LGAS was present in 43/122 (35%). AVCS within 1 year of echo was available for 36% of patient with SR HGAS and 34% of AS LGAS. Median AVCS was not different in SR HGAS 2424 (IQR 1623, 3445) vs AF LGAS with at least one high Doppler signal 2509 [IQR1547, 3119], p =0.10 AVCS threshold for severe AS (men &gt;2000 women &gt;1200) was met in 80% SR HGAS vs 86% AF LGAS with high signals.

Conclusions

High Doppler signals in AF LGAS are associated with high AVCS more frequently exceeding thresholds for severe AS. Single-beat high Doppler signals instead of the average correlate better with AVCS and classic HGAS.

P670Clincal and echocardiographic characteristics in patients with pathology proven cardiac papillary fibroelastomas

Background

Papillary fibroelastoma (PFE) is a rare benign cardiac tumor with embolic potential. It is most commonly found on cardiac valves but can also be present on non-valvular endocardial surfaces. We sought to better understand the average PFE growth and recurrence rates, and characteristics that might be associated with embolization.

Purpose

To examine growth and recurrence rates and factors associated with embolization in patients with pathology-proven PFE.

Methods

Pathology-proven PFEs from 279 patients were identified at a single center between January 1995 and December 2018,and those with at least two transesophageal echocardiograms (TEE) more than 30 days apart were analyzed (n=62). Medical records were retrospectively reviewed for clinical characteristics and outcomes. In addition, intra-operative TEEs were manually reviewed and compared to previous TEEs at our institution to estimate overall size, location, and average PFE growth rates.

Results

The TEEs from 62 patients with pathology-proven PFE (mean age 65±12 years, female 63%) were reviewed. PFE was discovered incidentally during cardiac surgery in 18% of patients. Most PFEs were located on the aortic valve (AV) (73%) followed by the mitral valve (MV) (16%). The majority of PFEs (71%) presented with a stalk versus a sessile configuration. Average maximal length for PFE (including stalk if present) on the AV was 8.5±3.3 mm, and on the MV 6.8±2.0 mm. The number of PFEs located in other locations was too small to be analyzed for growth. PFE growth varied depending on location and configuration. The PFE growth on the AV was an average increase of 0.47 mm/year, those on the MV was 0.115 mm/year.

Valvular PFE was associated with significant functional valve abnormality in 15% of patients, and the abnormality was attributed to the PFE in 9% of patients. There were 25 patients (40%) who had a documented stroke/transient ischemic attack prior to PFE removal (46% located on AV, 44% on MV, 10% other locations). In addition, some patients had other documented embolic complications, such as myocardial infarction, amaurosis fugax, and peripheral embolization to the spleen and kidney. PFE size and location (up-/ downstream of the valve) were not predictive of cardiovascular thromboembolic events. At a median follow up of 2 years, PFEs recurred in the same location in 7.5% of the patients.

Conclusion

PFE is highly associated with thromboembolic events and seem to grow slowly, with an average growth rate of 0.47mm/year on AV and 0.115mm/year on MV. Growth rates for PFE have not been previously described. PFE can be safely excised with preservation of the native valve and recurs in 7.5% of patients, suggesting that close follow-up maybe warranted.

Teach-Back Method: Using a Nursing Education Intervention to Improve Discharge Instructions on an Adult Oncology Unit

BACKGROUND

Transitions from acute clinical care to the outpatient setting can be daunting. Clear explanations of discharge instructions from nurses and assessment of the patient's understanding can have a positive impact.

OBJECTIVES

The purpose of this study was to assess the effect of an education intervention on nurses' use of the teach-back method, as well as the effects on patient satisfaction at discharge.

METHODS

The setting was a 20-bed adult oncology unit. Nurses' understanding of the teach-back method pre- and posteducation intervention was assessed using the Conviction and Confidence Scale. The effect of the intervention on patient satisfaction was assessed using the Press Ganey survey three months before and after teach-back education.

FINDINGS

The results of this study indicated that nurses were more confident in their ability to use the teach-back method and integrated many teach-back competencies into clinical practice. Although few follow-up surveys were received, longer-term data indicated continued improvement in patient satisfaction and understanding of discharge instructions.

A Markov Multi-State model of lupus nephritis urine biomarker panel dynamics in children: Predicting changes in disease activity

BACKGROUND

A urine 'biomarker panel' comprising alpha-1-acid-glycoprotein, ceruloplasmin, transferrin and lipocalin-like-prostaglandin-D synthase performs to an 'excellent' level for lupus nephritis identification in children cross-sectionally. The aim of this study was to assess if this biomarker panel predicts lupus nephritis flare/remission longitudinally.

METHODS

The novel urinary biomarker panel was quantified by enzyme linked immunoabsorbant assay in participants of the United Kingdom Juvenile Systemic Lupus Erythematosus (UK JSLE) Cohort Study, the Einstein Lupus Cohort, and the South African Paediatric Lupus Cohort. Monocyte chemoattractant protein-1 and vascular cell adhesion molecule-1 were also quantified in view of evidence from other longitudinal studies. Serial urine samples were collected during routine care with detailed clinical and demographic data. A Markov Multi-State model of state transitions was fitted, with predictive clinical/biomarker factors assessed by a corrected Akaike Information Criterion (AICc) score (the better the model, the lower the AICc score).

RESULTS

The study included 184 longitudinal observations from 80 patients. The homogeneous multi-state Markov model of lupus nephritis activity AICc score was 147.85. Alpha-1-acid-glycoprotein and ceruloplasmin were identified to be the best predictive factors, reducing the AICc score to 139.81 and 141.40 respectively. Ceruloplasmin was associated with the active-to-inactive transition (hazard ratio 0.60 (95% confidence interval [0.39, 0.93])), and alpha-1-acid-glycoprotein with the inactive-to-active transition (hazard ratio 1.49 (95% confidence interval [1.10, 2.02])). Inputting individual alpha-1-acid-glycoprotein/ceruloplasmin values provides 3, 6 and 12 months probabilities of state transition.

CONCLUSIONS

Alpha-1-acid-glycoprotein was predictive of active lupus nephritis flare, whereas ceruloplasmin was predictive of remission. The Markov state-space model warrants testing in a prospective clinical trial of lupus nephritis biomarker led monitoring.

Systemic Yersinia pseudotuberculosis as a Cause of Osteomyelitis in a Captive Ring-tailed Lemur (Lemur catta)

Yersinia pseudotuberculosis and Yersinia enterocolitica are ubiquitous pathogens with wildlife and domestic animal reservoirs. Outbreaks of 'non-plague' yersiniosis in man and non-human primates are reported frequently (including zoological specimens and research breeding colonies) and are usually characterized by enteritis, mesenteric lymphadenitis and occasionally organ abscessation. In people, non-septic reactive arthritis is a common sequela to yersiniosis. However, there have been rare reports in people of septic arthritis and osteomyelitis because of active systemic infection with Y. pseudotuberculosis. Osteomyelitis has also been reported rarely in historical yersiniosis outbreaks in farmed turkeys in England and the USA. This paper reports the first case of osteomyelitis caused by systemic infection with Y. pseudotuberculosis O:1 in a non-human primate, a captive ring-tailed lemur (Lemur catta). The lemur had a short clinical history of hyporexia and weight loss with reduction in mobility, especially of the left hindlimb. On post-mortem examination there was evidence of multi-organ abscessation. In addition, severe necrosis, inflammation and large bacterial colonies were present in the musculature, periosteum and bone marrow in the hip, ribs and a vertebra at the cervicothoracic junction. Osteomyelitis should be considered as a rare clinical presentation in non-human primates with systemic Y. pseudotuberculosis infection.

Growing international evidence for urinary biomarker panels identifying lupus nephritis in children - verification within the South African Paediatric Lupus Cohort

BACKGROUND

A urinary biomarker panel including alpha-1-acid-glycoprotein (AGP), lipocalin-like-prostaglandin-D-synthase (LPGDS), transferrin and ceruloplasmin demonstrates an 'excellent' ability for identifying active lupus nephritis in UK/US children. This study aimed to assess whether this panel identifies active lupus nephritis within the South African Paediatric Lupus Cohort.

METHODS

Juvenile-onset-systemic lupus erythematosus (JSLE) patients aged < 19 years at diagnosis and healthy controls were recruited. Patients were categorized as having active lupus nephritis (renal BILAG score; A/B and previous histological confirmation) or inactive lupus nephritis (renal BILAG score: D/E). Urinary biomarkers were quantified by ELISA. Mann-Whitney U-test compared biomarker levels between groups. Binary logistic regression and receiver operating curve analysis assessed biomarker combinations.

RESULTS

Twenty-three juvenile-onset-systemic lupus erythematosus patients were recruited with a median age of 13.5 years (interquartile range (IQR) 12.7-14.9) and disease duration of 2.6 years (IQR 1.8-4.0). Eighteen healthy controls had a median age of 11.0 years (IQR 10.0-12.0). AGP, LPGDS, transferrin, ceruloplasmin and VCAM-1 were significantly higher in active than in inactive lupus nephritis patients (corrected p-values, all p_c < 0.05), with no difference between inactive lupus nephritis patients and healthy controls (all p_c = 1.0). The optimal biomarker combination included AGP, ceruloplasmin, LPGDS and transferrin (area under the curve = 1.0).

CONCLUSIONS

A urinary biomarker panel comprising AGP, ceruloplasmin, LPGDS and transferrin previously validated within UK/US cohorts also performed excellently within a racially distinct South African cohort which displayed more severe lupus nephritis.

Measurement of Typhi Vi antibodies can be used to assess adaptive immunity in patients with immunodeficiency

Vaccine‐specific antibody responses are essential in the diagnosis of antibody deficiencies. Responses to Pneumovax II are used to assess the response to polysaccharide antigens, but interpretation may be complicated. Typhim Vi^®, a polysaccharide vaccine for Salmonella typhoid fever, may be an additional option for assessing humoral responses in patients suspected of having an immunodeficiency. Here we report a UK multi‐centre study describing the analytical and clinical performance of a Typhi Vi immunoglobulin (Ig)G enzyme‐linked immunosorbent assay (ELISA) calibrated to an affinity‐purified Typhi Vi IgG preparation. Intra‐ and interassay imprecision was low and the assay was linear, between 7·4 and 574 U/ml (slope = 0·99–1·00; R² > 0·99); 71% of blood donors had undetectable Typhi Vi IgG antibody concentrations. Of those with antibody concentrations  > 7·4 U/ml, the concentration range was 7·7–167 U/ml. In antibody‐deficient patients receiving antibody replacement therapy the median Typhi Vi IgG antibody concentrations were  < 25 U/ml. In vaccinated normal healthy volunteers, the median concentration post‐vaccination was 107 U/ml (range 31–542 U/ml). Eight of eight patients (100%) had post‐vaccination concentration increases of at least threefold and six of eight (75%) of at least 10‐fold. In an antibody‐deficient population (n = 23), only 30% had post‐vaccination concentration increases of at least threefold and 10% of at least 10‐fold. The antibody responses to Pneumovax II and Typhim Vi^® correlated. We conclude that IgG responses to Typhim Vi^® vaccination can be measured using the VaccZyme Salmonella typhi Vi IgG ELISA, and that measurement of these antibodies maybe a useful additional test to accompany Pneumovax II responses for the assessment of antibody deficiencies.

Evaluation of the Tuberculosis Infection Control Training Center, Tajikistan, 2014-2015

SETTING

Training center on tuberculosis (TB) infection control (IC) for health care workers in the Central Asian Republics region.

OBJECTIVE

To assess the effects of TB IC training courses conducted at the Tuberculosis Infection Control Training Center in Machiton, Tajikistan.

DESIGN

Participants who participated in training (n = 89) during the first year of operation (April 2014-February 2015) were invited to participate in a post-training interview.

RESULTS

Of the 89 participants, 84 (94%) completed the interview and expressed satisfaction with the training. Eighty (95%) participants reported meeting with workplace leadership to discuss the training. Of these, 69 (85%) reported discussing changes required to meet TB IC standards. Self-reported changes in TB IC practices at work facilities post training included the creation of TB IC committees, designation of a TB IC focal person, TB IC planning, policies to separate infectious patients in waiting rooms, provision of masks for infectious patients, development of cough etiquette policies, improved glove availability, hand hygiene programs, and TB IC posters in waiting rooms.

CONCLUSIONS

Participant satisfaction and reported changes in TB IC activities illustrate the potential of these training courses to improve TB IC in the region. Future training courses may be tailored to specific audiences using a structured conceptual framework to impact administration, budgeting, and facilities management of TB IC practices.

Ocular Findings in Low Birthweight and Premature Babies in the First Year: Do We Need to Screen?

Purpose

There is no standardized approach for the ophthalmic care follow-up of children screened for retinopathy of prematurity (ROP). The authors report the ocular findings at 12 months in preterm and low birthweight babies screened for ROP over a 5-year period (1998–2003).

Methods

The case notes of 211 babies were retrospectively reviewed for birth details, maternal details, presence of ROP, and findings at follow-up screening which included visual acuity, refraction at 12 months, presence of squint, and any other ocular problems.

Results

At 1 year follow-up, 16.6% of ROP positive children failed a screening visit because of squint (6.66%), refractive error (6.66%), and optic nerve abnormalities (3.33%). At 1 year follow-up, 10% of ROP negative children had failed a screening visit because of squint (3.75 %), refractive error (3.75%), and other pathology (2.5%).

Conclusions

The authors recommend screening all babies with ROP at 12 months to identify amblyogenic factors such as squint and refractive error. Parents of infants who do not develop ROP should be advised of the increased risk of visual problems in their children and to have their child examined in the preschool period.

Aspirin reduces lipopolysaccharide-induced pulmonary inflammation in human models of ARDS

RATIONALE

Platelets play an active role in the pathogenesis of acute respiratory distress syndrome (ARDS). Animal and observational studies have shown aspirin's antiplatelet and immunomodulatory effects may be beneficial in ARDS.

OBJECTIVE

To test the hypothesis that aspirin reduces inflammation in clinically relevant human models that recapitulate pathophysiological mechanisms implicated in the development of ARDS.

METHODS

Healthy volunteers were randomised to receive placebo or aspirin 75  or 1200 mg (1:1:1) for seven days prior to lipopolysaccharide (LPS) inhalation, in a double-blind, placebo-controlled, allocation-concealed study. Bronchoalveolar lavage (BAL) was performed 6 hours after inhaling 50 µg of LPS. The primary outcome measure was BAL IL-8. Secondary outcome measures included markers of alveolar inflammation (BAL neutrophils, cytokines, neutrophil proteases), alveolar epithelial cell injury, systemic inflammation (neutrophils and plasma C-reactive protein (CRP)) and platelet activation (thromboxane B2, TXB2). Human lungs, perfused and ventilated ex vivo (EVLP) were randomised to placebo or 24 mg aspirin and injured with LPS. BAL was carried out 4 hours later. Inflammation was assessed by BAL differential cell counts and histological changes.

RESULTS

In the healthy volunteer (n=33) model, data for the aspirin groups were combined. Aspirin did not reduce BAL IL-8. However, aspirin reduced pulmonary neutrophilia and tissue damaging neutrophil proteases (Matrix Metalloproteinase (MMP)-8/-9), reduced BAL concentrations of tumour necrosis factor α and reduced systemic and pulmonary TXB2. There was no difference between high-dose and low-dose aspirin. In the EVLP model, aspirin reduced BAL neutrophilia and alveolar injury as measured by histological damage.

CONCLUSIONS

These are the first prospective human data indicating that aspirin inhibits pulmonary neutrophilic inflammation, at both low and high doses. Further clinical studies are indicated to assess the role of aspirin in the prevention and treatment of ARDS.

TRIAL REGISTRATION NUMBER

NCT01659307 Results.