Parental awareness and attitudes towards prevention of respiratory syncytial virus in infants and young children in Australia

AIM

To assess parental awareness of respiratory syncytial virus (RSV) and the level of acceptance of future RSV prevention strategies.

METHODS

A cross-sectional online survey was implemented targeting "future" and "current" parents of children aged ≤5 years in Australia.

RESULTS

From 1992 eligible participants, two non-mutually exclusive subgroups were formed: "current" parents (N = 1931) and "pregnant/planning" parents (N = 464: 403 also "current" parents and 61 "future" parents). Participants were predominantly (86.6%) aged 25-39 years and 68.5% with university education. The majority (89.6% current; 78.7% future) had heard of RSV. Of those, 64.2% (current) and 50.0% (future) were aware that pneumonia is associated with RSV; 71.8% (current) and 52.1% (future) were aware that bronchiolitis is associated with RSV. In multivariable logistic regression analyses, Australian-born parents (aOR = 2.47 [95% CI: 1.48-4.12]), living in the eastern states (e.g., New South Wales: aOR = 6.15 [95% CI:2.10-18.04]), with a university-level education (aOR = 2.61 [95% CI:1.38-4.94]) and being a current parent (aOR = 12.26 [95% CI:2.82-53.28]) were associated with higher RSV awareness. There was a high level of acceptance for maternal vaccines (future: 79.3%) and infant immunisation (all: 81.7%).

CONCLUSION

While RSV awareness and immunisation acceptance were high, there was limited knowledge of severity of RSV, especially in future parents. Education campaigns need to be developed to increase RSV knowledge.

Respiratory syncytial virus in children: epidemiology and clinical impact post-COVID-19

PURPOSE OF REVIEW

Respiratory syncytial virus (RSV) remains a leading cause of mortality and morbidity worldwide. RSV seasonality was disrupted by COVID-19-associated nonpharmaceutical interventions (NPIs). We review RSV seasonality, molecular epidemiology, clinical manifestations, and community awareness to inform future prevention strategies.

RECENT FINDINGS

An initial reduction of RSV disease observed with NPIs, and subsequent global resurgence was associated with a collapse in genetic diversity. A lack of immunity is suggested to have contributed to the resurgence of RSV cases experienced post COVID-19. The median age of children admitted with RSV increased during the resurgence, likely secondary to the expanded cohort of RSV-immune naive children. The pandemic also played a role in increased community awareness, which can be utilized as part of a coordinated public health effort to introduce prevention strategies. Further education on signs and symptoms of RSV is still required.

SUMMARY

mAbs and maternal vaccines targeting RSV have the potential to reduce paediatric morbidity, however this new era of RSV prevention will require ongoing research to facilitate community awareness and engagement, and better respiratory surveillance. Tackling the global burden of RSV will require a coordinated effort and measures to ensure access and affordability of new prevention strategies.

Presence and identity of Babesia microti in Ireland

Babesia microti is a tick-transmitted protozoan parasite of wildlife that can also cause serious disease in humans. It is now well established that B. microti represents an assemblage of different strains or species, only some of which are important zoonotic pathogens. Therefore, in order to assess the potential public health risk associated with B. microti in any given location, it is important to determine the strains that are present. This is the first study on the presence and identity of B. microti in Ireland. Overall, 314 wood mice (Apodemus sylvaticus), 243 bank voles (Myodes glareolus) and 634 questing Ixodes ricinus nymphs collected in various locations across Ireland were screened for the presence of B. microti by metabarcoding and nested PCR, respectively. Overall 8 rodent spleen samples (1.4%) were positive for B. microti, while all tick samples tested negative. Rodent isolates were identified as the 'Munich' strain which rarely causes human disease and is chiefly transmitted by the mouse tick, Ixodes trianguliceps. Together with reports from the UK these results suggest that B. microti does not represent a significant public health risk in Britain or Ireland.

Experimental Validation of a Kinetic Ballooning Mode in High-Performance High-Bootstrap Current Fraction Fusion Plasmas

We report the observation of a set of coherent high frequency electromagnetic fluctuations that leads to a turbulence induced self-regulating phenomenon in the DIII-D high bootstrap current fraction plasma. The fluctuations have frequency of 130-220  kHz, the poloidal wavelength and phase velocity are 16-30  m^{-1} and ∼30  km/s, respectively, in the outboard midplane with the estimated toroidal mode number n∼5-9. The fluctuations are located in the internal transport barrier (ITB) region at large radius and are experimentally validated to be kinetic ballooning modes (KBM). Quasilinear estimation predicts the KBM to be able to drive experimental particle flux and non-negligible thermal flux, suggesting its significant role in regulating the ITB saturation.

A-45 Clinical Considerations of Neuropsychologists for Treating Concussions

Purpose: The purpose of this study was to explore sex specific clinical considerations by neuropsychologists’ and general clinical considerations for the treatment of concussion. Methods: Fourteen clinical neuropsychologists who see concussion patients regularly (>1 case per week) were interviewed using a semi-structured guide that included a generic patient vignette. Participants were asked about clinical considerations that they faced while assessing, managing, and treating concussion. Two investigators independently coded the transcriptions and met to compare coding processes, definitions, and categories. A final codebook was developed in an iterative fashion and reapplied to all transcripts. Independent coding and member checks contributed to the trustworthiness of the data. Results: Participants’ clinical experience in treating concussion ranged from 1 to 40 years, and the sample was 64% female (9/14). Four major themes were identified, including patients’ sex considerations, sleep and napping, patient education and reassurance, and mental health considerations. Several participants (4/14; 29%) noted the lack of action-oriented clinical recommendations for previously documented sex differences (i.e., menstruation). There was a lack of uniformity in sleep and napping recommendations across the participants (e.g., permitting napping vs recommended nap-length). Participants noted that a large portion of their clinical time was spent educating and reassuring patients that concussion is treatable. Comorbid mental health considerations such as anxiety were a prevailing clinical concern across participants. Conclusions: The study revealed the need for better action-oriented clinical recommendations in consensus statements that address the four main themes of sex considerations, sleep and napping considerations, patient education and reassurance, and mental health considerations.

POS0684 IS UPADACITINIB CAPABLE OF IMPROVING PATIENT-REPORTED OUTCOMES OF RHEUMATOID ARTHRITIS IN A REAL-WORLD SETTING? RESULTS FROM THE POST-MARKETING OBSERVATIONAL UPwArds STUDY

Background

The efficacy of Upadacitinib (UPA), a selective Janus kinase inhibitor, has been evaluated in the SELECT clinical program 1-6. In addition, recent results from the non-interventional UPwArds study further confirmed UPAs clinical effectiveness regarding standard disease activity scores for rheumatoid arthritis (RA) in a real-world setting 7. However, patient-reported outcomes (PROs) as another cornerstone of clinical decision making yet remain to be addressed in the context of a post-marketing setting. This interim analysis, conducted after 250 patients had completed the 6-month follow-up visit, aims to fill this gap.

Objectives

To evaluate the change of selected PROs over 6 months in patients treated with UPA in a real-world data environment.

Methods

UPwArds is a prospective, open-label, multicenter, non-interventional, post-marketing study including adult patients with moderate-to-severe RA (swollen joint count [SJC28] ≥ 3 and inadequate response or intolerance to at least one previous disease-modifying antirheumatic drug). According to the German label, patients were treated with UPA 15 mg once daily, as monotherapy or in combination with methotrexate. For this analysis, the following PROs were included: 0-10 numerical rating scales (NRS) for pain and fatigue, the Health Assessment Questionnaire Disability Index (HAQ-DI), the duration and severity of morning stiffness, the Patient Health Questionnaire 9 (PHQ-9), and the Rheumatoid Arthritis Impact of Disease Questionnaire (RAID). Changes from baseline were evaluated for follow-up periods of 1 month, 3 months, and 6 months. Results are presented for the total sample using descriptive measures reflecting sample size (N), average values (standard deviation) for each assessment and average change scores (standard deviation) for follow-up visits. All data were analyzed as observed, with no imputation of missing data.

Results

483 patients (369 female, 114 male) were included in the study, with available baseline PRO information for 481 patients. 6-months follow-up data were yet available from 279 patients The baseline average age and disease duration were 58.0 (12.3) years and 9.0 (8.0) years, respectively, whereas the mean initial DAS28-CRP was 4.6 (1.0). At baseline, 60.8% of enrolled patients had previously been treated with biologic or targeted synthetic disease-modifying antirheumatic drugs. Overall, PRO scores improved from baseline throughout month 6 with a considerable amelioration at month 3, which was maintained at month 6. Responses were rapid, with improvement already evident at month 1 (Table 1). The NRS pain as a crucial PRO in RA confirmed the previously described pattern of results seen for most of the other PROs (Figure 1).

Table 1.

Baseline scores and average changes from baseline scores

NBaseline scores (SD)NChange from baseline - month 1 (SD)NChange from baseline - month 3 (SD)NChange from baseline - month 6(SD)Pain (NRS)4816.2 (2.2)393-2.2 (2.3)392-2.5 (2.5)258-2.4 (2.4)Fatigue (NRS)4815.5 (2.6)393-1.4 (2.3)393-1.6 (2.4)259-1.5 (2.3)HAQ-DI4711.3 (0.6)380-0.2 (0.3)376-0.2 (0.4)253-0.2 (0.4)Morning stiffness (duration, minutes)43968.9 (63.9)313-25.0 (55.3)296-29.6 (54.9)179-31.6 (51.7)Morning stiffness (severity)4785.2 (2.7)386-1.8 (2.3)393-2.2 (2.6)258-2.2 (2.9)PHQ-94778.7 (5.2)383-1.9 (3.9)381-2.3 (4.0)255-2.2 (3.8)RAID4815.6 (2.0)393-1.7 (1.8)392-2.0 (2.0)258-1.9 (1.9)

Conclusion

This interim analysis confirmed a meaningful improvement regarding included PROs that cover various RA-related symptoms, depressiveness and the impact of symptoms of RA on daily life.

References

[1]Smolen JS, et al. Lancet 2019;393:2303–11

[2]Burmester GR, et al. Lancet 2018;391:2503–12

[3]Genovese MC, et al. Lancet 2018;391:2513–24

[4]van Vollenhoven R, et al. Arthritis Rheumatol 2020;72:1607–20

[5]Fleischmann R, et al. Arthritis Rheumatol 2019;71:1788–800

[6]Rubbert-Roth A, et al. N Engl J Med 2020;383:1511–21

[7]Witte T et al. P0833 at ACR, Nov 5–9, 2021

Acknowledgements

AbbVie funded this study; contributed to its design; participated in data collection, analysis, and interpretation of the data; and in the writing, review, and approval of the abstract. AbbVie and the authors thank all study investigators for their contributions and the patients who participated in this study. No honoraria or payments were made for authorship. The medical writing support was provided by Matthias Englbrecht, Freelance Healthcare Data Scientist (Eckental, Germany) and was funded by AbbVie. Statistical analyses were provided by Dr. Daniela Adolf of StatConsult GmbH (Magdeburg, Germany) which was funded by AbbVie.

Disclosure of Interests

Torsten Witte Grant/research support from: AbbVie, Amgen, Bristol-Myers Squibb, Celgene, Chugai, Gilead, Janssen, Lilly, MSD, Mylan, Novartis, Pfizer, Roche, and UCB, Uta Kiltz Consultant of: AbbVie, Biocad, Eli Lilly and Company, Grünenthal, Hexal, Janssen, MSD, Novartis, Pfizer, Roche, and UCB, Grant/research support from: AbbVie, Amgen, Biogen, Fresenius, GSK, Hexal, Novartis, and Pfizer, Florian Haas Consultant of: AbbVie, Celgene, Novartis, and Pfizer, Grant/research support from: AbbVie, BMS, Celgene, Chugai, MSD, Novartis, Pfizer, Roche, and Sanofi Genzyme, Elke Riechers Consultant of: AbbVie, Chugai, Novartis, and UCB, Grant/research support from: AbbVie, Chugai, Lilly, Janssen, Novartis, Pfizer, Roche, and UCB, Ulrich Prothmann Grant/research support from: AbbVie, Amgen, Bristol-Myers Squibb, Chugai, Glaxo Smith Kline, Novartis, Pfizer, Roche, Sanofi, SOBI, and UCB, Daniela Adolf Shareholder of: Employee of StatConsult and may own stock or options, Employee of: Employee of StatConsult, Carsten Holland Shareholder of: Employee of AbbVie and may own stock or options, Employee of: Employee of AbbVie, Alexander Roessler Shareholder of: Employee of AbbVie and may own stock or options, Employee of: Employee of AbbVie, Kirsten Famulla Shareholder of: Employee of AbbVie and may own stock or options, Employee of: Employee of AbbVie, Konrad Götz Shareholder of: Employee of AbbVie and may own stock or options, Employee of: Employee of AbbVie, Klaus Krueger Grant/research support from: AbbVie, Biogen, BMS, Celltrion, Gilead, Hexal, Janssen, Lilly, Medac, MSD, Novartis, Pfizer, Roche, and UCB

POS0598 PERSISTING PAIN IN RHEUMATOID ARTHRITIS: DO WE NEED TO RECONSIDER OUR IDEA OF PAIN ALLEVIATION DESPITE ANTI-INFLAMMATORY TREATMENT?

Background

Pain significantly impacts life of patients with rheumatoid arthritis (RA) (1). Besides articular pain due to systemic inflammation, neuropathic pain (NeP) represents another challenge that can pose a considerable burden on the life of patients (2).

Objectives

To investigate persisting pain in RA patients and to analyse NeP along with patient-reported outcomes (PROs).

Methods

PAIN-CONTROL is a prospective, non-interventional study in rheumatology centres in Germany. Inclusion criteria were fulfilment of the 2010 ACR/EULAR RA classification criteria, disease duration ≤ 8 yrs, DAS28 > 3.2, SJC > 3, CRP normal or above reference range, and pain rating ≥ 50 (0-100 VAS). Eligible subjects had to be scheduled for escalation of anti-inflammatory treatment according to national guidelines. At wk 24 subjects were allocated to three subgroups given DAS28-CRP change and VAS pain: i) reference group: VAS pain < 50 with either DAS28 improvement > 1.2 or DAS28 ≤ 3.2, ii) non-responders: DAS28 improvement ≤ 1.2 and DAS28 > 3.2 with or without pain alleviation, iii) persisting pain: VAS pain ≥ 50 with either DAS28 improvement > 1.2 or DAS28 ≤ 3.2. For groups 1 and 2 end of study was at week 24, patients with persisting pain continued until wk 48. Patients were assessed for NeP using a score of ≥ 19 in the painDETECT questionnaire (PD-Q) (3). Pain-related PROs, i.e. the Rheumatoid Arthritis Impact of Disease Questionnaire (RAID) and the Patient Health Questionnaire (PHQ-9), were analysed along with demographic background information (1,4). Descriptive results are presented as mean (SD) or mean (SD) | Nvalid, as well as n (%) or n (%) | Nvalid, respectively.

Results

567 subjects were analysed with the following distribution: Reference group 337 (59.4%), non-responders 102 (18.0%), and persisting pain 128 (22.6%), of which 115 patients were available at wk 48. Subgroups showed similar demographic baseline characteristics but differed in PROs (Table 1). Until wk 24, proportion of patients with NeP indication decreased in the reference group (-19.8%) and slightly in non-responders (-6.0%) and persisting pain group (-9.5%). Non-responders showed the highest NeP proportion at wk 24 (35.0%) (Table 1). Of 115 patients with persisting pain at wk 24, 47 (40.9%) tested NeP negative at wk 48, 21 (18.3%) tested unclear, 28 (24.3%) were missing and 19 (16.5%) tested positive. Of the latter 9 patients (47.4%) still had persisting pain at week 48, while this was the case for 14 patients (29.8%) in the former group. 49 (42.6%) of 115 patients with severe persisting pain at wk 24 reported pain alleviation at wk 48 and fulfillment of reference group criteria. RAID and PHQ-9 scores improved in the reference group but only slightly in the other two subgroups.

Table 1.

Demographic background and PROs

CharacteristicReference group(N = 337)Non-responders(N = 102)Persisting pain(N = 128)Gender (f/m)233 (69.1%) /65 (63.7%) /87 (68.0%) /104 (30.9%)37 (36.3%)41 (32.0%)Age57.1 (13.2) | 33759.9 (12.0) | 10257.1 (13.0) | 128Disease duration (yrs)2.5 (2.6) | 3372.7 (2.8) | 1022.5 (2.5) | 128PD-Q (≥ 19) (Bl)82 (28.6%) | 28732 (41.0%) | 7840 (36.0%) | 111PD-Q (≥ 19) (wk 24)21 (8.8%) | 23928 (35.0%) | 8027 (26.5%) | 102PD-Q (Bl)14.0 (6.8) | 28715.5 (7.1) | 7815.5 (6.5) | 111PD-Q (wk 24)8.8 (5.8) | 23914.8 (6.7) | 8013.8 (7.2) | 102RAID (Bl)5.8 (2.0) | 3326.0 (1.9) | 1006.6 (1.7) | 125RAID (wk 24)2.4 (1.8) | 3215.4 (1.9) | 975.1 (1.9) | 123PHQ-9 (Bl)7.3 (5.1) | 3288.4 (5.4) | 987.9 (5.1) | 123PHQ-9 (wk 24)3.8 (3.5) | 3187.3 (4.5) | 956.6 (4.5) | 122

Conclusion

NeP is common among RA non-responders to anti-inflammatory treatment and in patients with persisting pain, meriting a routine NeP screening to more adequately address persisting pain in these patients. However, even late improvements (after 24 wks) regarding persisting pain seem likely during anti-inflammatory treatment.

References

[1]Gossec L, Ann Rheum Dis. 2011 Jun;70(6):935–42.

[2]Noda K, Mod Rheumatol. 2020 Sep;30(5):828–34.

[3]Freynhagen R, Curr Med Res Opin. 2006 Oct;22(10):1911–20.

[4]Kroenke K, J Gen Intern Med. 2001 Sep;16(9):606–13.

Acknowledgements

Statistical analysis was provided under lead of Dr. Daniela Adolf of StatConsult GmbH, which was funded by AbbVie.

Medical writing support was provided by Dr. Matthias Englbrecht of Statscoach, which was funded by AbbVie.

Disclosure of Interests

Christoph Baerwald Speakers bureau: Prof. Christoph G. Baerwald has served as consultant to AbbVie and has received research funding and speaker fees from AbbVie., Consultant of: Prof. Christoph G. Baerwald has served as consultant to AbbVie and has received research funding and speaker fees from AbbVie., Grant/research support from: Prof. Christoph G. Baerwald has served as consultant to AbbVie and has received research funding and speaker fees from AbbVie., Edgar Stemmler Shareholder of: Dr. Edgar Stemmler is employee of AbbVie and may own AbbVie stock., Employee of: Dr. Edgar Stemmler is employee of AbbVie and may own AbbVie stock., Sixten Gnuechtel Shareholder of: Dr. Sixten Gnüchtel is employee of AbbVie and may own AbbVie stock., Employee of: Dr. Sixten Gnüchtel is employee of AbbVie and may own AbbVie stock., Katharina Jeromin Shareholder of: Dr. Katharina Jeromin is employee of AbbVie and may own AbbVie stock, Employee of: Dr. Katharina Jeromin is employee of AbbVie and may own AbbVie stock, Carsten Holland Shareholder of: Dr. Carsten Holland is employee of AbbVie and may own AbbVie stock, Employee of: Dr. Carsten Holland is employee of AbbVie and may own AbbVie stock, björn fritz Shareholder of: Dr. Björn Fritz is employee of AbbVie and may own AbbVie stock., Employee of: Dr. Björn Fritz is employee of AbbVie and may own AbbVie stock., Daniela Adolf Consultant of: Dr. Daniela Adolf is an employee of StatConsult GmbH.

Statistical analysis was provided under lead of Dr. Daniela Adolf of StatConsult GmbH, which was funded by AbbVie, Peter C. Taylor Speakers bureau: Peter C. Taylor has served as consultant to AbbVie and has received speaker fees from AbbVie, Consultant of: Peter C. Taylor has served as consultant to AbbVie and has received speaker fees from AbbVie, Ralf Baron Speakers bureau: Prof. Ralf Baron has served as consultant to AbbVie and has received speaker fees from AbbVie., Consultant of: Prof. Ralf Baron has served as consultant to AbbVie and has received speaker fees from AbbVie.

159 BARRIERS AND FACILITATORS TO IMPLEMENTING NON-PHARMACOLOGICAL STRATEGIES TO MANAGE RESPONSIVE BEHAVIOURS OF NURSING HOME RESIDENTS WITH DEMENTIA

Background

Many nursing home residents with dementia exhibit responsive behaviours including agitation and aggression. Psychotropic drugs are often prescribed to manage responsive behaviours but increase the rate of falls, strokes and death in residents with dementia. Therefore, the aim of this research is to conceptualise the barriers and facilitators to implementing non-pharmacological strategies to manage responsive behaviours.

Methods

Twenty-five interviews were conducted with nursing home managers, nurses and healthcare assistants from twenty-one private and voluntary nursing homes. Reflexive thematic analysis was used to conceptualise the barriers and facilitators to implementing non-pharmacological strategies to manage responsive behaviours. Ethical approval was obtained from the University Research Ethics Committee (Ref. FHMREC20091). All participants provided written informed consent.

Results

Three themes were constructed conceptualising the barriers and facilitators to taking a non-pharmacological approach to manage responsive behaviours. Strong leadership, specialised training in gerontology or dementia care and retention of staff long term supported the development of trusting relationships with residents. Treating residents with dementia with love and respect while providing meaningful activities enhanced resident’s self-esteem, facilitating a non-pharmacological approach to managing responsive behaviours. In addition, the engagement of families in residents’ care was found to be a powerful facilitator. However, sub-optimal teamwork between nurses and healthcare assistants and a lack of multidisciplinary collaboration posed barriers to taking a non-pharmacological approach to behaviour management. Furthermore, most healthcare assistants perceived that they were not valued, this also had a detrimental impact on residents’ care.

Conclusion

Conceptualisation of the barriers and facilitators to taking a non-pharmacological approach to manage responsive behaviours enables formulation of recommendations to address these barriers. These recommendations will assist in the development of dementia policy including the national dementia strategy, to implement sustainable non-pharmacological strategies to manage responsive behaviours of nursing home residents with dementia.

AB0255 BASELINE CHARACTERISTICS OF PATIENTS WITH RHEUMATOID ARTHRITIS TREATED WITH UPADACITINIB IN GERMAN REAL-WORLD PRACTICE: RESULTS FROM THE POST-MARKETING OBSERVATIONAL UPwArds STUDY

Background:

The efficacy and safety of upadacitinib (UPA), a selective Janus kinase inhibitor, has been evaluated in the SELECT rheumatoid arthritis (RA) clinical program,1–6 but its real-world effectiveness remains to be investigated. The UPwArds study will assess the association of C-reactive protein (CRP) level with remission and other efficacy outcomes in patients with RA treated with UPA in German real-world practice.

Objectives:

To describe the baseline characteristics of patients enrolled in the UPwArds study.

Methods:

The prospective, open-label, multicenter, non-interventional, post-marketing UPwArds study included adult patients with moderate-to-severe RA (swollen joint count [SJC28] ≥3 and inadequate response or intolerance to ≥1 disease-modifying antirheumatic drug [DMARD]). Patients were treated with UPA 15 mg once daily, as monotherapy or in combination with methotrexate (MTX; 50:50 mono:combo enrollment planned), according to the German label. Variables assessed included medical history (disease duration, previous RA therapy, and vaccination status), CRP level, and disease activity (disease activity score [DAS28(CRP)], tender joint count [TJC28], and SJC28). There was no recruitment restriction regarding CRP level. This descriptive interim analysis reports patient baseline characteristics after enrollment was complete. All data were analyzed as observed, with no imputation of missing data.

Results:

533 patients (UPA monotherapy: 257 [48%]; UPA plus MTX: 276 [52%]) were included. Mean patient age was 58 years; mean disease duration was 9 years (Table 1). Despite having active RA, almost half the population (44%; n=237) did not have elevated CRP at the start of UPA treatment. Mean DAS28(CRP) was 4.6; mean TJC28 and SJC28 were 7.7 and 5.6, respectively. Overall, 39% of patients had not been treated with any biologic (b) DMARD or targeted synthetic (ts) DMARD before enrollment; 25% and 36% had previously been treated with 1 or ≥2 bDMARDs or tsDMARDs, respectively (Figure 1). 8.7% of patients had previously received a herpes zoster vaccination (8.1% Shingrix; 0.6% Zostavax).

Conclusion:

In German clinical practice, the population of patients with RA in the UPwArds study was predominantly treatment-refractory. Half of these patients had no elevated CRP despite active disease; future analyses will assess the impact of CRP on efficacy outcomes.

References:

[1]Smolen JS, et al. Lancet 2019;393:2303–11;

[2]Burmester GR, et al. Lancet 2018;391:2503–12;

[3]Genovese MC, et al. Lancet 2018;391:2513–24;

[4]van Vollenhoven R, et al. Arthritis Rheumatol 2020;72:1607–20;

[5]Fleischmann R, et al. Arthritis Rheumatol 2019;71:1788–800;

[6]Rubbert-Roth A, et al. N Engl J Med 2020;383:1511–21.

Table 1.

Baseline characteristics

Age, yearsUPAUPA + MTXTotal57.7 (13.2)n=25758.1 (11.4)n=27657.9 (12.3)n=533Disease duration, years9.4 (8.3)8.5 (7.7)9.0 (8.0)n=253n=272n=525CRP, mg/dL1.3 (1.9)1.1 (1.7)1.2 (1.8)n=257n=276n=533CRP >ULN, n (%)137 (53.3)159 (57.6)296 (55.5)n=257n=276n=533TJC287.4 (6.0)7.9 (6.4)7.7 (6.2)n=257n=276n=533SJC285.5 (3.7)5.6 (4.1)5.6 (3.9)n=257n=276n=533Patient’s Global Assessment6.2 (1.9)6.3 (1.8)6.3 (1.8)n=257n=276n=533Physician’s Global Assessment5.8 (1.5)5.9 (1.6)5.9 (1.6)n=257n=276n=533DAS28(CRP)4.6 (1.0)4.6 (1.0)4.6 (1.0)n=257n=276n=533DAS28(ESR)4.8 (1.1)4.9 (1.2)4.9 (1.1)n=224n=239n=463CDAI24.9 (10.2)25.7 (10.8)25.4 (10.5)n=257n=276n=533SDAI26.2 (10.5)26.9 (11.3)26.6 (10.9)n=257n=276n=533RAID5.7 (2.0)5.7 (2.0)5.7 (2.0)n=255n=275n=530Pain (RAID-1)6.2 (2.2)6.1 (2.3)6.2 (2.2)n=255n=275n=530SF-12 Physical Component Summary32.6 (8.5)33.9 (8.6)33.3 (8.6)n=245n=262n=507SF-12 Mental Component Summary42.4 (11.6)42.6 (11.3)42.5 (11.5)n=245n=262n=507HAQ-DI1.3 (0.7)1.3 (0.6)1.3 (0.6)n=250n=270n=520PHQ-98.9 (5.3)8.6 (5.3)8.7 (5.3)n=252n=272n=524Erosions, n (%)87 (33.9)95 (34.4)182 (34.1)n=257n=276n=533

Data are mean (SD), n unless otherwise stated

Acknowledgements:

AbbVie funded this study; contributed to its design; participated in data collection, analysis, and interpretation of the data; and in the writing, review, and approval of the abstract. AbbVie and the authors thank all study investigators for their contributions and the patients who participated in this study. No honoraria or payments were made for authorship. Medical writing support was provided by Grant Thomas Kirkpatrick, MSc, of 2 the Nth (Cheshire, UK), and was funded by AbbVie.

Disclosure of Interests:

Torsten Witte Grant/research support from: AbbVie, Amgen, Bristol-Myers Squibb, Celgene, Chugai, Gilead, Janssen, Lilly, MSD, Mylan, Novartis, Pfizer, Roche, and UCB., Uta Kiltz Consultant of: AbbVie, Biocad, Eli Lilly and Company, Grünenthal, Hexal, Janssen, MSD, Novartis, Pfizer, Roche, and UCB, Grant/research support from: AbbVie, Amgen, Biogen, Fresenius, GSK, Hexal, Novartis, and Pfizer, Florian Haas Consultant of: AbbVie, Celgene, Novartis, and Pfizer, Grant/research support from: AbbVie, BMS, Celgene, Chugai, MSD, Novartis, Pfizer, Roche, and Sanofi Genzyme, Elke Riechers Consultant of: AbbVie, Chugai, Novartis, and UCB, Grant/research support from: AbbVie, Chugai, Lilly, Janssen, Novartis, Pfizer, Roche, and UCB, Ulrich Prothmann Grant/research support from: AbbVie, Amgen, Bristol-Myers Squibb, Chugai, Glaxo Smith Kline, Novartis, Pfizer, Roche, Sanofi, SOBI, and UCB, Daniela Adolf Employee of: Employee of StatConsult and may own stock or options, Carsten Holland Employee of: Employee of AbbVie and may own stock or options, Rouven Hecht Employee of: Employee of AbbVie and may own stock or options, Alexander Roessler Employee of: Employee of AbbVie and may own stock or options, Kirsten Famulla Employee of: Employee of AbbVie and may own stock or options, Klaus Krueger Grant/research support from: AbbVie, Biogen, BMS, Celltrion, Gilead, Hexal, Janssen, Lilly, Medac, MSD, Novartis, Pfizer, Roche, and UCB.

SAT0272 THE VALUE OF CLINICAL AND LABORATORY FEATURES TO PREDICT EXTENT OF LARGE VESSEL VASCULITIS ON PET CT

Background:

Giant cell arteritis (GCA) is an idiopathic vasculitis affecting large and medium-sized vessels. The pattern of arterial involvement is heterogeneous with two overlapping categories recognised: classical cranial GCA and extra-cranial GCA (or large vessel vasculitis – LVV) that predominantly affects the aorta and its proximal branches. Although LVV is present in around 80% of patients with cranial GCA, and around one third will develop large vessel complications, there are no guidelines for which patients should be screened for it (1). We sought to investigate whether clinical and laboratory features were a useful guide to the severity of LVV on FDG PET-CT.

Objectives:

To retrospectively analyse whether baseline patient characteristics are able to predict the extent of large vessel vasculitis on PET-CT.

Methods:

Clinical data for 65 patients referred for a PET-CT scan by Rheumatology at the Freeman Hospital, Newcastle between January 2015 and May 2018 were retrospectively analysed. The most recent full blood count and inflammatory markers prior to the scan were used. Scans were reviewed by a consultant radiologist and trainee. The arterial network was split in to ten potentially involved territories (aortic arch, thoracic aorta, abdominal aorta, iliac vessels, axillary, brachiocephalic, subclavian, carotid, vertebral and femoral arteries. Both the value of highest standardised uptake value (SUV max) and the territory affected was recorded for each positive scan.

Results:

In the period analysed 65 PET-CT scans were requested, mostly (77%) as baseline investigations for symptoms with LVV in the differential diagnosis. Of these 22 (34%) were positive for LVV and in that group the majority of patients (64%) were female. In those with a negative scan, 47.5% were on concurrent steroid treatment compared to 9% with a positive scan. Regression analysis suggested that the number of systemic features (weight loss, pyrexia, polymyalgia) was weakly correlated with the number of affected territories (p=0.04). In contrast there was no correlation between laboratory tests ((CRP (p=0.91), ESR (p=0.46), Hb (p=0.44), platelets (p=0.74)) and the number of territories affected. The aortic arch (47%) was most commonly the territory with the highest degree of FDG uptake (SUV max) followed by the abdominal aorta (21%) and thoracic (10%) and femoral arteries (10%). There was no correlation between SUV max and laboratory tests ((CRP (p=0.55), ESR (p=0.89), Hb (p=0.82), platelets (p=0.17)) or the number of systemic features (p=0.7). There was no significant difference in the number of territories affected between those on steroid treatment at the time of the scan and steroid-naïve patients, albeit the number of positive scans in those on steroid treatment was low (n=5).

Conclusion:

These results suggest that clinical and laboratory features are a poor guide to predicting the maximal severity and extent of disease on FDG PET-CT.

References:

[1]Koster MJ, Matteson EL, Warrington KJ. Large-vessel giant cell arteritis: diagnosis, monitoring and management. Rheumatology (Oxford). 2018;57(suppl_2):ii32-ii42.

Disclosure of Interests:

None declared

Role of Microtearing Turbulence in DIII-D High Bootstrap Current Fraction Plasmas

We report on the first direct comparisons of microtearing turbulence simulations to experimental measurements in a representative high bootstrap current fraction (f_{BS}) plasma. Previous studies of high f_{BS} plasmas carried out in DIII-D with large radius internal transport barriers (ITBs) have found that, while the ion energy transport is accurately reproduced by neoclassical theory, the electron transport remains anomalous and not well described by existing quasilinear transport models. A key feature of these plasmas is the large value of the normalized pressure gradient, which is shown to completely stabilize conventional drift-wave and kinetic ballooning mode instabilities in the ITB, but destabilizes the microtearing mode. Nonlinear gyrokinetic simulations of the ITB region performed with the cgyro code demonstrate that the microtearing modes are robustly unstable and capable of driving electron energy transport levels comparable to experimental levels for input parameters consistent with the experimental measurements. These simulations uniformly predict that the microtearing mode fluctuation and flux spectra extend to significantly shorter wavelengths than the range of linear instability, representing significantly different nonlinear dynamics and saturation mechanisms than conventional drift-wave turbulence, which is also consistent with the fundamental tearing nature of the instability. The predicted transport levels are found to be most sensitive to the magnetic shear, rather than the temperature gradients more typically identified as driving turbulent plasma transport.

Comparison of Clinical Outcomes Following Patients' First and Second Concussions

Purpose

The objective of this study was to examine differences in self-reported symptoms, neurocognitive performance, and vestibular-ocular insufficiencies between patients’ first and second concussions. A secondary purpose was to explore the role of risk factors on recovery.

Methods

We conducted a retrospective medical chart review of 73 (32-M/41-F) patients aged 15.69 (SD=1.67) years from a concussion specialty clinic with two separate concussions (84.9% of 1st and 79.5% of 2nd sport-related) that occurred between August 2010 and April 2018. Clinical outcomes included the PCSS, ImPACT, and the Vestibular/Ocular Motor Screening (VOMS). A series of paired samples t-tests were used to compare clinical outcomes along with chi-square analyses for risk factor associations.

Results

Verbal memory scores were higher following the second (M=80.67, SD=15.3) (M=76.32, SD=15.65) (t[73]=–2.18, p=.03) concussion. Visual motor processing speed was faster following the second concussion (M=35.04, SD= 7.90) (M=31.35, SD=7.63) (t[73]=–5.72, p<.001). There were no other significant differences observed. Recovery time was similar for the first (61.07, SD=58.41.5) and second (67.91 SD=70.10) respectively, t(70)=–.91, p=.37. There was no relationship between any risk factors, and recovery time for either injury with the exception a significant association between gender and recovery time (>21 days) with the 1st injury for females (χ2, N=73)=10.58, p=.001.

Conclusion

Findings suggest that a second concussion does not result in more pronounced symptoms, worse neurocognitive performance, or increased deficits on vestibular/ocular performance and/or longer recovery time. The only significant risk factor to a recovery over 21 days included gender.

Reliability and Factors Associated with False Positives on the Vestibular/Ocular Motor Screening (VOMS) Tool in US Military Personnel

Purpose

The US Military recently added the Vestibular/Ocular Motor Screening (VOMS) to the Military Acute Concussion Evaluation-2 (MACE-2). However, there are no published data on the VOMS in US military personnel. The purpose of this study was to examine the reliability of the VOMS and factors associated with false positives in healthy US Army Special Operations (USASOC) personnel.

Methods

206 healthy USASOC military personnel aged 18–40 completed VOMS between March 2018 – January 2019. Analyses included internal consistency, false-positive rates, intraclass correlation coefficients (ICC), chi-square analyses with odds ratios (OR), and independent samples t-tests. VOMS clinical cut-off scores (2+ on any symptom, >5cm for NPC) were used to determine false positives.

Results

Reliability for the VOMS symptom items (Cronbach alpha=.98, ICC=.90) and NPC distance (Cronbach’s alpha=.98, ICC=.93) were high. False positive rates ranged from 10.2% (smooth pursuits) to 16.9% (NPC distance). Concussion history was associated with a 2.5 fold increase for one or more VOMS items above cut-offs (p=.01). Participants with at least one VOMS item above cut-offs were deployed nearly 6 months longer on average than those without (p=.04).

Conclusion

The findings indicate that VOMS is reliable in US military personnel with few false positives. False positives were associated with concussion history and longer deployment history, which should be considered by military medical providers when administering and interpreting VOMS in this population. Moving forward, researchers should examine the stability of VOMS and its ability to identify mTBI in this population.

Incremental Validity of Components of the Vestibular/Ocular Motor Screening for Concussion

Purpose

The Vestibular/Ocular Motor Screening (VOMS) tool for concussion evaluates symptom provocation (in a fixed order) across the following neuromotor tasks: smooth pursuits (SP), saccades-horizontal (Sac-H), saccades-vertical (Sac-V), near point of convergence (NPC), vestibular-ocular reflex-horizontal (VOR-H), vestibular-ocular reflex-vertical (VOR-V), and visual motion sensitivity (VMS). The current study evaluates the incremental validity of each VOMS component in consecutive order.

Methods

Retrospective record review of 193 subjects (49% male) aged 10–22 years old diagnosed with concussion (sport and non-sport injuries) and demonstrated an abnormal VOMS (defined by symptom provocation >2 or NPC >5cm) at initial evaluation in a specialty concussion clinic. Hierarchical regression was performed with VOMS total score (range: 0-320) as the dependent variable and each VOMS component as predictors in seven consecutive steps.

Results

The model was significant (p<.001) at each step; the final model including all seven VOMS components in order (SP, Sac-H, Sac-V, NPC, VOR-H, VOR-V, and VMS) was significant, F(7,185)= 6.87, p<.001 and accounted for 20.6% of the variance in total VOMS score. The only significant predictors in the final model included: SP (p=.01), NPC (p=.04), and VOR-H (p=.04).

Conclusion

Provocation of symptoms on SP, NPC, and VOR-H are the best predictors of total VOMS score. NPC and VOR-H symptom provocation provide unique value to vestibular screening beyond symptom provocation on SP and after completion of all other VOMS components. This information may be clinically useful when vestibular screening must be expedited (e.g., highly symptomatic patient, sideline assessment).

Building Bridges for Innovation in Ageing: Synergies between Action Groups of the EIP on AHA

The Strategic Implementation Plan of the European Innovation Partnership on Active and Healthy Ageing (EIP on AHA) proposed six Action Groups. After almost three years of activity, many achievements have been obtained through commitments or collaborative work of the Action Groups. However, they have often worked in silos and, consequently, synergies between Action Groups have been proposed to strengthen the triple win of the EIP on AHA. The paper presents the methodology and current status of the Task Force on EIP on AHA synergies. Synergies are in line with the Action Groups' new Renovated Action Plan (2016-2018) to ensure that their future objectives are coherent and fully connected. The outcomes and impact of synergies are using the Monitoring and Assessment Framework for the EIP on AHA (MAFEIP). Eight proposals for synergies have been approved by the Task Force: Five cross-cutting synergies which can be used for all current and future synergies as they consider overarching domains (appropriate polypharmacy, citizen empowerment, teaching and coaching on AHA, deployment of synergies to EU regions, Responsible Research and Innovation), and three cross-cutting synergies focussing on current Action Group activities (falls, frailty, integrated care and chronic respiratory diseases).

Combined numerical and experimental biomechanical characterization of soft collagen hydrogel substrate

This work presents a combined experimental-numerical framework for the biomechanical characterization of highly hydrated collagen hydrogels, namely with 0.20, 0.30 and 0.40% (by weight) of collagen concentration. Collagen is the most abundant protein in the extracellular matrix of animals and humans. Its intrinsic biocompatibility makes collagen a promising substrate for embedding cells within a highly hydrated environment mimicking natural soft tissues. Cell behaviour is greatly influenced by the mechanical properties of the surrounding matrix, but the biomechanical characterization of collagen hydrogels has been challenging up to now, since they present non-linear poro-viscoelastic properties. Combining the stiffness outcomes from rheological experiments with relevant literature data on collagen permeability, poroelastic finite element (FE) models were developed. Comparison between experimental confined compression tests available in the literature and analogous FE stress relaxation curves showed a close agreement throughout the tests. This framework allowed establishing that the dynamic shear modulus of the collagen hydrogels is between 0.0097 ± 0.018 kPa for the 0.20% concentration and 0.0601 ± 0.044 kPa for the 0.40% concentration. The Poisson's ratio values for such conditions lie within the range of 0.495-0.485 for 0.20% and 0.480-0.470 for 0.40%, respectively, showing that rheology is sensitive enough to detect these small changes in collagen concentration and thus allowing to link rheology results with the confined compression tests. In conclusion, this integrated approach allows for accurate constitutive modelling of collagen hydrogels. This framework sets the grounds for the characterization of related hydrogels and to the use of this collagen parameterization in more complex multiscale models.

The Role of More Sensitive Helminth Diagnostics in Mass Drug Administration Campaigns: Elimination and Health Impacts

Diagnostics play a crucial role in determining treatment protocols and evaluating success of mass drug administration (MDA) programmes used to control soil-transmitted helminths (STHs). The current diagnostic, Kato-Katz, relies on inexpensive, reusable materials and can be used in the field, but only trained microscopists can read slides. This diagnostic always underestimates the true prevalence of infection, and the accuracy worsens as the true prevalence falls. We investigate how more sensitive diagnostics would impact on the management and life cycle of MDA programmes, including number of mass treatment rounds, health impact, number of unnecessary treatments and probability of elimination. We use an individual-based model of STH transmission within the current World Health Organization (WHO) treatment guidelines which records individual disability-adjusted life years (DALY) lost. We focus on Ascaris lumbricoides due to the availability of high-quality data on existing diagnostics. We show that the effect of improving the sensitivity of diagnostics is principally determined by the precontrol prevalence in the community. Communities at low true prevalence (<30%) and high true prevalence (>70%) do not benefit greatly from improved diagnostics. Communities with intermediate prevalence benefit greatly from increased chemotherapy application, both in terms of reduced DALY loss and increased probability of elimination. Our results suggest that programmes should be extended beyond school-age children, especially in high prevalence communities. Finally, we argue against using apparent or measured prevalence as an uncorrected proxy for true prevalence.

Horses and cows might teach us about human knees

Our comparative study of the knees of horses and cows (paraphrased as highly evolved joggers and as domesticated couch-potatoes, respectively) demonstrates significant differences in the posterior sections of bovine and equine tibial cartilage, which are consistent with specialisation for gait. These insights were possible using a novel analytical measuring technique based on the shearing of small biopsy samples, called dynamic shear analysis. We assert that this technique could provide a powerful new tool to precisely quantify the pathology of osteoarthritis for the medical field.

Endoscopic ultrasound-guided fine needle aspiration training: evaluation of a new porcine lymphadenopathy model for in vivo hands-on teaching and training, and review of the literature

BACKGROUND AND STUDY AIMS

Adequate training is required to achieve successful endoscopic ultrasound (EUS)-guided fine-needle aspiration (EUS-FNA). Of the variety of training models currently available, none offers verisimilitude to the tactile feel of puncturing a human lymph node. The aim of the current study was to evaluate a new porcine lymph node model for EUS-FNA training and to evaluate its impact on trainees' performance in patients compared with the literature of other models available.

METHODS

Two trainees each performed EUS-FNA of 96 lymph nodes in 18 animals with induced lymphadenopathy (mean 1.6 cm [range 0.9-3.5 cm]). Accuracy, speed, adequacy of sampling, and trainees' performance pre- and post-training were measured. Using a questionnaire, data were gathered regarding the effect of training and comfort level in patients. Results were compared with those in the literature.

RESULTS

Trainees progressed from hands-on assistance to occasional verbal guidance toward the end of animal training. There was good correlation between puncture time and number of EUS-FNA procedures performed in all but the subcarinal location (r = - 0.17). Comparison of trainee performance in patients before and after training showed a reduction in puncture time (P = 0.0014). Questionnaire analysis revealed increased confidence in echoendoscope- and needle-handling. Comparison with other published models supports these results.

CONCLUSION

Results from the literature and the current study showed that animal training improves trainee performance, confidence, and procedural comfort when returning to patient examinations. The new model produces a realistic response that is similar to EUS-FNA in patients; this experience provides a benefit to endoscopists in terms of improved performance in patients and could be considered for use in accreditation. Due to the small numbers of trainees, larger experiences are needed to confirm training efficacy.

Observation of a critical gradient threshold for electron temperature fluctuations in the DIII-D Tokamak

A critical gradient threshold has been observed for the first time in a systematic, controlled experiment for a locally measured turbulent quantity in the core of a confined high-temperature plasma. In an experiment in the DIII-D tokamak where L(T(e))(-1) = |∇T(e)|/T(e) and toroidal rotation were varied, long wavelength (k(θ)ρ(s) ≲ 0.4) electron temperature fluctuations exhibit a threshold in L(T(e))(-1): below, they change little; above, they steadily increase. The increase in δT(e)/T(e) is concurrent with increased electron heat flux and transport stiffness. Observations were insensitive to rotation. Accumulated evidence strongly enforces the identification of the experimentally observed threshold with ∇T(e)-driven trapped electron mode turbulence.

2D full wave modeling for a synthetic Doppler backscattering diagnostic

Doppler backscattering (DBS) is a plasma diagnostic used in tokamaks and other magnetic confinement devices to measure the fluctuation level of intermediate wavenumber (k(θ)ρ(s) ~ 1) density fluctuations and the lab frame propagation velocity of turbulence. Here, a synthetic DBS diagnostic is described, which has been used for comparisons between measurements in the DIII-D tokamak and predictions from nonlinear gyrokinetic simulations. To estimate the wavenumber range to which a Gaussian beam would be sensitive, a ray tracing code and a 2D finite difference, time domain full wave code are used. Experimental density profiles and magnetic geometry are used along with the experimental antenna and beam characteristics. An example of the effect of the synthetic diagnostic on the output of a nonlinear gyrokinetic simulation is presented.

Forensic Mitochondrial DNA Analysis: Current Practice and Future Potential

Current practices for performing forensic mitochondrial DNA (mtDNA) sequence analysis, as employed in public and private laboratories across the United States, have changed remarkably little over the past 20 years. Alternative approaches have been developed and proposed, and new technologies have emerged, but the core methods have remained relatively unchanged. Once DNA has been recovered from biological material (for example, from older skeletal remains and hair shafts), segments of the mtDNA control region are amplified using a variety of approaches, dictated by the quality of the sample being tested. The amplified mtDNA products are subjected to Sanger-based sequencing and data interpretation is performed using one of many available software packages. These relatively simple methods, at least in retrospect, have remained robust, and have stood the test of time. However, alternative methods for mtDNA analysis remain viable options (for example, linear array assays and dHPLC), and should be revisited as the desire to streamline the testing process, interpret heteroplasmy, and deconvolute mixed mtDNA profiles intensifies. Therefore, it is important to periodically reassess the alternative methods available to the mtDNA practitioner, and to evaluate newer technologies being put forth by the scientific community, for example, next-generation sequencing. Although the basic mitochondrial DNA protocols and practices of public and private laboratories are similar, an overview of the current practices of forensic mtDNA analysis is provided, helping to frame the path forward.

Frequency-resolved nonlinear turbulent energy transfer into zonal flows in strongly heated L-mode plasmas in the HL-2A tokamak

The absolute rate of nonlinear energy transfer among broadband turbulence, low-frequency zonal flows (ZFs) and geodesic acoustic modes (GAMs) was measured for the first time in fusion-grade plasmas using two independent methods across a range of heating powers. The results show that turbulent kinetic energy from intermediate frequencies (20-80 kHz) was transferred into ZFs and GAMs, as well as into fluctuations at higher frequencies (>80  kHz). As the heating power was increased, the energy transfer from turbulence into GAMs and the GAM amplitudes increased, peaked and then decreased, while the energy transfer into the ZFs and the ZFs themselves increased monotonically with heating power. Thus there exists a competition between ZFs and GAMs for the transfer of turbulent energy, and the transfer into ZFs becomes dominant as the heating power is increased. The poloidal-radial Reynolds stress and the mean radial electric field profiles were also measured at different heating powers and found to be consistent with the energy transfer measurement. The results suggest that ZFs play an important role in the low-to-high (L-H) plasma confinement transition.

Impact of cell salvage during cardiac surgery on the thrombelastomeric coagulation profile: a pilot study

Intraoperative cell salvage of the cardiopulmonary bypass residual volume can dilute platelets and coagulation factors. This is a report of a randomised control trial of 20 patients undergoing coronary bypass surgery. Residual cardiopulmonary bypass volume was processed and transfused after surgery in the cell salvage group and the residual volume was transfused unprocessed in the control group. The coagulation profile was measured using the Rotem(®) thrombelastometry system. Mean (SD) maximum clot firmness after surgery was 52.8 (5.4) mm in the cell salvage group compared to 57.2 (5.0) mm in the control group (p=0.04). Clot formation time was prolonged after surgery by 39 (27) s in the cell saver group compared to 19 (17) s in the control group (p=0.045). Platelet count was reduced after surgery by 96 (32) x 10(9).L(-1) in the cell saver group and 70 (19) x 10(9).L(-1) in the control group (p=0.03). Blood volume in the chest drains 4 hours after surgery was similar in both groups. There was a strong association between clot formation time after surgery and blood loss (R = 0.68, p=0.001). The increase in blood loss was 4.1 ml for every one-second increase in clot formation time (95% CI 1.9 - 6.4, p=0.001). Cell salvage of the residual cardiopulmonary bypass volume reduced platelet numbers and prolonged clot formation time and maximum clot firmness was less in this group.

Endoscopic transesophageal vs. thoracoscopic removal of mediastinal lymph nodes: a prospective randomized trial in a long term animal survival model

BACKGROUND AND STUDY AIMS

In cases where biopsies remain inconclusive, removal of mediastinal lymph nodes for further analysis requires surgical means. Natural orifice transluminal endoscopic surgery (NOTES) procedures allow incision/closure of the gut wall, which might enable endoscopic excision of pre-marked nodes. The aims of the current study were to investigate the feasibility, safety, and reproducibility of lymph node generation in an animal model to enable endoscopic ultrasound-guided (EUS) lymph node removal (ELR) using transesophageal NOTES access/closure and to compare this procedure with thoracoscopic lymph node removal (TLR) in a randomized long term survival animal study.

PATIENTS AND METHODS

Lymph node creation using graphite injection was performed in 12 pigs. After randomization into ELR and TLR groups, lymph nodes were marked with newly developed anchors under EUS guidance and removed using either ELR or TLR. ELR included incision of the esophageal wall and closure after lymph node removal. The main outcome measures were success in lymph node generation, technical success of lymph node removal, complications, and comparability of ELR and TLR.

RESULTS

Generation of lymph nodes proved successful in all animals in 46/48 sites injected (96 %). Anchors were placed through the selected nodes in a mean of 9.4 minutes. TLR and ELR were successful in all cases. One bleeding occurred during esophageal incision in ELR, which was stopped endoscopically. After lymph node removal, endoscopic suturing of the incision took a mean of 18 minutes. Procedure time was longer for ELR than TLR (mean 48 vs. 42 minutes). All animals survived the procedures. Autopsy after 4 weeks showed two thoracic wall abscesses in the TLR group and none in the ELR group.  Microscopic analysis revealed well healed esophageal scars.

CONCLUSION

ELR proved to be feasible in this limited sample size and complications were not observed more frequently in this group than in the TLR group.