Long-term efficacy of a 2-year MRI treat-to-target strategy on disease activity and radiographic progression in patients with rheumatoid arthritis in clinical remission: 5-year follow-up of the IMAGINE-RA randomised trial

OBJECTIVE

To investigate whether a 2-year MRI treat-to-target strategy targeting the absence of osteitis combined with clinical remission, compared with a conventional treat-to-target strategy targeting clinical remission only (IMAGINE-rheumatoid arthritis (RA) trial) improves clinical and radiographic outcomes over 5 years in patients with RA in clinical remission.

METHODS

IMAGINE-more was an observational extension study of the original 2-year IMAGINE-RA randomised trial (NCT01656278). Clinical examinations and radiographs (hands and feet) were obtained yearly. Prespecified coprimary outcomes at year 5 were Disease Activity Score in 28 joints C reactive protein (DAS28-CRP) remission rate (DAS28-CRP<2.6) and no radiographic progression (van der Heijde-modified Sharp score (vdHSS) ≤0) from baseline. Secondary outcomes included 5-year changes in radiographic, MRI and clinical measures of disease activity and physical function.

RESULTS

In total 131 patients, 86 women (67%), mean age 61.2, disease duration 9.5 years, median baseline DAS28-CRP 1.9 (IQR 1.6-2.2) and vdHSS 16.0 (IQR 7.0-36.0) were included in the study; 59 (59%) patients from the original MRI treat-to-target group and 72 (72%) from the conventional group. At year 5, 47 patients (80%) in the MRI treat-to-target group vs 54 patients (75%) in the conventional treat-to-target group were in DAS28-CRP remission (OR 2.00 (95% CI 0.76 to 5.28); p=0.16) while 14 patients (24%) vs 19 patients (26%) had no radiographic progression (OR 0.70, (95% CI 0.28 to 1.71); p=0.43).

CONCLUSION

A 2-year combined MRI and clinical treat-to-target strategy, compared with a conventional clinical treat-to-target strategy alone, had no effect on the long-term probability of achieving DAS28-CRP remission and of avoiding radiographic progression.

Thoracic spine X-ray examination of patients with back pain using different breathing technique and exposure times - A diagnostic study

INTRODUCTION

The breathing and suspended inspiration techniques are often used interchangeably for spine X-ray examinations. However, these techniques are not always adequately supported by clinical evidence. This study aimed to determine the two techniques' diagnostic value and adverse image outcomes.

METHODS

A total of 400 participants were examined on a Siemens Ysio Max system and randomized into four examination groups: suspended inspiration or breathing techniques with exposure times of 1, 2, and 3.2 s, respectively. Two consultant radiologists conducted the evaluation of the X-ray images. If disagreement was present, the radiologists collaboratively reviewed the X-ray images until a consensus was reached.

RESULTS

The final 394 study population comprised 275 women and 119 men with a mean age of 64 years (range:18-96 years). The proportions of visually sharp reproduction of the endplates and trabecular structures did not differ significantly with regards to differences in exposure times between groups. The breathing technique groups had significantly higher proportions of blurring and motion artifacts (p < 0.001). However, adverse image outcomes (motions artifacts) were significantly lower in the 1-s exposure group.

CONCLUSIONS

The suspended inspiration and breathing techniques performed equally well regarding visually sharp reproduction. However, the suspended inspiration technique was superior to the breathing technique. regarding adverse image outcomes, although the latter could be improved by using a shorter exposure time.

IMPLICATIONS FOR PRACTICE

The suspended inspiration and breathing technique appeared to perform at equal diagnostic levels. The suspended inspiration technique should be preferred due to its reduced risk of adverse image outcomes. However, the risk could also be reduced using a short exposure time with the breathing technique.

Synthetic Mirnov diagnostic for the validation of experimental observations

A synthetic Mirnov diagnostic has been developed to investigate the capabilities and limitations of an arrangement of Mirnov coils in terms of a mode analysis. Eight test cases have been developed, with different coil arrangements and magnetic field configurations. Three of those cases are experimental configurations of the stellarator Wendelstein 7-X. It is observed that, for a high triangularity of the flux surfaces, the arrangement of the coils plays a significant role in the exact determination of the poloidal mode number. For the mode analysis, torus and magnetic coordinates have been used. In most cases, the reconstruction of the poloidal mode number of a prescribed mode was found to be more accurate in magnetic coordinates. As an application, the signal of an Alfvén eigenmode, which has been calculated with a three-dimensional magnetohydrodynamics code, is compared to experimental observations at Wendelstein 7-X. For the chosen example, the calculated and measured mode spectra agree very well and additional information on the toroidal mode number and localization of the mode has been inferred.

Towards a Precise NMR Quantification of Acute Phase Inflammation Proteins from Human Serum

Nuclear Magnetic Resonance (NMR) spectra of human serum and plasma show, besides metabolites and lipoproteins, two characteristic signals termed GlycA and B arising from the acetyl groups of glycoprotein glycans from acute phase proteins, which constitute good markers for inflammatory processes. Here, we report a comprehensive assignment of glycoprotein glycan NMR signals observed in human serum, showing that GlycA and GlycB signals originate from Neu5Ac and GlcNAc moieties from N-glycans, respectively. Diffusion-edited NMR experiments demonstrate that signal components can be associated with specific acute phase proteins. Conventionally determined concentrations of acute phase glycoproteins correlate well with distinct features in NMR spectra (R2 up to 0.9422, p-value <0.001), allowing the simultaneous quantification of several acute phase inflammation proteins. Overall, a proteo-metabolomics NMR signature of significant diagnostic potential is obtained within 10-20 min acquisition time. This is exemplified in serum samples from COVID-19 and cardiogenic shock patients showing significant changes in several acute phase proteins compared to healthy controls.

Discovery of drug-omics associations in type 2 diabetes with generative deep-learning models

The application of multiple omics technologies in biomedical cohorts has the potential to reveal patient-level disease characteristics and individualized response to treatment. However, the scale and heterogeneous nature of multi-modal data makes integration and inference a non-trivial task. We developed a deep-learning-based framework, multi-omics variational autoencoders (MOVE), to integrate such data and applied it to a cohort of 789 people with newly diagnosed type 2 diabetes with deep multi-omics phenotyping from the DIRECT consortium. Using in silico perturbations, we identified drug-omics associations across the multi-modal datasets for the 20 most prevalent drugs given to people with type 2 diabetes with substantially higher sensitivity than univariate statistical tests. From these, we among others, identified novel associations between metformin and the gut microbiota as well as opposite molecular responses for the two statins, simvastatin and atorvastatin. We used the associations to quantify drug-drug similarities, assess the degree of polypharmacy and conclude that drug effects are distributed across the multi-omics modalities.

POS0550 LONG TERM EFFICACY OF A 2-YEAR MRI TREAT-TO-TARGET STRATEGY ON DISEASE ACTIVITY, MRI INFLAMMATION AND PHYSICAL FUNCTION IN RHEUMATOID ARTHRITIS PATIENTS IN CLINICAL REMISSION: FIVE YEAR FOLLOW-UP OF THE IMAGINE RA-COHORT

Background

Targeting MRI remission in rheumatoid arthritis (RA) patients in clinical remission may improve long term clinical, functional and MRI outcomes.

Objectives

To investigate whether a 2-year treat-to-target (T2T) strategy, based on structured MRI assessments targeting absence of osteitis combined with clinical remission, compared with a conventional clinical T2T strategy targeting clinical remission only, improves disease activity, physical function and suppresses MRI-inflammation over 5 years in RA patients.

Methods

The IMAGINE-more trial was designed as an extension protocol to the 2-year IMAGINE-RA randomised controlled trial (RCT). IMAGINE-RA included 200 RA patients, in clinical remission (DAS28-CRP<3.2 and no swollen joints), who received conventional synthetic disease-modifying antirheumatic drugs (csDMARD) and investigated whether an MRI T2T strategy targeting absence of osteitis in combination with clinical remission (DAS28-CRP≤3.2 and no swollen joints) could increase remission rates and prevent erosive progression compared with a conventional T2T strategy targeting clinical remission only. If target was not met, treatment was escalated according to a predefined treatment algorithm starting with increment in csDMARDs and then adding biologics. At the end of the study, participants were invited to participate in the IMAGINE-more follow-up study. Patients were managed in routine outpatient clinic and had three IMAGINE-more visits including clinical examination (year 3, 4 and 5) and contrast-enhanced MRI of the dominant wrist and 2nd-5th metacarpophalangeal joints (year 3 and 5). The primary clinical endpoint was the proportion of patients achieving DAS28-CRP remission (DAS28-CRP<2.6) at year 5. Predefined key secondary outcomes were disease activity (DAS28-CRP), and changes in MRI osteitis (OMERACT RA MRI scoring system (RAMRIS)) and functional level (Health Assessment Questionnaire (HAQ)) from baseline to 5-years follow up. Endpoints were analysed by logistic regression models and repeated measures mixed effects models adjusted for propensity scores corresponding to (remaining in) group allocation.

Results

Fifty-nine patients in the MRI T2T arm and 72 patients in conventional T2T arm consented to participate. Of these, 47 patients (80%) in the MRI T2T group and 54 patients (75%) in the conventional T2T group reached the primary clinical endpoint (p=0.161) (Table 1 and Figure 1). No statistically significant differences between treatment strategies in key secondary outcomes were seen.

Table 1.

Primary and key secondary outcomes at 5 years

MRI T2TConventional T2TDifference between groupsP valueN=59N=72Primary endpointDAS28-CRP remission (DAS28-CRP<2.6), No. (%)47 (80%)54 (75%)2.00 (0.76 to 5.28)0.161Key secondary endpointsDAS28-CRP1.79 (0.08)1.94 (0.08)-0.15 (-0.38 to 0.07)0.176Change from baseline in MRI osteitis (RAMRIS)-0.17 (0.58)0.18 (0.54)-0.35 (-1.96 to 1.25)0.663Change from baseline in HAQ-0.02 (0.03)0.05 (0.03)-0.07 (-0.15 to 0.01)0.080

Group estimates are presented as No. (%) for dichotomous data and least squares means (SE) for continuous data. For the primary endpoint, adjusted odds ratio and 95%CI between groups were calculated from a logistic regression model including a fixed factor for treatment arm, and an adjustment for propensity score as a covariate. For endpoints with continuous data, least squares mean differences between groups were calculated based on repeated-measures mixed linear models adjusted for baseline values and propensity scores.

Conclusion

A 2-year MRI T2T strategy targeting absence of MRI osteitis combined with clinical remission as compared to a conventional clinical T2T strategy in RA patients had no effect on the long-term probability of achieving DAS28-CRP remission. These findnings do not support the use of an MRI-guided strategy for treating patients with RA.

References

[1]Møller-Bisgaard S et al: JAMA 2019, 321(5):461-472.

Disclosure of Interests

Signe Møller-Bisgaard Grant/research support from: AbbVie, Kim Hørslev-Petersen: None declared, Daniel Glinatsi: None declared, Bo Ejbjerg: None declared, Merete L. Hetland: None declared, Jakob Møllenbach Møller: None declared, Robin Christensen: None declared, Sabrina Mai Nielsen: None declared, Mikael Boesen: None declared, Kristian Stengaard-Pedersen: None declared, Ole Madsen: None declared, Bente Jensen: None declared, Jan Alexander Villadsen: None declared, Ellen Margrethe Hauge: None declared, Oliver Hendricks: None declared, Hanne Merete Lindegaard: None declared, Niels Steen Krogh: None declared, Anne Grethe Jurik: None declared, Henrik Thomsen: None declared, Mikkel Østergaard Speakers bureau: Abbvie, BMS, Celgene, Eli-Lilly, Galapagos, Gilead, Janssen, Merck, Novartis, Orion, Pfizer, Roche and UCB, Consultant of: Abbvie, BMS, Boehringer-Ingelheim, Celgene, Eli-Lilly, Hospira, Janssen, Merck, Novartis, Novo, Orion, Pfizer, Regeneron, Roche, Sandoz, Sanofi and UCB, Grant/research support from: Abbvie, Amgen, BMS, Merck, Celgene and Novartis.

Four groups of type 2 diabetes contribute to the etiological and clinical heterogeneity in newly diagnosed individuals: An IMI DIRECT study

The presentation and underlying pathophysiology of type 2 diabetes (T2D) is complex and heterogeneous. Recent studies attempted to stratify T2D into distinct subgroups using data-driven approaches, but their clinical utility may be limited if categorical representations of complex phenotypes are suboptimal. We apply a soft-clustering (archetype) method to characterize newly diagnosed T2D based on 32 clinical variables. We assign quantitative clustering scores for individuals and investigate the associations with glycemic deterioration, genetic risk scores, circulating omics biomarkers, and phenotypic stability over 36 months. Four archetype profiles represent dysfunction patterns across combinations of T2D etiological processes and correlate with multiple circulating biomarkers. One archetype associated with obesity, insulin resistance, dyslipidemia, and impaired β cell glucose sensitivity corresponds with the fastest disease progression and highest demand for anti-diabetic treatment. We demonstrate that clinical heterogeneity in T2D can be mapped to heterogeneity in individual etiological processes, providing a potential route to personalized treatments.

Prediction of clinical diagnosis of Alzheimer's disease, vascular, mixed, and all-cause dementia by a polygenic risk score and APOE status in a community-based cohort prospectively followed over 17 years

The strongest genetic risk factor for Alzheimer's disease (AD) is the ε4 allele of Apolipoprotein E (APOE) and recent genome-wide association meta-analyses have confirmed additional associated genetic loci with smaller effects. The aim of this study was to investigate the ability of an AD polygenic risk score (PRS) and APOE status to predict clinical diagnosis of AD, vascular (VD), mixed (MD), and all-cause dementia in a community-based cohort prospectively followed over 17 years and secondarily across age, sex, and education strata. A PRS encompassing genetic variants reaching genome-wide significant associations to AD (excluding APOE) from the most recent genome-wide association meta-analysis data was calculated and APOE status was determined in 5203 participants. During follow-up, 103, 111, 58, and 359 participants were diagnosed with AD, VD, MD, and all-cause dementia, respectively. Prediction ability of AD, VD, MD, and all-cause dementia by the PRS and APOE was assessed by multiple logistic regression and receiver operating characteristic curve analyses. The PRS per standard deviation increase in score and APOE4 positivity (≥1 ε4 allele) were significantly associated with greater odds of AD (OR, 95% CI: PRS: 1.70, 1.45-1.99; APOE4: 3.34, 2.24-4.99) and AD prediction accuracy was significantly improved when adding the PRS to a base model of age, sex, and education (ASE) (c-statistics: ASE, 0.772; ASE + PRS, 0.810). The PRS enriched the ability of APOE to discern AD with stronger associations than to VD, MD, or all-cause dementia in a prospective community-based cohort.

Demonstration of reduced neoclassical energy transport in Wendelstein 7-X

Research on magnetic confinement of high-temperature plasmas has the ultimate goal of harnessing nuclear fusion for the production of electricity. Although the tokamak1 is the leading toroidal magnetic-confinement concept, it is not without shortcomings and the fusion community has therefore also pursued alternative concepts such as the stellarator. Unlike axisymmetric tokamaks, stellarators possess a three-dimensional (3D) magnetic field geometry. The availability of this additional dimension opens up an extensive configuration space for computational optimization of both the field geometry itself and the current-carrying coils that produce it. Such an optimization was undertaken in designing Wendelstein 7-X (W7-X)2, a large helical-axis advanced stellarator (HELIAS), which began operation in 2015 at Greifswald, Germany. A major drawback of 3D magnetic field geometry, however, is that it introduces a strong temperature dependence into the stellarator's non-turbulent 'neoclassical' energy transport. Indeed, such energy losses will become prohibitive in high-temperature reactor plasmas unless a strong reduction of the geometrical factor associated with this transport can be achieved; such a reduction was therefore a principal goal of the design of W7-X. In spite of the modest heating power currently available, W7-X has already been able to achieve high-temperature plasma conditions during its 2017 and 2018 experimental campaigns, producing record values of the fusion triple product for such stellarator plasmas3,4. The triple product of plasma density, ion temperature and energy confinement time is used in fusion research as a figure of merit, as it must attain a certain threshold value before net-energy-producing operation of a reactor becomes possible1,5. Here we demonstrate that such record values provide evidence for reduced neoclassical energy transport in W7-X, as the plasma profiles that produced these results could not have been obtained in stellarators lacking a comparably high level of neoclassical optimization.

Author Correction: Cardiac hypoxic resistance and decreasing lactate during maximum apnea in elite breath hold divers

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

AB0209 PREDICTORS OF ACHIEVING STRINGENT REMISSION IN PATIENTS WITH ESTABLISHED RHEUMATOID ARTHRITIS IN CLINICAL REMISSION FOLLOWING A TREAT-TO-TARGET STRATEGY

Background:

Achieving remission according to stringent criteria such as Simplified Disease Activity Index (SDAI) and ACR/EULAR Boolean remission is associated with a better long-term outcome in patients with RA1. Possible predictors of achieving stringent remission in patients in clinical remission, following targeted treatment strategies, have not been investigated.

Objectives:

To investigate the predictive value of clinical, radiographic and MRI variables on achieving more stringent remission in RA patients in clinical remission, following MRI and conventional treat-to-target (T2T) strategies.

Methods:

In this post-hoc study, data were used from 171 RA patients in clinical remission (DAS28-CRP< 3.2 and no swollen joints) on conventional synthetic DMARDs, included in the IMAGINE-RA randomized clinical trial2, where they followed an MRI T2T strategy (targeting absence of osteitis) combined with clinical remission (DAS28-CRP≤3.2 and no swollen joints) or a conventional T2T strategy (targeting clinical remission only). Baseline contrast-enhanced MRIs of the dominant wrist and 2nd-5thMCP joints and radiographs of hands and feet were evaluated according to the OMERACT RAMRIS scoring system and Sharp/van der Heijde method, respectively, by two experienced readers. Potential clinical, radiographic and MRI baseline predictors of remission were first tested in univariate logistic regression analyses with achievement of Clinical Disease Activity Index (CDAI), SDAI, and ACR/EULAR Boolean remission at 24 months as dependent variables. Variables with p<0.25 were subsequently tested in multivariate logistic regression analyses with backward selection, adjusted for age, gender and strategy group. Missing values of covariates were imputed using chained equations.

Results:

Based on the univariate analyses, tender joint count, patient VAS global, VAS pain, VAS fatigue, physician VAS global, HAQ, MRI osteitis, radiographic and MRI erosion and joint space narrowing scores were included in multivariate analyses (Table).

Following the MRI T2T strategy was a positive predictor and high patient VAS global a negative predictor of achieving all definitions of remission. Furthermore, high patient VAS pain was negatively associated with achieving SDAI and ACR/EULAR Boolean remission and high tender joint count negatively associated with achieving CDAI and SDAI remission.

Multivariate logistic regression analyses with backward selection, final modelsDependent variables, remission at 24 monthsCDAISDAIACR/EULAR BooleanOR95% CIp-valueOR95% CIp-valueOR95% CIp-valueCovariatesMRI T2T strategy group2.941.25-7.520.0132.461.03-6.350.0435.472.33-14.11<0.001Female0.900.36-2.250.820.800.31-2.050.640.800.32-1.970.63Age1.020.98-1.070.321.020.98-1.070.331.030.99-1.070.15Tender joint count (0-28)0.330.12-0.860.0230.290.10-0.780.013Patient VAS global0.910.88-0.94<0.0010.930.88-0.97<0.0010.930.88-0.980.003Patient VAS pain0.950.91-1.000.0490.920.87-0.980.004

Conclusion:

In RA patients in clinical remission, poor patient reported outcomes and tender joint count were associated with decreased chance of achieving stringent remission, while following an MRI T2T strategy predicted stringent remission across all definitions thereof.

References:

[1]Smolen et al. Ann Rheum Dis 2017

[2]Møller-Bisgaard et al. JAMA 2019

Disclosure of Interests:

Signe Møller-Bisgaard Grant/research support from: AbbVie, Consultant of: BMS, Speakers bureau: BMS, Celgene, Pfizer, Stylianos Georgiadis Grant/research support from: Novartis, Kim Hørslev-Petersen: None declared, Bo Ejbjerg: None declared, Merete L. Hetland Grant/research support from: BMS, MSD, AbbVie, Roche, Novartis, Biogen and Pfizer, Consultant of: Eli Lilly, Speakers bureau: Orion Pharma, Biogen, Pfizer, CellTrion, Merck and Samsung Bioepis, Lykke Ørnbjerg: None declared, Daniel Glinatsi: None declared, Jakob Møllenbach Møller: None declared, Mikael Boesen Consultant of: AbbVie, AstraZeneca, Eli Lilly, Esaote, Glenmark, Novartis, Pfizer, UCB, Paid instructor for: IAG, Image Analysis Group, AbbVie, Eli Lilly, AstraZeneca, esaote, Glenmark, Novartis, Pfizer, UCB (scientific advisor)., Speakers bureau: Eli Lilly, Esaote, Novartis, Pfizer, UCB, Kristian Stengaard-Pedersen: None declared, Ole Rintek Madsen: None declared, Bente Jensen: None declared, Jan Villadsen: None declared, Ellen Margrethe Hauge: None declared, Philip Bennett: None declared, Oliver Hendricks: None declared, Karsten Asmussen: None declared, Marcin Kowalski: None declared, Hanne Merete Lindegaard: None declared, Henning Bliddal Grant/research support from: received research grant fra NOVO Nordic, Consultant of: consultant fee fra NOVO Nordic, Niels Steen Krogh: None declared, Torkell Ellingsen: None declared, Agnete Nielsen: None declared, Lone Balding: None declared, Anne Grethe Jurik: None declared, Henrik Thomsen: None declared, Mikkel Ǿstergaard Grant/research support from: AbbVie, Bristol-Myers Squibb, Celgene, Merck, and Novartis, Consultant of: AbbVie, Bristol-Myers Squibb, Boehringer Ingelheim, Celgene, Eli Lilly, Hospira, Janssen, Merck, Novartis, Novo Nordisk, Orion, Pfizer, Regeneron, Roche, Sandoz, Sanofi, and UCB, Speakers bureau: AbbVie, Bristol-Myers Squibb, Boehringer Ingelheim, Celgene, Eli Lilly, Hospira, Janssen, Merck, Novartis, Novo Nordisk, Orion, Pfizer, Regeneron, Roche, Sandoz, Sanofi, and UCB

FRI0019 MRI INFLAMMATION, DISEASE ACTIVITY AND FUNCTIONAL IMPAIRMENT ARE MORE EFFECTIVELY REDUCED BY ESCALATION TO BIOLOGICS COMPARED TO CSDMARD-ESCALATION IN RHEUMATOID ARTHRITIS PATIENTS IN CLINICAL REMISSION FOLLOWING A TREAT-TO-TARGET STRATEGY: SECONDARY ANALYSES OF THE IMAGINE-RA TRIAL

Background:

The effect of different treatment escalations on MRI inflammation in rheumatoid arthritis (RA) patients following an MRI treat-to-target (T2T) strategy has not previously been investigated.

Objectives:

To compare the effect of different treatment escalations on MRI inflammation, physical function and disease activity in RA patients in clinical remission, following an MRI T2T strategy.

Methods:

One hundred RA patients in clinical remission (DAS28-CRP<3.2 and no swollen joints), on conventional synthetic (cs) DMARDs following an MRI T2T strategy targeting DAS28-CRP≤3.2, no swollen joints plus absence of MRI osteitis, were followed for 2 years with clinical and MRI (wrist and 2nd-5thMCP joints) evaluation every 4 months1. If target was not met, a predefined treatment escalation algorithm dictated: First: increase in csDMARDs (A), second: adding a TNF inhibitor (TNFi) (B), third and onwards: switch between biologics (C). If target was met, no change in baseline csDMARDs was done (D). Outcomes were assessed 4 months after treatment change. MRIs were evaluated with known chronology by one experienced reader. Repeated measures mixed linear models were used to express estimates of group differences on predefined co-primary outcomes (MRI osteitis, HAQ) and key secondary outcomes (MRI combined inflammation, Simplified Disease Activity Index (SDAI)).

Results:

Escalation to first TNFi (B) or to 2ndor later biologic (C) compared to csDMARDs (A) was consistently more effective on all outcomes (e.g. in group B osteitis was reduced with 1.8 units more than A) (Table). Unchanged (D) compared to escalation in csDMARD (A) treatment did not differ, except for HAQ-score. Escalation to a 2ndor later biologics (C) compared to the first TNFi (B) was more effective suppressing MRI inflammation. Escalation to TNFi treatment (B) or to 2ndor later biologic (C) compared to unchanged treatment (D) was more effective on all outcomes except from HAQ-score (no difference between groups).

Comparisons of treatment escalations1A: Increment in csDMARD mono/combination therapy (n=73)); B: Switch from csDMARD combination therapy to TNFi (n=39); C: Switch from TNFi to 2ndbiologic/switch between biologics (n=21); D: No change in csDMARDs from baseline (n=58)A vs BA vs CA vs DB vs CB vs DC vs DOutcomesPrimaryMRIOsteitis1.8 (1.0; 2.6) p<.00013.6 (2.3; 4.8) p<.00010.3 (−0.3; 1.0)p=.321.8 (0.8; 2.9) p=.0006−1.4 (−2.4; −0.5) p=.0045−3.3 (−4.6; −1.9) p<.0001HAQ0.081(0.033; 0.13) p=.00110.091(0.031; 0.15) p=.00320.054(0.014; 0.095) p=.00910.0092(−0.051; 0.070) p=.77−0.027(−0.082; 0.028) p=.33−0.037(−0.10; 0.031) p=.29Key secondaryMRI combined inflammationa2.5 (0.9; 4.1) p=.00185.4 (3.1; 7.7) p<.00010.4 (−0.9; 1.8)p=.522.9 (0.8; 4.9) p=.0064−2.1 (−4.0; −0.2) p=.032−5.0 (−7.5; −2.4) p=.0002SDAI2.7 (1.9; 3.5) p<.00012.4 (1.4; 3.4) p<.00010.5 (−0.2; 1.2)p=.14−0.3 (−1.3; 0.7)p=.60−2.2 (−3.1; −1.3) p<.0001−1.9 (−3.0; 0.8) p=.0006

1Estimates of group differences (least squares means (95% CI)).

aSum score of synovitis, osteitis and tenosynovitis

Conclusion:

T2T-based treatment escalations to biologics compared to csDMARD-escalations more effectively improved MRI inflammation, physical function and disease activity. Further optimization of the treatment in RA patients in clinical remission may improve long-term outcomes.

References:

[1]Møller-Bisgaard et al. JAMA 2019

Disclosure of Interests:

Signe Møller-Bisgaard Grant/research support from: AbbVie, Consultant of: BMS, Speakers bureau: BMS, Celgene, Pfizer, Kim Hørslev-Petersen: None declared, Bo Ejbjerg: None declared, Merete L. Hetland Grant/research support from: BMS, MSD, AbbVie, Roche, Novartis, Biogen and Pfizer, Consultant of: Eli Lilly, Speakers bureau: Orion Pharma, Biogen, Pfizer, CellTrion, Merck and Samsung Bioepis, Robin Christensen: None declared, Lykke Ørnbjerg: None declared, Daniel Glinatsi: None declared, Jakob Møllenbach Møller: None declared, Mikael Boesen Consultant of: AbbVie, AstraZeneca, Eli Lilly, Esaote, Glenmark, Novartis, Pfizer, UCB, Paid instructor for: IAG, Image Analysis Group, AbbVie, Eli Lilly, AstraZeneca, esaote, Glenmark, Novartis, Pfizer, UCB (scientific advisor)., Speakers bureau: Eli Lilly, Esaote, Novartis, Pfizer, UCB, Kristian Stengaard-Pedersen: None declared, Ole Rintek Madsen: None declared, Bente Jensen: None declared, Jan Villadsen: None declared, Ellen Margrethe Hauge: None declared, Philip Bennett: None declared, Oliver Hendricks: None declared, Karsten Asmussen: None declared, Marcin Kowalski: None declared, Hanne Merete Lindegaard: None declared, Henning Bliddal Grant/research support from: received research grant fra NOVO Nordic, Consultant of: consultant fee fra NOVO Nordic, Niels Steen Krogh: None declared, Torkell Ellingsen: None declared, Agnete Nielsen: None declared, Anne Grethe Jurik: None declared, Lone Balding: None declared, Henrik Thomsen: None declared, Mikkel Ǿstergaard Grant/research support from: AbbVie, Bristol-Myers Squibb, Celgene, Merck, and Novartis, Consultant of: AbbVie, Bristol-Myers Squibb, Boehringer Ingelheim, Celgene, Eli Lilly, Hospira, Janssen, Merck, Novartis, Novo Nordisk, Orion, Pfizer, Regeneron, Roche, Sandoz, Sanofi, and UCB, Speakers bureau: AbbVie, Bristol-Myers Squibb, Boehringer Ingelheim, Celgene, Eli Lilly, Hospira, Janssen, Merck, Novartis, Novo Nordisk, Orion, Pfizer, Regeneron, Roche, Sandoz, Sanofi, and UCB

First Observation of a Stable Highly Dissipative Divertor Plasma Regime on the Wendelstein 7-X Stellarator

For the first time, the optimized stellarator Wendelstein 7-X has operated with an island divertor. An operation regime in hydrogen was found in which the total plasma radiation approached the absorbed heating power without noticeable loss of stored energy. The divertor thermography recorded simultaneously a strong reduction of the heat load on all divertor targets, indicating almost complete power detachment. This operation regime was stably sustained over several energy confinement times until the preprogrammed end of the discharge. The plasma radiation is mainly due to oxygen and is located at the plasma edge. This plasma scenario is reproducible and robust at various heating powers, plasma densities, and gas fueling locations. These experimental results show that the island divertor concept actually works and displays good power dissipation potential, producing a promising exhaust concept for the stellarator reactor line.

Inference of temperature and density profiles via forward modeling of an x-ray imaging crystal spectrometer within the Minerva Bayesian analysis framework

At the Wendelstein 7-X stellarator, the X-ray imaging crystal spectrometer provides line integrated measurements of ion and electron temperatures, plasma flows, as well as impurity densities from a spectroscopic analysis of tracer impurity radiation. In order to infer the actual profiles from line integrated data, a forward modeling approach has been developed within the Minerva Bayesian analysis framework. In this framework, the inversion is realized on the basis of a complete forward model of the diagnostic, including error propagation and utilizing Gaussian processes for generation and inference of arbitrary shaped plasma parameter profiles. For modeling of line integrated data as measured by the detector, the installation geometry of the spectrometer, imaging properties of the crystal, and Gaussian detection noise are considered. The inversion of line integrated data is achieved using the maximum posterior method for plasma parameter profile inference and a Markov chain Monte Carlo sampling of the posterior distribution for calculating uncertainties of the inference process. The inversion method shows a correct and reliable inference of temperature and impurity density profiles from synthesized data within the estimated uncertainties along the whole plasma radius. The application to measured data yields a good match of derived electron temperature profiles to data of the Thomson scattering diagnostic for central electron temperatures between 2 and 5 keV using argon impurities.

ECCD operations in the second experimental campaign at W7-X

In the Wendelstein 7-X stellarator, up to 7MW of power are delivered to the plasma by an electron cyclotron resonance heating system consisting of ten 140 GHz gyrotrons [1].

Due to the flexible front steering mirror of each beam line, the power deposition can be varied over the whole plasma radius and is optionally combinable with additional current drive. This flexibility, together with small toroidal currents in the stellarator, makes W7-X a perfect testbed for electron cyclotron current drive (ECCD) experiments, which have been successfully accomplished during the first two experimental campaigns OP1.1 and OP1.2a.

Long discharges (lasting up to 30s) have been performed in OP1.2a, thus allowing the study of the current drive time evolution and the possibility to compensate the bootstrap current.

ECCD efficiency has been studied using different power deposition profiles combined with a variation of the injection angles in relation to the magnetic field.

During ECCD experiments, saw-tooth-like oscillations have been observed. Depending on the driven current density, ECCD can significantly modify the rotational transform (iota) profile, which can locally reach low order rational, thus triggering plasma instabilities.

Different current density profiles have been tested, in order to try to understand the main trigger parameter for the instabilities. In particular, effects caused by current density gradient have been investigated producing both co- and counter-current drive at different radial positions: the total current drive is negligible, but a strong current gradient arises by driving currents in opposite directions.

In this work an overview of ECCD operations in OP1.2a is given and first results, comparing different diagnostics, are presented. An initial 1-D model, coupled with the ray tracer TRAVIS, is developed, in order to have an estimation of current diffusion times and the radial position where a low order rational crosses the disturbed iota profile.

Plasma impurities observed by a pulse height analysis diagnostic during the divertor campaign of the Wendelstein 7-X stellarator

The paper reports on the optimization process of the soft X-ray pulse height analyzer installed on the Wendelstein 7-X (W7-X) stellarator. It is a 3-channel system that records X-ray spectra in the range from 0.6 to 19.6 keV. X-ray spectra, with a temporal and spatial resolution of 100 ms and 2.5 cm (depending on selected slit sizes), respectively, are line integrated along a line-of-sight that crosses near to the plasma center. In the second W7-X operation phase with a carbon test divertor unit, light impurities, e.g., carbon and oxygen, were observed as well as mid- to high-Z elements, e.g., sulfur, chlorine, chromium, manganese, iron, and nickel. In addition, X-ray lines from several tracer elements have been observed after the laser blow-off injection of different impurities, e.g., silicon, titanium, and iron, and during discharges with prefill or a gas puff of neon or argon. These measurements were achieved by optimizing light absorber-foil selection, which defines the detected energy range, and remotely controlled pinhole size, which defines photon flux. The identification of X-ray lines was confirmed by other spectroscopic diagnostics, e.g., by the High-Efficiency XUV Overview Spectrometer, HEXOS, and high-resolution X-ray imaging spectrometer, HR-XIS.

Design, capabilities, and first results of the new laser blow-off system on Wendelstein 7-X

We present a detailed overview and first results of the new laser blow-off system on the stellarator Wendelstein 7-X. The system allows impurity transport studies by the repetitive and controlled injection of different tracer ions into the plasma edge. A Nd:YAG laser is used to ablate a thin metal film, coated on a glass plate, with a repetition rate of up to 20 Hz. A remote-controlled adjustable optical system allows the variation of the laser spot diameter and enables the spot positioning to non-ablated areas on the target between laser pulses. During first experiments, clear spectral lines from higher ionization stages of the tracer ions have been observed in the X-ray to the extreme ultraviolet spectral range. The temporal behavior of the measured emission allows the estimate of transport properties, e.g., impurity transport times in the order of 100 ms. Although the strong injection of impurities is well detectable, the global plasma parameters are barely changed.

A genome-wide association study identifies risk loci for childhood acute lymphoblastic leukemia at 10q26.13 and 12q23.1

Genome-wide association studies (GWASs) have shown that common genetic variation contributes to the heritable risk of childhood acute lymphoblastic leukemia (ALL). To identify new susceptibility loci for the largest subtype of ALL, B-cell precursor ALL (BCP-ALL), we conducted a meta-analysis of two GWASs with imputation using 1000 Genomes and UK10K Project data as reference (totaling 1658 cases and 7224 controls). After genotyping an additional 2525 cases and 3575 controls, we identify new susceptibility loci for BCP-ALL mapping to 10q26.13 (rs35837782, LHPP, P=1.38 × 10-11) and 12q23.1 (rs4762284, ELK3, P=8.41 × 10-9). We also provide confirmatory evidence for the existence of independent risk loci at 9p21.3, but show that the association marked by rs77728904 can be accounted for by linkage disequilibrium with the rare high-impact CDKN2A p.Ala148Thr variant rs3731249. Our data provide further insights into genetic susceptibility to ALL and its biology.

Overview of diagnostic performance and results for the first operation phase in Wendelstein 7-X (invited)

Wendelstein 7-X, a superconducting optimized stellarator built in Greifswald/Germany, started its first plasmas with the last closed flux surface (LCFS) defined by 5 uncooled graphite limiters in December 2015. At the end of the 10 weeks long experimental campaign (OP1.1) more than 20 independent diagnostic systems were in operation, allowing detailed studies of many interesting plasma phenomena. For example, fast neutral gas manometers supported by video cameras (including one fast-frame camera with frame rates of tens of kHz) as well as visible cameras with different interference filters, with field of views covering all ten half-modules of the stellarator, discovered a MARFE-like radiation zone on the inboard side of machine module 4. This structure is presumably triggered by an inadvertent plasma-wall interaction in module 4 resulting in a high impurity influx that terminates some discharges by radiation cooling. The main plasma parameters achieved in OP1.1 exceeded predicted values in discharges of a length reaching 6 s. Although OP1.1 is characterized by short pulses, many of the diagnostics are already designed for quasi-steady state operation of 30 min discharges heated at 10 MW of ECRH. An overview of diagnostic performance for OP1.1 is given, including some highlights from the physics campaigns.

Effect of a treat-to-target strategy based on methotrexate and intra-articular betamethasone with or without additional cyclosporin on MRI-assessed synovitis, osteitis, tenosynovitis, bone erosion, and joint space narrowing in early rheumatoid arthritis: results from a 2-year randomized double-blind placebo-controlled trial (CIMESTRA)

OBJECTIVES

To investigate whether a treat-to-target strategy based on methotrexate (MTX) and intra-articular (IA) betamethasone suppresses magnetic resonance imaging (MRI)-determined measures of disease activity and reduces joint destruction in early rheumatoid arthritis (eRA) patients, and to investigate whether concomitant cyclosporin A (CyA) provides an additional effect.

METHOD

In the 2-year randomized, double-blind, treat-to-target trial CIMESTRA, 160 patients with eRA (< 6 months) were randomized to MTX, intra-articular betamethasone and CyA, or placebo CyA. A total of 129 patients participated in the MRI substudy, and had contrast-enhanced MR images of the non-dominant hand at months 0, 6, 12, and 24. MR images were evaluated for osteitis, synovitis, tenosynovitis, bone erosion, and joint space narrowing (JSN), using validated scoring methods.

RESULTS

Significant reductions were seen at 6 months in all inflammatory parameters [synovitis, mean change -1.6 (p < 0.001, Wilcoxon), tenosynovitis, -3.5 (p < 0.001), and osteitis, -1.3 (p < 0.05)] and at 12/24 months in synovitis and tenosynovitis [-1.6/-2.2 and -3.6/-3.8, respectively; all p < 0.001]. MRI signs of inflammation were not fully eliminated, and increases in erosion and JSN scores were observed at 6 months [0.4 (p < 0.01)/0.1 (p < 0.05)], 12 months [0.8 (p < 0.001)/0.3 (p < 0.01)], and 24 months [1.0 (p < 0.001)/0.4 (p < 0.001)]. Clinical measures decreased significantly (p < 0.001) at all time points. There were no consistent statistically significant differences between treatment groups.

CONCLUSIONS

In this eRA treat-to-target trial, MTX and intra-articular glucocorticoids markedly reduced, but did not eliminate, MRI osteitis, synovitis, and tenosynovitis. Accordingly, minimal but statistically significant increases in bone erosion and JSN were observed. No additional effect of CyA was demonstrated.

COMPARISON OF THE LONG-TERM EFFECTS OF LIRAGLUTIDE AND GLIMEPIRIDE MONOTHERAPY ON BONE MINERAL DENSITY IN PATIENTS WITH TYPE 2 DIABETES

OBJECTIVE

Patients with type 2 diabetes have an increased risk of fragility fractures; the cause is unclear but is likely multifactorial. Some diabetes treatments induce bone loss, accentuating underlying skeletal fragility and increasing fracture risk. This subgroup analysis aimed to compare long-term effects of liraglutide and glimepiride on bone mineral density (BMD) in patients with type 2 diabetes.

METHODS

LEAD-3, a 52-week, double-blind, active-control, phase III, multicenter trial, investigated the efficacy of liraglutide (1.2 and 1.8 mg/day) versus glimepiride monotherapy in type 2 diabetes. A 52-week, open-label extension followed, in which participants remained on randomized therapy. A subgroup of participants underwent BMD measurement by dual-energy X-ray absorptiometry at baseline, 52, and 104 weeks. The main outcome measure was change from baseline in total body BMD at 52 and 104 weeks, assessed by analysis of covariance.

RESULTS

A total of 746 patients with type 2 diabetes aged 19 to 79 years were randomized into the main trial. Of these, 61 patients (20 assigned to liraglutide 1.8 mg/day, 23 to liraglutide 1.2 mg/day, 18 to glimepiride 8 mg/day) had BMD measurements. Baseline age, body mass index, diabetes duration, glycated hemoglobin, and total BMD were similar across treatment groups. There was no apparent difference in mean total BMD change from baseline in patients receiving liraglutide 1.8 or 1.2 mg/day or glimepiride 8 mg/day at 52 or 104 weeks.

CONCLUSION

In this small subgroup analysis, liraglutide monotherapy did not negatively affect total BMD in a 2-year prospective study, suggesting it may not exacerbate the consequences of bone fragility.

Resolving structural transitions in spherical dust clusters

Finite systems in confining potentials are known to undergo structural transitions similar to phase transitions. However, these systems are inhomogeneous, and their "melting" point may depend on the position in the trap and vary with the particle number. Focusing on three-dimensional Coulomb systems in a harmonic trap a rich physics is revealed: in addition to radial melting we demonstrate the existence of intrashell disordering and intershell angular melting. Our analysis takes advantage of a novel melting criterion that is based on the spatial two- and three-particle distribution functions and the associated reduced entropy which can be directly measured in complex plasma experiments.

[Ischaemic colitis after loperamide treatment]

Ischaemic colitis is a potentially mortal illness which usually arises from decreased mesenteric blood flow. Loperamide is used in the treatment of both acute and chronic diarrhoea. We present a case of a 62-year-old man with no history of abdominal illness who was admitted with a distended and sore abdomen. Ten days prior to admission he was treated with loperamide. Because of his severe condition he had an emergency laparotomy which showed a necrotic colon and terminal ileum - both were resected. No thromboembolic cause was found and we therefore suggest loperamide as an inducing factor.

Status of the diagnostics development for the first operation phase of the stellarator Wendelstein 7-X

An overview of the diagnostics which are essential for the first operational phase of Wendelstein 7-X and the set of diagnostics expected to be ready for operation at this time are presented. The ongoing investigations of how to cope with high levels of stray Electron Cyclotron Resonance Heating (ECRH) radiation in the ultraviolet (UV)/visible/infrared (IR) optical diagnostics are described.

Metastatic sites and survival in lung cancer

OBJECTIVES

Population-based data on metastatic sites and survival in site-specific metastases are lacking for lung cancer and for any cancer because most cancer registries do not record metastases. This study uses a novel population-based approach to identify metastases from both death certificates and national inpatient data to describe metastatic pathways in lung cancer patients.

MATERIALS AND METHODS

17,431 deceased lung cancer patients diagnosed 2002-2010 were identified from the nationwide Swedish Cancer Registry, which is based on compulsory reports. The influence of age at diagnosis, sex, and histological subtype on metastatic spread was investigated. Survival in metastatic lung cancer was assessed by histology and metastatic site.

RESULTS

The most frequent metastatic sites were the nervous system, bone, liver, respiratory system, and adrenal gland. Liver (35%) and nervous system (47%) metastases were common in patients with metastases from small cell lung cancer, and bone (39%) and respiratory system (22%) metastases in adenocarcinoma. Women (43% vs. 35%) and younger patients had more metastases to the nervous system. Median survival after diagnosis was 13 months for non-metastatic and five months for metastatic lung cancer. In this novel data, liver metastases conferred the worst prognosis (three months), especially for large cell histology. Bone metastases also featured poor survival, whereas survival in respiratory and nervous system metastases was better.

CONCLUSION

Metastatic sites and survival in metastatic lung cancer is influenced by sex, histological subtype, and age at diagnosis. Liver and bone metastases signal poor survival, compared with nervous system metastases.

Darstellung, 11B-und 19F-NMR-Spektren des Monofluoropentaiodo- closo-hexaboratanions sowie Kristallstruktur von (CH2Py2)[B6FI5]/ Synthesis, 11B and 19F NMR Spectra of the Monofluoropentaiodo-closo-hexaborate Anion and the Crystal Structure of (CH2Py2)[B6FI5]

By reaction of closo-[B6H5F]2- in alkaline solution with excess iodine the monofluoropentaiodo- closo-hexaborate anion [B6FI5]2- is formed in good yield. The crystal structure of (CH2Py2)[B6FI5] has been determined by single crystal X-ray diffraction analysis (orthorhombic, space group Pnma, a = 13.803(2), b = 11.759(2), c = 13.936(2) Å, Z = 4). The B-F-bond length is 1.41 Å, the B-I distances range from 2.13 to 2.17 Å, the B-B distances from 1.69 to 1.76 A. According to the C4v point symmetry the 11B NMR spectrum of the anion exhibits three singlets at +3.8,-30.1 and-33.3 ppm with the intensity ratio 1:4:1, the 19F NMR spectrum one quartet at -247.6 ppm with the coupling constant 1J (19F, 11B) = 54 Hz.

Darstellung und 11B-NMR-Spektrum von Heptabromo-closo-heptaborat, [B7Br7]2- sowie Kristallstruktur von [(C5H5N)2CH2][B7Br7] / Preparation and 11B NMR Spectrum of Heptabromo-closo-heptaborate, [B7Br7]2-, and the Crystal Structure of [(C5H5N)2CH2][B7Br7]

By reaction of conjuncto-[B6H6-B6H6]2- in alkaline solution with excess bromine the heptabromo-closo-heptaborate, [B7Br7]2 is formed. The crystal structure of [(CsH3N)2CH2][B7Br7] has been determined by single crystal X-ray diffraction analysis (monoclinic, space group P21/a with a = 15.0843(14), b = 9.8882(14), c = 17.057(2) Å, β = 114.039°(7)). In accordance with the D5h point symmetry, the anion shows two singlets at -23.3 and -0.1 ppm with the intensity ratio 2:5 in its 11B NMR spectrum.

Darstellung, 11B-NMR-Spektren, Schwingungsspektren und Normalkoordinatenanalyse von conjuncto-Bis-hexahydro-closo-hexaborat, [B6H6-B6H6]2-, sowie Kristallstruktur von [P(C6H5)4]2-conjuncto-[B6H6-B6H6] / Preparation, 11B NMR Spectra, Vibrational Spectra and Normal Coordinate Analysis of conjuncto-Bis-hexahydro-closo-hexaborate, [B6H6-B6H6]2-, and the Crystal Structure of [ P(C6H5)4]2-conjuncto-[B6H6-B6H6]

By reaction of [B6H6]2- with dibenzoylperoxide in dichloromethane conjuncto-[B6H6- B6H6]2- is formed. The product could be separated from excess [B6H6]2- by ion exchange chromatography on diethylaminoethyl cellulose. The crystal structure of [P(C6H5)4]2 -conjuncto- [B6H6-B6H6] has been determined by single crystal X-ray diffraction analysis; triclinic, space group P1̄ with a = 10.8315(10), b = 11,2422( 12), c = 20.340(2) Å, α = 91.278° (9), β = 90.178° (9), γ = 105.662°(9). The 11B NMR spectrum reveals three signals with the intensity ratio 1:1:4, for two equivalent moieties of the conjuncto molecule ion with local C4v symmetry. The IR and Raman spectra of the deprotonated Cs salts of the 10B, 11B and their respective D isotopomers of conjuncto-[B6H5-B6H5]4- exhibit characteristic shifts. Using averaged crystallographic data and assuming idealized D4h symmetry, normal coordinate analyses have been performed based on a modified valence force field. With a set of eleven force constants (e.g. fd(BB)conjuncto = 2.9, fd(BB)cage = 1.6 mdyn/Å) very good agreement between observed and calculated frequencies has been achieved. From strong vibrational coupling with the B6 clusters two vibrations result for the conjuncto B-B bond at 1142/1198 and 292/304cm-1 for 11B/10B species, respectively. They can be assigned as anti-phase and in-phase motions of the conjuncto B atoms related to the equatorial B4 planes.

ab-initio-Rechnungen, Schwingungsspektren und Normalkoordinatenanalyse von closo-[B6H5F]2– / ab initio Calculations, Vibrational Spectra, and Normal Coordinate Analysis of closo-[B6H5F]2–

The structural parameters of closo-[B6H5F]2- with C4v symmetry have been determined by MP2/6-31G* optimization. They reveal typical B-F and B-B bond lenghts of 143.4 and 172.5 -173.9 pm, respectively. A frequency analysis at the same theoretical level has been performed. The vibrational spectra of [B6H5F]2- labelled with 10B, 11B and D have been additionally assigned by normal coordinate analysis based on a modified valence force field using the ab initio structure parameters. With a set of 10 force constants (e.g. fd(BB)=1.92, fd(BF)=5.25 mdyn/Å) a good agreement between observed and calculated frequencies can be achieved. The results correspond with the scaled (Fscale=0.97) ab initio frequencies and assignments.

[Acute oesophageal necrosis in patients with diabetic ketoacidosis]

Acute oesophageal necrosis is a rarely seen phenomenon, occurring in situations with ischaemic insult in combination with gastric outlet obstruction or gastro-oesophageal reflux. The hallmark is circumferential necrosis of the oesophageal mucosa and it is associated with a high mortality. Two patients presented with haematemesis. They were admitted to hospital in a state of diabetic ketoacidosis. Endoscopy revealed acute oesophageal necrosis. They were stabilized and treated with high-dose proton pump inhibitors. Both patients recovered and were discharged without sequelae.

[Spontaneous rupture of the spleen after infectious mononucleosis]

Non-traumatic rupture of the spleen (NRS) is a rare but serious complication to infectious mononucleosis (IM) and it is important to have in mind, when patients have IM. Although splenectomy has been advocated as the appropriate treatment for this problem, the trend goes towards conservative treatment of the haemodynamically stable patients, but because of its rarity no clear guidelines have been suggested. We present a case of a 18-year-old boy with IM who had NRS with subcapsular haematoma and was treated conservatively. He recovered completely.

Bayesian soft X-ray tomography using non-stationary Gaussian Processes

In this study, a Bayesian based non-stationary Gaussian Process (GP) method for the inference of soft X-ray emissivity distribution along with its associated uncertainties has been developed. For the investigation of equilibrium condition and fast magnetohydrodynamic behaviors in nuclear fusion plasmas, it is of importance to infer, especially in the plasma center, spatially resolved soft X-ray profiles from a limited number of noisy line integral measurements. For this ill-posed inversion problem, Bayesian probability theory can provide a posterior probability distribution over all possible solutions under given model assumptions. Specifically, the use of a non-stationary GP to model the emission allows the model to adapt to the varying length scales of the underlying diffusion process. In contrast to other conventional methods, the prior regularization is realized in a probability form which enhances the capability of uncertainty analysis, in consequence, scientists who concern the reliability of their results will benefit from it. Under the assumption of normally distributed noise, the posterior distribution evaluated at a discrete number of points becomes a multivariate normal distribution whose mean and covariance are analytically available, making inversions and calculation of uncertainty fast. Additionally, the hyper-parameters embedded in the model assumption can be optimized through a Bayesian Occam's Razor formalism and thereby automatically adjust the model complexity. This method is shown to produce convincing reconstructions and good agreements with independently calculated results from the Maximum Entropy and Equilibrium-Based Iterative Tomography Algorithm methods.

Diagnostics development for quasi-steady-state operation of the Wendelstein 7-X stellarator (invited)

The critical issues in the development of diagnostics, which need to work robust and reliable under quasi-steady state conditions for the discharge durations of 30 min and which cannot be maintained throughout the one week duration of each operation phase of the Wendelstein 7-X stellarator, are being discussed.