AB0589 TOCILIZUMAB FOR GIANT CELL ARTERITIS: BASELINE AND TWELVE MONTH AUDIT DATA FROM THE UK BRISTOL AND BATH MULTIDISCIPLINARY MEETING

Background

Giant Cell Arteritis (GCA) is a systemic vasculitis involving large and medium-sized blood vessels. Treatment is with high dose glucocorticoids. Steroid-sparing agents and Tocilizumab (TCZ) are used for refractory or relapsing cases. NHS England requires all GCA patients to be discussed in a regional multidisciplinary team meeting (MDT) prior to commencing TCZ. TCZ has only been permitted for a maximum of one year; this time limitation was extended during the Covid-19 pandemic (1). The monthly virtual Bristol and Bath regional MDT started in November 2018.

Objectives

We aimed to review: 1) Baseline data on all patients referred to the Bristol and Bath TCZ for GCA MDT, including demographics, clinical presentation and previous steroid-sparing agents used and 2) 12 month follow up data including number of completions, adverse effects, and flares on treatment.

Methods

The TCZ MDT referral proforma, adapted from the NHS England Blueteq approval form, was reviewed for all patients referred. 12 month follow up data was obtained from clinic letters.

Results

Baseline data

Thirty-eight cases were referred between November 2018 and September 2021. Of these, 31 were approved for TCZ usage; 100% fulfilled the criteria for either refractory (n=11) or relapsing (n=20) disease. Mean age was 74 years and 74.2% were female. Average disease duration was 161.5 days for the refractory and 827.3 days for the relapsing group.

77.4% had cranial GCA, 48.4% had large vessel involvement, 45.2% had visual symptoms and 25.8% had ischaemic visual loss. The positive investigations were PET-CT (48.4%), temporal artery ultrasound (41.9%) and temporal artery biopsy (32.3%).

64.5% had trialled a steroid-sparing agent at time of referral (61.3 % methotrexate, 9.7% azathioprine, 6.5% leflunomide), 35.5% had received intravenous methylprednisolone and 58% were receiving greater than 40mg prednisolone at the time of referral.

Glucocorticoid adverse effects of osteoporosis, weight gain, cataracts and hypertension were each seen in 19.4%; whilst diabetes, neuropsychiatric symptoms and sleep disturbance were each reported in 16.1%.

Those with ocular involvement tended to be referred earlier than those without (478.2 days vs 648.1 days), were referred on higher doses of glucocorticoids (71.4% vs 47.1% on ≥ 40mg) and had less steroid-sparing agents prior to referral.

Follow up data

In December 2021, a follow-up audit revealed 14/31 patients had completed at least 12 months of tocilizumab; 5 of these had had an extension under Covid-19 exceptional guidance (mean duration of 5.2 months). Of the remaining 17: 3 patients had stopped early (1 death, 1 moved away, 1 due to adverse effects of headache and gastro-intestinal side effects), 4 had not started tocilizumab and 10 had not completed 12 months of treatment at that point.

Adverse events in the 14 patients at 12 months included: liver abnormalities (2/14; 14.3%), neutropenia (2/14; 14.3%), thrombocytopaenia (1/14; 7.1%), soft tissue infections (3/14; 21.4%), urinary tract infection (1/14; 7.1%) and lipid derangement (4/14 28.6%). One case of GCA relapse occurred on TCZ (mild headache and raised inflammatory markers settled on small increase in prednisolone). After 12 months, mean prednisolone dose was 3mg (range 0-15mg).

Conclusion

All patients approved for Tocilizumab in the GCA MDT fulfilled NHS England criteria for either relapsing or refractory disease. The majority of cases had cranial disease, but almost half had either ocular or large vessel involvement, reflecting a severe spectrum of disease. Cases showed a high burden of glucocorticoid toxicity. Follow up data suggests that TCZ was effective in allowing glucocorticoid weaning and disease control, but with some adverse effects. Future work to follow up patients after stopping Tocilizumab would be informative, as the twelve month limitation on treatment is likely to be re-instated.

References

[1]https://www.england.nhs.uk/coronavirus/publication/tocilizumab-for-giant-cell-arteritis-gca-during-the-covid-19-pandemic-rps-2007/

Disclosure of Interests

Chandrin N. R. Jayatilleke: None declared, Aishwarya Anilkumar: None declared, Shalini Janagan: None declared, Robert W Marshall: None declared, Sarah Skeoch: None declared, Catherine Guly Grant/research support from: Eli Lilly and Company - paid consultant for a research trial, Fang En Sin: None declared, Keziah Austin: None declared, Laith Al-Sweedan: None declared, Alexandra Bourn: None declared, Lynsey Clarke: None declared, Harsha Gunawardena: None declared, Baashar Boyce: None declared, Sally Knights: None declared, John D Pauling: None declared, Elizabeth Reilly: None declared, Timothy D Reynolds: None declared, Sarah Villar: None declared, Joanna C Robson: None declared

67 A BLENDED MODEL OF CARE USED IN THE ROLLOUT OF AN EARLY SUPPORTED DISCHARGE FOR STROKE SERVICE DURING COVID-19

Background

The Health and Social Care Professionals budget was augmented to develop rehabilitation services that facilitated hospital discharges. Early Supported discharge (ESD) for stroke is a proven model of best care for stroke patients with mild to moderate disability (Langhorne et al., 2005). A pilot was implemented with the team consisting of an Occupational Therapist, Speech and Language Therapist, Physiotherapist and Medical Social Worker.

Methods

The service facilitated an early discharge from the hospital with the delivery of specialist stroke rehabilitation in the home. Therapy is provided with the same intensity and expertise that would be received in hospital and is available for up to 8 weeks, it was provided using a blended model of domiciliary care and the introduction of telehealth in response to COVID 19.

Data was recorded for 100 service users using an excel spreadsheet. Data was recorded to measure number of new referrals, length of stay, bed days released back into the hospital system, mode of service delivery and functional outcomes. A cost analysis was completed. Service user experience was captured using questionnaires.

Results

From September 2020 to July 2021, 100 patients accessed ESD with a reduction of 7.2 days in hospital stay per patient. Improvements in pre- and post- rehabilitation scores on the FIM/FAM were evident. Very positive feedback regarding the rehabilitation experience was captured within the patient satisfaction questionnaire. Therapy delivery was 60% face to face, 37% via telehealth and 3% outpatient appointments. Telehealth received good compliance but with varying reports of experience in comparison to face to face.

Conclusion

ESD provided in the home environment facilitated earlier discharge from hospital with positive outcomes for the hospital and service users. Telehealth ensured that rehabilitation was maintained throughout the pandemic. Telehealth increased access for patients residing outside of the catchment area. However service user preference remains face to face.

A prospective 20-year longitudinal follow-up of dementia in persons with Down syndrome

GOAL

To examine dementia characteristics, age at onset and associated co-morbidities in persons with Down syndrome.

METHOD

A total of 77 people with Down syndrome aged 35 years and older were followed up from 1996 to 2015. The diagnosis of dementia was established using the modified ICD 10 Criteria and a combination of objective and informant-based tests. Cognitive tests included the Test for Severe Impairment and the Down Syndrome Mental Status Examination; adaptive behaviour was measured using the Daily Living Skills Questionnaire, and data from the Dementia Questionnaire for People with Intellectual Disabilities have been available since 2005.

RESULTS

Over the 20-year period, 97.4% (75 of 77) persons developed dementia with a mean age of dementia diagnosis of 55 years (SD = 7.1, median = 56 years). Clinical dementia was associated with cognitive and function decline and seizure activity. Risk for dementia increased from 23% in those aged 50 years to 80% in those aged 65 years and above. There were no differences by level of ID.

CONCLUSION

The previously reported high risk levels for dementia among people with Down syndrome were confirmed in this data as was the relationship with late onset epilepsy. The value of the instruments utilised in tracking decline and helping to confirm diagnosis is further highlighted.

A prospective 14-year longitudinal follow-up of dementia in persons with Down syndrome

BACKGROUND

To examine dementia characteristics, age at onset and associated comorbidities in persons with Down syndrome.

METHOD

Seventy-seven people with Down syndrome aged 35 years and older were followed longitudinally. The diagnosis of dementia was established using the modified International Classification of Diseases, Tenth Revision (ICD-10) criteria and a combination of objective and informant-based tests. Cognitive tests included the Test for Severe Impairment and the Down Syndrome Mental Status Examination; adaptive behaviour was measured using the Daily Living Skills Questionnaire. The Dementia Questionnaire for Mental Retarded Persons (DMR) was added to the test battery in 2005 and this study includes follow-up data for this instrument.

RESULTS

Over the 14-year period the average age of diagnosis at 55.41 years (SD = 7.14) was in the higher range of previously reported estimates (51-56 years) and a median survival of 7 years after diagnosis. Persons with dementia in the sample were significantly older than persons without dementia. The presence of dementia was also associated with epilepsy and sensory impairments. Among instruments the DMR appeared most sensitive to tracking change in symptoms over time before diagnosis.

CONCLUSION

The previously reported high risk levels for dementia among people with Down syndrome was confirmed in these data as was the value of the instruments utilised in tracking decline and helping to confirm diagnosis even in persons with severe intellectual disability.

Electric field-induced magnetization switching in epitaxial columnar nanostructures

We present direct evidence for room-temperature magnetization reversal induced by an electric field in epitaxial ferroelectric BiFeO3-ferrimagnetic CoFe2O4 columnar nanostructures. Piezoelectric force microscopy and magnetic force microscopy were used to locally image the coupled piezoelectric-magnetic switching. Quantitative analyses give a perpendicular magnetoelectric susceptibility of approximately 1.0 x 10(-2) G cm/V. The observed effect is due to the strong elastic coupling between the two ferric constituents as the result of the three-dimensional heteroepitaxy.

Multiple organ failure syndrome

Although many new areas of research are directed at the regulatory aspects of the metabolic response, the prognosis of MOF remains poor. Critical care nurses, challenged to provide a supportive environment during this life-threatening syndrome, must understand its onset, clinical patterns, and prolonged support required by patients. Such knowledge will enable critical care nurses to detect subtle changes while monitoring clinical status, and facilitate timely interventions in order to decrease the morbidity and mortality associated with MOF.

Multiple organ failure syndrome

Although many new areas of research are directed at the regulatory aspects of the metabolic response, the prognosis of MOF remains poor. Critical care nurses, challenged to provide a supportive environment during this life-threatening syndrome, must understand its onset, clinical patterns, and prolonged support required by patients. Such knowledge will enable critical care nurses to detect subtle changes while monitoring clinical status, and facilitate timely interventions in order to decrease the morbidity and mortality associated with MOF.

Genetic and molecular analysis of a Caenorhabditis elegans beta-tubulin that conveys benzimidazole sensitivity

Benzimidazole anti-microtubule drugs, such as benomyl, induce paralysis and slow the growth of the nematode Caenorhabditis elegans. We have identified 28 mutations in C. elegans that confer resistance to benzimidazoles. All resistant mutations map to a single locus, ben-1. Virtually all these mutations are genetically dominant. Molecular cloning and DNA sequence analysis established that ben-1 encodes a beta-tubulin. Some resistant mutants are completely deleted for the ben-1 gene. Since the deletion strains appear to be fully resistant to the drugs, the ben-1 product appears to be the only benzimidazole-sensitive beta-tubulin in C. elegans. Furthermore, since animals lacking ben-1 are viable and coordinated, the ben-1 beta-tubulin appears to be nonessential for growth and movement. The ben-1 function is likely to be redundant in the nematode genome.

Reduced sensitivity of red blood cell (Na+,K+)-ATPase to ethanol in vitro in male alcoholic patients: relationship to clinical characteristics

We examined red blood cell (Na+,K+)-ATPase, its sensitivity to inhibition by ethanol in vitro, and its relationship to clinical characteristics and history in 41 newly admitted alcoholic patients and 14 age-matched healthy controls. Sensitivity to ethanol was significantly lower in the alcoholic patients and correlated negatively with ethanol intake. In addition, sensitivity of enzyme to ethanol was lower in patients with high agitation-anxiety ratings and correlated negatively with agitation and anxiety scores on the Brief Psychiatric Rating Scale. There were no relationships between (Na+,K+)-ATPase measures and depressive symptoms, history of treatment for depression, or family history of depression. These data suggest that tolerance to the effects of ethanol on (Na+,K+)-ATPase occurs in man and may be related to the severity of ethanol dependence or withdrawal.

Mutations affecting microtubule structure in Caenorhabditis elegans

Three types of microtubules are seen in the neuronal processes of the nematode Caenorhabditis elegans. Single cytoplasmic microtubules of most neurones have 11 protofilaments whereas those of six touch receptor cells have 15 protofilaments. The axonemes of sensory cilia have nine outer doublets with a variable number (up to seven) of singlet microtubules. Mutations in 11 genes affect the appearance of these microtubules.

Electroencephalogram monitoring during carotid endarterectomy

Cerebral protection during carotid endarterectomy is of critical importance. This study reviews our experience with continuous EEG monitoring under general anesthesia during carotid endarterectomy. This experience defines indications for intraluminal shunting based upon electroencephalographic criteria as well as defining the utility of EEG monitoring of both intraoperative anesthesia and the post operative course.

A practical adult education tool

Active involvement of the learner in program development is an important part of the teaching-learning process. Because many programs are designed without the benefit of direct input by participants, an attempt should be made to mesh the learning objectives of the participants with those of the program designers and instructors. This article describes a form that can accomplish this, as well as set a climate of learner involvement.

Urethane modification of EEG-like activity and acoustically evoked field potentials recorded from deep nuclei

Average acoustic-evoked responses (AAER) and EEGs were recorded from the lateral hypothalamus (LH), ventromedial hypothalamus (VMH), medial forebrain bundle (MFB) and reticular formation (RF) of freely behaving rats before and after various doses (0.2, 0.4, 0.8, 1.2 g/5g) of the anesthetic drug, urethane. The effect of a surgical level of urethane (1.2 g/5g) over time (8--14 h) was also studied. Urethane produced a dose-dependent slowing in the EEG frequency. The effect of 1.2 g/kg over time was a bimodal depression of the EEG frequency. Three components of the AAER were recorded consistently and evaluated in terms of amplitude. With increasing doses, the early component (P2) was depressed in the LH2, VMH and MFB, but not in the RF which remained at control values or higher. The later components (N2 and P2) were depressed in all four structures. This suggests that urethane may be blocking the integrative function of the RF, as well as in the thalamus, resulting in lower sensory input to higher CNS structures.

The freezing lesion. III. The effects of diphenylhydantoin on potassium transport within nerve terminals from the primary foci

Possible mechanisms by which dephenylhydantoin (DPH) controls seizures were examined. The effects of intraperitoneal DPH on seizure discharges within epileptogenic freeze lesions were correlated with DPH action on in vitro potassium uptake within synaptosomes isolated from the same freeze foci. When in vivo DPH suppressed seizure discharges, it stimulated in vitro potassium uptake within synaptosomes incubated in a high-Kplus (10 mM) media. With 2-5 mM Naplus and 10mM Kplus, DPH stimulation of synaptosome potassium uptake was reversed by ouabain. With 50 mM Naplus and 10 mM Kplus, DPH stimulation of potassium uptake was not reversed by ouabain. In low-Kplus (0.2-5 mM) media, DPH did not affect potassium uptake even when sodium concentrations were varied at 10-100 mM. In sham-operated controls and in non-epileptogenic lesions, the effects of DPH on synaptosome potassium uptake were identical to those previously reported in normal brains. These results strongly suggest that DPH controls the epileptogenic state by stimulating potassium uptake within synaptic terminals. DPH controls the epileptogenic state by stimulating potassium uptake within synaptic terminals. DPH enhances synaptic potassium uptake by stimulating the (Naplus-Kplus) pump and a second potassium uptake process which is insensitive to ouabain.

Gene-specific messenger RNA: isolation by the deletion method

Messenger RNA molecules, homologous to a small portion of the genome of bacteriophage T4, have been isolated. RNA fragments specific to the rII A and the rII B cistrons have been separated by hybridization with DNA isolated from appropriate deletion mutants. An RNA species homologous in nucleotide sequence to a defined part of the rII A cistron has been identified.