A novel method to estimate the response of habitat types to nitrogen deposition

Increasing nitrogen depositions adversely affect European landscapes, including habitats within the Natura2000 network. Critical loads for nitrogen deposition have been established to quantify the loss of habitat quality. When the nitrogen deposition rises above a habitat-specific critical load, the quality of the focal habitat is expected to be negatively influenced. Here, we investigate how the quality of habitat types is affected beyond the critical load. We calculated response curves for 60 terrestrial habitat types in the Netherlands to the estimated nitrogen deposition (EMEP-data). The curves for habitat types are based on the occurrence of their characteristic plant species in North-Western Europe (plot data from the European Vegetation Archive). The estimated response curves were corrected for soil type, mean annual temperature and annual precipitation. Evaluation was carried out by expert judgement, and by comparison with gradient deposition field studies. For 39 habitats the response to nitrogen deposition was judged to be reliable by five experts, while out of the 41 habitat types for which field studies were available, 25 showed a good agreement. Some of the curves showed a steep decline in quality and some a more gradual decline with increasing nitrogen deposition. We compared the response curves with both the empirical and modelled critical loads. For 41 curves, we found a decline already starting below the critical load.

Advancements in kidney organoids and tubuloids to study (dys)function

The rising prevalence of kidney diseases urges the need for novel therapies. Kidney organoids and tubuloids are advanced in vitro models and have recently been described as promising tools to study kidney (patho)physiology. Recent developments have shown their application in disease modeling, drug screening, and nephrotoxicity. These applications rely on their ability to mimic (dys)function in vitro including endocrine activity and drug, electrolyte, and water transport. This review provides an overview of these emerging kidney models and focuses on the most recent developments that utilize their functional capabilities. In addition, we cover current limitations and provide future perspectives for this rapidly evolving field, including what these functional properties mean for translational and personalized medicine now and in the future.

Differentiated mouse kidney tubuloids as a novel in vitro model to study collecting duct physiology

Kidney tubuloids are cell models that are derived from human or mouse renal epithelial cells and show high similarities with their in vivo counterparts. Tubuloids grow polarized in 3D, allow for long-term expansion, and represent multiple segments of the nephron, as shown by their gene expression pattern. In addition, human tubuloids form tight, functional barriers and have been succesfully used for drug testing. Our knowledge of mouse tubuloids, on the other hand, is only minimal. In this study, we further characterized mouse tubuloids and differentiated them towards the collecting duct, which led to a significant upregulation of collecting duct-specific mRNAs of genes and protein expression, including the water channel AQP2 and the sodium channel ENaC. Differentiation resulted in polarized expression of collecting duct water channels AQP2 and AQP3. Also, a physiological response to desmopressin and forskolin stimulation by translocation of AQP2 to the apical membrane was demonstrated. Furthermore, amiloride-sensitive ENaC-mediated sodium uptake was shown in differentiated tubuloids using radioactive tracer sodium. This study demonstrates that mouse tubuloids can be differentiated towards the collecting duct and exhibit collecting duct-specific function. This illustrates the potential use of mouse kidney tubuloids as novel in vitro models to study (patho)physiology of kidney diseases.

ON THE PLACEMENT OF APRON DOSEMETERS AND DOSE ASSESSMENT IN INTERVENTIONAL CARDIOLOGY PROCEDURES: PRELIMINARY RESULTS

Personnel involved in interventional practices are likely to be exposed to higher radiation doses than other workers in the medical field. Personnel monitoring and radiation protection measures play a crucial role in keeping these doses below the limits. EURADOS (European Radiation Dosimetry Group) Working Group 12 performed a series of investigations showing how the complexity of the scattered field reaching the operators can influence the doses to the operators. The present work was aimed at determining the possible effects on the registered doses of the scattered field and the actual position of a dosemeter on apron. This study has been performed through Monte Carlo simulations and it was validated through measurements. It does not claim to identify the 'best' position for the dosemeter, but to assess the variability of its response, showing how a variability of the order of +/- 30% to 40 should be taken into account.

POS0651 IMPACT OF ADVERSE DRUG REACTIONS ON THE TREATMENT PATHWAYS OF EARLY RHEUMATOID ARTHRITIS PATIENTS

Background

Rheumatoid arthritis (RA) patients frequently pass through several medications in order to achieve and maintain acceptable disease control The clinical heterogeneity and variable course of the disease, plus the availability of multiple classes and subclasses of DMARDs may lead to very different and complex treatment sequencing in individual patients. Limited real-world data exists regarding treatment pathways among patients with RA. Adverse drug reactions (ADRs) belong to the stop reasons of medication, but the impact of ADRs on treatment pathways has not been quantified.

Objectives

To assess differences in treatment pathways between RA patients with and without adverse drug reactions (ADRs).

Methods

Single center retrospective observational study, using real-world data collected in the Dutch Rheumatoid Arthritis Monitoring (DREAM-RA) registry from Medisch Spectrum Twente (Enschede, the Netherlands). From all early RA patients enrolled between 16 July 2006 and 30 April 2020, the first four consecutive courses of treatment were assessed. Patients were selected from the DREAM early RA treat-to-target cohort I.1 The use of corticosteroids per protocol was allowed but not considered as a DMARD treatment. Any alteration in (a combination of) medication was viewed as a separate treatment, and thus any addition, subtraction or change in medication was the start of a new treatment. If a patient was without continuous treatment for 90 days or more in between treatments, this was considered a temporary stop of treatment. Treatment pathways were stratified for occurrence of at least one ‘ADR or ‘No ADR’. Differences in duration of treatment, number of treatments, and the proportion of treatments with csDMARDs, bDMARDs and a combination of csDMARDs and bDMARDs between patients with and without ADRs are assessed.

Results

Treatment pathways of 372 RA patients (66.1% females) were assessed (Table 1). The average duration of treatment was shorter in patients that experienced at least one ADR (1.8 vs. 2.7 years, p<0.001), and the number of treatments was higher (3.5 vs. 2.5, p<0.001), than in those that experienced no ADR. Furthermore, there was a difference between these groups in the proportion of treatments with csDMARD(s), bDMARD(s) or a combination of the two (p<0.001). This was for the ‘No ADR’ group respectively 93%; 1%; 6%, and for the ‘ADR’ group respectively: 77%; 8%; 15%.

Table 1.

Characteristics of patient with and without adverse drug reactions (ADRs) and treatment pathways

All patientsFemalesMalesPatients without ADRsPatients with ADRsTotal, n (% of all patients)372 (100.0)246 (66.1)126 (33.8)285 (76.6)87 (23.3)Female, n (% of total)246 (66.1)N/AN/A183 (64.2)63 (72.4)Age at start of treatment in years, mean ±SD57.8 ±14.057.3 ±14.359.0 ±13.258.4 ±14.456.0 ±12.3Follow-up time in years, mean ±SD6.7 ±3.76.8 ±3.66.6 ±3.96.9 ±3.86.2 ±3.4Duration per treatment in years, mean ±SD2.4 ±2.92.4 ±2.82.4 ±2.92.7 ±3.01.8 ±2.2*Distribution of treatments:1113 (30.4)72 (29.3)41 (32.5)104 (36.5)8 (9.2)225 (6.7)18 (7.3)7 (5.6)20 (7.0)5 (5.8)number of patients that received 1, 2, 3 or 4 treatments, n (%)383 (22.3)53 (21.5)30 (23.8)70 (24.6)13 (14.9)*4 or more151 (40.6)103 (41.9)48 (38.0)91 (31.9)61 (70.1)Number of treatments, mean ±SD2.7 ±1.32.8 ±1.32.7 ±1.32.5 ±1.33.5 ±1.0*Number of patients stopped with treatment, n (% of total)84 (22.6)56 (22.8)28 (22.2)71 (24.9)18 (20.7)

* p<0.001

Conclusion

Treatment pathways for patients with and without ADRs differ significantly. Patients that experience ADRs have shorter duration of treatments and have more consecutive treatments utilizing more bDMARDs.

References

[1]Steunebrink LM, Versteeg GA, Vonkeman HE, et al. Initial combination therapy versus step-up therapy in treatment to the target of remission in daily clinical practice in early rheumatoid arthritis patients: results from the DREAM registry. Arthritis Res Ther 2016;18:60.

Disclosure of Interests

Fenna Poppelaars: None declared, Jurriaan Jansen: None declared, Peter ten Klooster: None declared, Tristan Coppes: None declared, Kimberly Velthuis: None declared, Harald Vonkeman Speakers bureau: Amgen, BMS, Celgene, Galapagos, GSK, Janssen-Cilag, Lilly, Novartis, Pfizer, Roche, Sanofi-Genzyme, UCB, Grant/research support from: Abbvie, Sanofi-Genzyme, Naomi Jessurun: None declared

POS0355-PARE LONGITUDINAL INVESTIGATION AND VISUALIZATION OF COURSE AND BURDEN OF ADVERSE DRUG REACTIONS IN PATIENTS WITH INFLAMMATORY RHEUMATIC DISEASES USING TNFα INHIBITORS

Background

Patients are increasingly involved in the decision process regarding their medicines, but a discrepancy exists between the information provided and preferred. Information on adverse drug reactions (ADRs) focuses on frequency, but little is known about the course and burden of ADRs.

Objectives

We aimed to investigate the course and burden of ADRs over time attributed to using TNFα-inhibitors in patients with inflammatory rheumatic diseases (IRDs) and to assess whether Sankey diagrams and polar plots are suitable to provide visualization of these aspects.

Methods

We used data of the Dutch Biologic Monitor [1], in which biologic users with an immune-mediated inflammatory disease filled out bimonthly surveys about ADRs experienced and specifically the ADR course and burden. ADRs were coded according to the MedDRA terminology. ADR course was scored as worsening, improving, remaining stable or resolving over time, with room to give a description. Furthermore, it was assessed whether an ADR was recurrent or not. Patients scored burden on a scale ranging from 1 (no burden) to 5 (very high burden). We selected patients with rheumatoid arthritis (RA), psoriatic arthritis or axial spondyloarthritis using a TNFα inhibitor (adalimumab, certolizumab pegol, etanercept, golimumab or infliximab). They also had to report an ADR belonging to the system organ classes ‘Infections and infestations’ or ‘Skin and subcutaneous tissue disorders’, or the high-level term ‘Injection site reactions’ and completed ≥2 consecutive questionnaires (representing circa ≥4 months). These types of ADRs were chosen as they impose the highest burden for patients. [2]

Results

A total of 202 patients met the inclusion criteria (71.8% female, mean age 54.8 years (±12.7 years)). The majority of the patients (61.9%) was diagnosed with RA. Most frequently used TNFα inhibitors were adalimumab (37.1%) and etanercept (54.0%). In total 353 ADRs were reported, of which 76 (21.5%) were categorized as ‘Skin and subcutaneous tissue disorders’, 122 (34.6%) as ‘Infections and infestations’ and 155 (43.9%) as ‘Injection site reactions’. The course of the ADRs is visualized in Sankey diagrams (Figure 1a-c); the flows show possible ADR courses, the width of each is proportional to the number of ADRs following that course. Most skin reactions did not change during follow-up (25.0%, Figure 1a), only a few were recurrent. Most infections resolved over time (50.8%, Figure 1b), with some remaining stable and some being recurrent. Most injection site reactions (72.3%, Figure 1c) were recurrent, and resolved in only a minority of the patients (13.4%) during follow-up. The polar plots (Figure 1d-f) visualizes the burden of the ADRs over time. For skin reactions and infections a decreasing trend was observed, represented by fading of the colors to the periphery. Infections had the highest burden at the start of the ADR, indicated by the darker colors in the inner circle. Injection site reactions had a relatively low and stable burden over time, shown by the lighter colors continuing over the circles.

Conclusion

Skin reactions attributed to the use of TNFα-inhibitors by IRD-patients show a stable course over time with a slightly diminishing burden over time. Infections have the highest burden at start but decrease over time and most of them resolve during follow-up. Injection site reactions are mostly recurrent with a low and stable burden over time. We propose that Sankey diagrams and polar plots are suitable to visualize the course and burden of ADRs over time.

References

[1]Kosse LJ et al. Patients with inflammatory rheumatic diseases: quality of self-reported medical information in a prospective cohort event monitoring system. Rheumatology. 2020; 59(6): 1253-1261.

[2]Davelaar JF, Jessurun NT, Tas SW, Nurmohamed MT, Bemt BJF van den, Vonkeman HE. Patient-reported burden of adverse drug reactions attributed to the use of adalimumab and etanercept in patients with inflammatory rheumatic diseases [abstract]. Arthritis Rheumatology. 2021; 73(10).

Disclosure of Interests

Merel de Boer: None declared, Helen Gosselt: None declared, Jurriaan Jansen: None declared, Martijn van Doorn Speakers bureau: Leopharma, Novartis, Janssen-Cilag and Pfizer, Consultant of: Leopharma, Novartis, Abbvie, BMS, Celgene, Janssen-Cilag, Lilly, MSD, Pfizer and Sanofi-Genzyme, Grant/research support from: Novartis, Frank Hoentjen Speakers bureau: Abbvie, Janssen-Cilag, MSD, Takeda, Celltrion, Teva, Sandoz and Dr Falk, Consultant of: Celgene​, Grant/research support from: Dr Falk, Janssen-Cilag, Abbvie, Michael Nurmohamed Speakers bureau: Abbvie, Leopharma, BMS, Celgene, Lilly, MSD, Pfizer, Sanofi-Genzyme, Janssen, Novartis, Consultant of: Abbvie, Leopharma, BMS, Celgene, Lilly, MSD, Pfizer, Sanofi-Genzyme, Janssen, Novarti, Grant/research support from: Novartis, Phyllis Spuls Grant/research support from: Prof. dr. Ph.I. Spuls has done consultancies in the past for Sanofi 111017 and AbbVie 041217 (unpaid), receives departmental independent research grants for TREAT NL registry, for which she is Chief Investigator (CI), from pharma companies since December 2019, is involved in performing clinical trials with many pharmaceutical industries that manufacture drugs used for the treatment of e.g. psoriasis and atopic dermatitis, for which financial compensation is paid to the department/hospital., Sander Tas Consultant of: Gebro, GSK, AbbVie, Galvani, Arthrogen, Galapagos, Grant/research support from: Pfizer, GSK, Celgene, BMS, Sanofi, AstraZeneca, Harald Vonkeman Consultant of: AbbVie, Amgen, AstraZeneca, BMS, Celgene, Celltrion, Galapagos, Gilead, GSK, Janssen-Cilag, Lilly, MSD, Novartis, Pfizer, Roche, Sanofi-Genzyme, all outside the submitted work., Grant/research support from: AbbVie, Sanofi, Naomi Jessurun: None declared

POS0262 HUMORAL AND CELLULAR SARS-CoV-2 VACCINE RESPONSES IN PATIENTS WITH GIANT CELL ARTERITIS AND POLYMYALGIA RHEUMATICA

Background

Giant cell arteritis (GCA) and polymyalgia rheumatica (PMR) are overlapping autoinflammatory diseases affecting people over 50 years. The diseases are treated with immunosuppressive drugs such as prednisolone, methotrexate, leflunomide and tocilizumab. Even though GCA and PMR patients have a substantially higher risk for infections, little is known about humoral and cellular immune responses after vaccination in these patients.

Objectives

In this study we assessed the immunogenicity and safety of SARS-CoV-2 vaccinations in these diseases.

Methods

Patients (n=45 GCA, n=33 PMR) visited the outpatient clinic twice: pre-vaccination and 4 weeks post-vaccination (BNT162b2 or ChAdOx1 vaccine). Patients with previous SARS-CoV-2 infection were excluded. In both pre- and post-vaccination samples, anti-Spike antibody concentrations were assessed and compared to age-, sex- and vaccine-matched control groups (n=98). In addition, the frequency of SARS-CoV-2 Spike-specific T-cells was assessed by IFN-γ ELIspot assay, and side-effects and disease activity were recorded.

Results

The GCA/PMR patients, as a group, did not have reduced antibody concentrations compared to controls. However, linear regression analysis revealed a significant association of methotrexate and >10mg/day prednisolone use with lower antibody concentrations in GCA/PMR patients. Evidence of cellular immunity, as assessed by ELIspot assay, was found in 67% of GCA/PMR patients, and was correlated with humoral immunity (Figure 1). Patients using >10mg/day prednisolone had reduced cellular immunity. Importantly, vaccination did not lead to significant side-effects or changes in disease activity.

Figure 1.

Spot-forming cell (SFC) counts in the ELIspot assay. SFC counts, indicating IFNγ producing cells, increased significantly (Mann Whitney U) at post-vaccination compared to pre-vaccination. Red line indicates the median (A). SFC counts correlated with Spike antibody concentrations in GCA/PMR patients vaccinated with BNT162b2 (B). GCA/PMR patients using >10 mg/day prednisolone are indicated in red. For the correlation, the specific SPC counts are used in the post-vaccination sample after subtracting the SPC count in the pre-vaccination sample. Statistical analysis by the Spearman correlation coefficient. BAU: binding antibody units

Conclusion

SARS-CoV-2 vaccination was safe for GCA/PMR patients and immunogenicity was comparable to other older individuals. However, patients using methotrexate and particularly >10mg/day prednisolone did show lower vaccine responses, which corroborates findings in other autoinflammatory patient populations. These patients may therefore be at higher risk of (potentially even severe) breakthrough SARS-CoV-2 infection.

Acknowledgements

This study was supported by the Dutch Vasculitis Foundation (Vasculitis stichting).

Disclosure of Interests

None declared

Exploring Employer Perspectives on Their Supportive Role in Accommodating Workers with Disabilities to Promote Sustainable RTW: A Qualitative Study

PURPOSE

Employers play an important role in facilitating sustainable return to work (RTW) by workers with disabilities. The aim of this qualitative study was to explore how employers who were successful in retaining workers with disabilities at work fulfilled their supportive role, and which facilitators were essential to support these workers throughout the RTW process.

METHODS

We conducted a semi-structured interview study among 27 employers who had experience in retaining workers with disabilities within their organization. We explored the different phases of RTW, from the onset of sick leave until the period, after 2-years of sick-leave, and when they can apply for disability benefit. We analyzed data by means of thematic analysis.

RESULTS

We identified three types of employer support: (1) instrumental (offering work accommodations), (2) emotional (encouragement, empathy, understanding) and (3) informational (providing information, setting boundaries). We identified three facilitators of employer support (at organizational and supervisor levels): (1) good collaboration, including (in)formal contact and (in)formal networks; (2) employer characteristics, including supportive organizational culture and leadership skills; and (3) worker characteristics, including flexibility and self-control.

CONCLUSIONS

Employers described three different possible types of support for the worker with disabilities: instrumental, emotional, and informational. The type and intensity of employer support varies during the different phases, which is a finding that should be further investigated. Good collaboration and flexibility of both employer and worker were reported as facilitators of optimal supervisor/worker interaction during the RTW process, which may show that sick-listed workers and their supervisors have a joint responsibility for the RTW process. More insight is needed on how this supervisor/worker interaction develops during the RTW process.

The implementation of a decision aid for women with early-stage breast cancer considering contralateral prophylactic mastectomy: A pilot study

OBJECTIVE

Despite little survival benefit and potential for harm, contralateral prophylactic mastectomy (CPM) rates are increasing amongst early-stage breast cancer patients at low contralateral breast cancer risk. We developed a CPM decision aid (DA) and conducted a pilot implementation.

METHODS

Surgeons and oncologists recruited eligible patients considering CPM. Consenting patients received the DA, completed a questionnaire and participated in a semi-structured interview. Clinicians were interviewed at study close.

RESULTS

Eleven clinicians and 31 patients participated. Three themes emerged: perceived utility and impact of the DA, disagreement regarding timing of delivery and target population, and implementation strategies. Both women and clinicians found the DA valuable, indicating it confirmed rather than changed preferences. Women (all of whom raised CPM themselves), preferred offering the DA early in treatment discussions whilst clinicians favoured targeting women who enquired about CPM.

CONCLUSION

A DA about CPM is feasible and acceptable, but questions remain about the role of DAs in these types of decisions where one option has limited medical benefit.

PRACTICE IMPLICATIONS

Some women have a high need to make an informed choice about CPM. Tools to support this could include a DA with a clear recommendation against CPM and an explanation why.

The Role of the Employer in Supporting Work Participation of Workers with Disabilities: A Systematic Literature Review Using an Interdisciplinary Approach

Purpose There is growing awareness that the employer plays an important role in preventing early labor market exit of workers with poor health. This systematic review aims to explore the employer characteristics associated with work participation of workers with disabilities. An interdisciplinary approach was used to capture relevant characteristics at all organizational levels. Methods To identify relevant longitudinal observational studies, a systematic literature search was conducted in PubMed, Web of Science, PsycINFO and EconLit. Three key concepts were central to the search: (a) employer characteristics, (b) work participation, including continued employment, return to work and long-term work disability, and (c) chronic diseases. Results The search strategy resulted in 4456 articles. In total 50 articles met the inclusion criteria. We found 14 determinants clustered in four domains: work accommodations, social support, organizational culture and company characteristics. On supervisor level, strong evidence was found for an association between work accommodations and continued employment and return to work. Moderate evidence was found for an association between social support and return to work. On higher organizational level, weak evidence was found for an association between organizational culture and return to work. Inconsistent evidence was found for an association between company characteristics and the three work outcomes. Conclusions Our review indicates the importance of different employer efforts for work participation of workers with disabilities. Workplace programs aimed at facilitating work accommodations and supervisor support can contribute to the prevention of early labor market exit of workers with poor health. Further research is needed on the influence of organizational culture and company characteristics on work participation.

To what extent do decision aids for prenatal screening and diagnosis address involvement of partners in decision-making? - An environmental scan

OBJECTIVE

Numerous decision aids (DAs) have been developed to inform pregnant people about prenatal screening as the decision whether or not to accept the prenatal screening offer may be difficult. Currently, little is known about the role of the decisional partner of the pregnant people in this decision-making process and to what extent DAs involve and engage the partner.

METHODS

A broad search was conducted to identify publicly available DAs in English and/or Dutch regarding prenatal screening and diagnosis. These DAs were analysed on aspects of partner involvement.

RESULTS

Ten of the 19 identified DAs (52.6%) contained at least one aspect of partner involvement. Several DAs acknowledged that both partners should be involved in the decision (n = 7). The content that was least likely to contain aspects of partner involvement in the DA was value clarification content (n = 2) and only one DA contained content with plural addressing.

CONCLUSION

Just over half of the included DAs included some aspect(s) of partner involvement.

PRACTICAL IMPLICATIONS

More research is needed to determine to what extent, and how, the partner should be involved in the decision-making process as expectant people consider the input of their partner as important.

Employer perspectives on their supportive role in promoting sustainable RTW of disabled workers

Background

Employers play an important supportive role in facilitating sustainable Return to Work (RTW) of workers with disabilities. Little is understood about how employers deal with their supportive role, what kind of support they offer and which facilitators of employer support are important to successful RTW.

Methods

A semi-structured interview study was conducted among 27 employer representatives (e.g. supervisors, HR managers, case managers) of companies in the Netherlands who had experience in retaining at least one disabled workers within their company. Participants were included through purposive sampling on sector and company size. Data was analyzed by means of thematic analysis.

Results

We identified three different types of employer support: 1. instrumental support (offering work accommodations), 2. emotional support (encouragement, empathy, understanding) and 3. informational support (providing information, setting boundaries). Facilitators of employer support were categorized into three main themes: 1. good collaboration, with subthemes (in)formal contact, trustful relationships, mutual responsibilities and (in)formal networks, 2. employer characteristics, including supportive organizational culture, leadership skills and flexibility, and 3. employee characteristics including flexibility and resilience.

Conclusions

Different types of employer support are considered as important in the RTW process of disabled workers. Besides offering work accommodations, also emotional and informational support are necessary. In addition, good collaboration and flexibility of both employer and employee may be viewed as facilitators for optimizing supervisor and employee interaction during the RTW process.

Key messages

Instrumental, emotional and informational support by the employer are important in the RTW process of disabled workers. Facilitating factors include collaboration, flexibility and leadership.

POS0620 TREATMENT PATHWAYS OF RHEUMATOID ARTHRITIS PATIENTS LEADING TO BIOLOGIC THERAPY VISUALIZED IN A SANKEY DIAGRAM

Background:

Treatment of rheumatoid arthritis (RA) has changed in the past 20 years due to the arrival of biologic disease-modifying antirheumatic drugs (bDMARDs) and the application of treat to target strategies. Many different combinations of conventional synthetic (cs)DMARDS and bDMARDS are being applied in daily practice. It is difficult to visualize and understand all the different treatment pathways that are sequentially being used over longer periods of time in a real-world setting. We therefore investigated whether a Sankey diagram is a suitable tool to study and visualize which treatment pathways exist and to what extent a RA treatment protocol is being followed.

Objectives:

To illustrate the treatment pathways over longer periods of time in a cohort of early RA patients and to assess adherence to the treatment protocol using Sankey diagrams.

Methods:

This single-centre retrospective, observational cohort study used data from the DREAM-RA registry. Patients were treated according to a treat to target strategy with a step-up DMARD treatment protocol when remission was not achieved, initial steps were starting with MTX 15 mg/wk, week 8 MTX 25 mg/wk, week 12 MTX+SSZ 2dd1000mg, week 20 MTX+SSZ 3dd1000mg, week 24 MTX+adalimumab 40mg/2wk, week 36 MTX+adalimumab 40mg/wk. Although the protocol met full consensus, adherence to the protocol in individual patients was at the discretion of the treating rheumatologist. In this study, patients were included if they received a continuous treatment with a conventional synthetic or biologic DMARD between 1 January 2002 and 30 April 2020. During treatment, corticosteroids per protocol were allowed but not considered as an individual treatment. Evaluated outcomes included: the consecutive treatments that patients followed including start- and stop-date of treatments, the proportion of patients that received bDMARDs, the number of switches until first bDMARD, and time to first bDMARD. Furthermore, the lower limit of adherence to the protocol was estimated by considering all patients (% of total) treated according to the protocol. This information was determined by verifying whether the patient was being treated according to the protocol after each switch.

Results:

A total of 372 patients were included in this study (Table 1). The mean overall follow-up time of the cohort was 8.83 (± 3.59) years. The follow-up time for the first 4 treatments, depicted in the Sankey diagram was 6.28 (± 3.31) years. At least 45 (12%) patients started with a bDMARD before all previous protocol steps were followed. At the start of treatment, 81% of the patients were treated according to the protocol, this was reduced to 28% after one switch. The lower limit of adherence to the predefined protocol after 3 switches were roughly 5% of all patients.

Table 1.

Absolute counts of T-cell subpopulations at baseline, after 6 and 12 m of TCZ therapy

All patients(n=372)Gender, female, n (%)246 (66.1)Age, year, mean ± SD67.9 ± 13.61Overall follow-up, years ± SD8.83 ± 3.59Follow-up first 4 treatments, years ± SD6.28 ± 3.31Baseline DAS-28 score, mean ± SD3.60 ± 1.41Rheumatoid factor positive, n (%)336 (90.3)Patients who eventually received a bDMARD, n (%)108 (29.0)Number of switches until first bDMARD, mean ± SD2.7 ± 1.41Time to first bDMARD, years ± SD3.66 ± 3.00Figure 1.

Sankey diagram of the treatment pathway of the first 3 switches of RA patients. The average duration of treatment of a flow is displayed in years if the flow included more than 20 patients. (MTX= methotrexate; SSZ= sulfasalazine; HCQ = hydroxychloroquine; LEF= leflunomide; bDMARD= monotherapy bDMARD; Combi csDMARDs= combination therapy of csDMARDS; csDMARD(s)+bDMARD= combination therapy of one or two csDMARD(s) + a bDMARD; No therapy= no treatment received >3 months; Other = medication that is not a (cs)(b)DMARD)

Conclusion:

Sankey diagramming can be used to illustrate complex real-world treatment data of a treat to target cohort of RA patients. Treatment protocol adherence can be assessed with the help of a Sankey diagram. After 3 switches, the lower limit of adherence to the protocol was roughly 5%.

Disclosure of Interests:

Tristan Coppes: None declared, Naomi Jessurun: None declared, Jurriaan Jansen: None declared, Kimberly Velthuis: None declared, Peter ten Klooster: None declared, Harald Vonkeman Consultant of: BMS, Celgene, Celltrion, Galapagos, Gilead, Janssen-Cilag, Lilly, Novartis, Pfizer, Sanofi-Genzyme, Grant/research support from: Abbvie

AB0196 SURVIVAL ANALYSIS OF TIME TO FIRST ADVERSE DRUG REACTION AND DRUG SURVIVAL IN RHEUMATOID ARTHRITIS PATIENTS TREATED WITH ADALIMUMAB AND ETANERCEPT

Background:

Treatment of rheumatoid arthritis (RA) with biologic disease-modifying antirheumatic drugs (bDMARDs) has been common practice in the last two decades. However, differences in patients experiencing adverse drug reactions (ADRs) between individual bDMARDs, such as adalimumab (ADA) and etanercept (ETN), during first time treatment has not been studied yet in real-world settings.

Objectives:

To compare proportions of RA patients experiencing ADRs as well as survival to first ADR and drug survival during treatment with ADA and ETN.

Methods:

Retrospective single centre cohort study including adult patients with RA, treated with either ADA or ETN between 1 January 2003 and 30 April 2020. The proportions of patients experiencing an ADR were compared by assessing the percentage of patients, treated with either ADA or ETN, experiencing at least one ADR during their first time treatment. Survival to first ADR and drug survival were assessed by calculating time between start of treatment and first ADR and start of treatment and discontinuation of treatment respectively. Stop and restart of treatment within 90 days was considered as continuous use. Differences in proportions were statistically tested using Fisher’s Exact Test. Differences in drug survival between ADA and ETN were tested by Kaplan-Meier analysis and Log Rank tests.

Results:

A total of 422 patients were included in this study (ADA 259, ETN 163). For 93 patients (21.2%) an ADR was registered during first time treatment. The proportion of patients experiencing at least one ADR during their first time treatment was 22.7% for ADA and 20.2% for ETN (p=0.628). Survival time to first ADR did not differ significantly between ADA and ETN (median survival ADA 10.34 years (95% CI [7.62-13.06], median survival ETN not reached, p=0.109, figure 1A). Median drug survival was 1.75 years for ADA (95 CI [1.38-2.11]) and 2.68 years for ETN (95% CI [1.73-3.64]). Drug survival differed significantly (p<0.001, figure 1B).

Figure 1.

Kaplan-Meier survival curves for adalimumab and etanercept with (a) survival to first ADR and (b) drug survival.

Conclusion:

Neither the proportion of patients experiencing ADRs nor survival to first ADR during first time treatment with ADA and ETN differed significantly. Drug survival of first time drug treatment of ADA was significantly lower compared to drug survival of first time drug treatment of ETN.

Disclosure of Interests:

My Nguyen: None declared, Kimberly Velthuis: None declared, Joep Scholl: None declared, Jurriaan Jansen: None declared, Leanne Kosse: None declared, Peter ten Klooster: None declared, Naomi Jessurun: None declared, Harald Vonkeman Consultant of: BMS, Celgene, Celltrion, Galapagos, Gilead, Janssen-Cilag, Lilly, Novartis, Pfizer, Sanofi-Genzyme, Grant/research support from: Abbvie

POS0648 SURVIVAL ANALYSIS OF TIME TO FIRST ADVERSE DRUG REACTION AND DRUG SURVIVAL IN RHEUMATOID ARTHRITIS PATIENTS TREATED WITH METHOTREXATE AND HYDROXYCHLOROQUINE MONOTHERAPIES OR COMBINATION THERAPY

Background:

Methotrexate (MTX) and hydroxychloroquine (HCQ) are first line treatments of rheumatoid arthritis (RA). Adverse drug reactions (ADRs) during treatment with these drugs are common. Survival analysis on time to first ADR and on first time drug use duration have not yet been performed for these drugs in real-world settings.

Objectives:

To compare proportions of patients with ADRs during first time use of either MTX monotherapy, HCQ monotherapy or MTX+HCQ combination therapy and to compare survival to first ADR and drug survival between these drugs.

Methods:

Retrospective single centre cohort study including adult RA patients treated with either MTX monotherapy, HCQ monotherapy or MTX+HCQ combination therapy. First time users between 1 January 2003 and 30 April 2020 were followed until discontinuation of their first time drug use. The proportion of patients with ADRs was defined as the percentage of patients experiencing an ADR during their first time drug use. Survival to first ADR and drug survival of first time drug use were also assessed. MTX+HCQ use was considered combination therapy when the start dates of these drugs differed less than 14 days. For both monotherapies, end of first time drug use was defined as drug discontinuation for more than 90 days. For MTX+HCQ combination therapy, end of first time drug use was defined as discontinuation of either MTX, HCQ or both for more than 90 days. Differences in the proportion of patients experiencing an ADR during first time drug use of MTX, HCQ or a combination of both was statistically tested using Fisher’s Exact Test. Survival to first ADR and drug survival were studied by Kaplan-Meier analysis and statistically tested by performing Log Rank tests.

Results:

In total, 794 patients were included (MTX 363, HCQ 77, MTX+HCQ 354). For 156 patients (19.6%) at least one ADR was registered during first time drug use (MTX 59 [16.3%], HCQ 9 [11.7%], MTX+HCQ 88 [24.9%]). Proportions of ADRs differed significantly between MTX monotherapy and MTX+HCQ combination therapy (p=0.005) and between HCQ monotherapy and MTX+HCQ combination therapy (p=0.011). Survival to first ADR also differed significantly for both monotherapies compared to MTX+HCQ combination therapy (medians not reached, p<0.001 and p<0.008, respectively (figure 1A)). Drug survival differed significantly between MTX and HCQ monotherapy and between MTX monotherapy and MTX+HCQ combination therapy (median survival MTX 3.32 years (95% CI [2.81-3.83]; HCQ 1.39 years (95% CI [1.03-1.75]); MTX+HCQ 1.23 years (95% CI [1.11-1.34]), both p<0.001 (figure 1B)).

Figure 1.

Kaplan-Meier curves of MTX and HCQ monotherapies and MTX+HCQ combination therapy, with (a) survival to first ADR and (b) drug survival.

Conclusion:

Patients using MTX+HCQ combination therapy are more likely to experience an ADR during the first time drug use compared to MTX and HCQ monotherapies. MTX+HCQ combination therapy also leads to experiencing an ADR sooner compared to both monotherapies. Drug survival of patients treated with HCQ monotherapy as well as MTX+HCQ combination therapy is shorter compared to MTX monotherapy.

Disclosure of Interests:

Kimberly Velthuis: None declared, My Nguyen: None declared, Joep Scholl: None declared, Jurriaan Jansen: None declared, Jette van Lint: None declared, Peter ten Klooster: None declared, Harald Vonkeman Consultant of: BMS, Celgene, Celltrion, Galapagos, Gilead, Janssen-Cilag, Lilly, Novartis, Pfizer, Sanofi-Genzyme, Grant/research support from: Abbvie, Naomi Jessurun: None declared

[Acute respiratory distress in a frail older patient: spontaneous tooth aspiration]

A 68-year-old man presented at the emergency room with acute difficulty breathing. On account of recent subarachnoidal haemorrhage the patient was a resident of a care facility, and was also being treated for acute bronchitis there. Radiographic imaging of the lungs revealed a tooth with crown and pontic to have been inhaled. The tooth was surgically removed. After 3 weeks in the intensive care unit, the patient died of aspiration pneumonia. Spontaneous tooth aspiration is rare, yet it can have fatal consequences in vulnerable older patients. Aspiration of a foreign body may lead to injury and infection of the trachea and lungs. In order to determine the correct diagnosis in patients with acute respiratory distress, adequate and targeted diagnostics is essential; especially in older patients with multimorbidity and polypharmacy. Sarcopenia, dysphagia, a decrease in functional chewing units and decreased sensation of the palate increase the risk of choking in patients. In addition, dysphagia and poor oral health are known to be strongly associated with aspiration pneumonia. Healthcare providers should pay more attention to oral health in frail older patients.

Clinicians’ perspectives on diagnosing polycystic ovary syndrome in Australia: a qualitative study

STUDY QUESTION

What are clinicians’ views about the diagnosis of polycystic ovary syndrome (PCOS), and how do they handle any complexities and uncertainties in practice?

SUMMARY ANSWER

Clinicians have to navigate many areas of complexity and uncertainty regarding the diagnosis of PCOS, related to the diagnostic criteria, limitations in current evidence and misconceptions surrounding diagnosis, and expressed concern about the risk and consequences of both under- and overdiagnosis.

WHAT IS KNOWN ALREADY

PCOS is a complex, heterogeneous condition with many areas of uncertainty, raising concerns about both underdiagnosis and overdiagnosis. Quantitative studies with clinicians have found considerable variation in diagnostic criteria used and care provided, as well as a lack of awareness around the breadth of PCOS features and poor uptake of recommended screening for metabolic complications. Clinicians’ views about the uncertainties and complexities of diagnosing PCOS have not been explored.

STUDY DESIGN, SIZE, DURATION

Semi-structured telephone interviews were conducted with clinicians from September 2017 to July 2018 to explore their perceptions about the diagnosis of PCOS, including how they handle any complexities and uncertainties in practice.

PARTICIPANTS/MATERIALS, SETTING, METHODS

A group of 36 clinicians (15 general practitioners, 10 gynaecologists and 11 endocrinologists) currently practicing in Australia, were recruited through advertising via professional organisations, contacting a random sample of endocrine and gynaecology teams across Australia and snowballing. Transcribed audio-recordings were analysed thematically using Framework analysis.

MAIN RESULTS AND THE ROLE OF CHANCE

Clinicians expressed a range of uncertainties and complexities regarding the diagnosis of PCOS, which were organised into three areas: (i) establishing diagnosis (e.g. lack of standardisation regarding diagnostic cut-offs, risk of misdiagnosis), (ii) factors influencing the diagnostic process (e.g. awareness of limitations in evidence and consideration of the benefits and harms) and (iii) strategies for handling challenges and uncertainties (e.g. using caution and communication of uncertainties). Clinicians also varied in their concerns regarding under- and overdiagnosis. Overall, most felt the diagnosis was beneficial for women provided that it was the correct diagnosis and time was taken to assess patient expectations and dispel misconceptions, particularly concerning fertility.

LIMITATIONS, REASONS FOR CAUTION

There is possible selection bias, as clinicians who are more knowledgeable about PCOS may have been more likely to participate. Clinicians’ views may also differ in other countries.

WIDER IMPLICATIONS OF THE FINDINGS

These findings underscore the vital need to first consider PCOS a diagnosis of exclusion and use caution before giving a diagnosis in order to reduce misdiagnosis, as suggested by clinicians in our study. Until there is greater standardisation of diagnostic criteria, more transparent conversations with women may help them understand the uncertainties surrounding the criteria and limitations in the evidence. Additionally, clinicians emphasised the importance of education and reassurance to minimise the potential harmful impact of the diagnosis and improve patient-centred outcomes.

STUDY FUNDING/COMPETING INTEREST(S)

The study was funded by the University of Sydney Lifespan Research Network and an NHMRC Program Grant (APP1113532). T.C. is supported by an Australian Government Research Training Program (RTP) Scholarship and a Sydney Medical School Foundation Scholarship, from the The University of Sydney, Australia. B.W.M. reports consultancy for ObsEva, Merck, Merck KGaA and Guerbet. No further competing interests exist.

TRIAL REGISTRATION NUMBER

N/A

The benefits and harms of receiving a polycystic ovary syndrome diagnosis: a qualitative study of women's experiences

STUDY QUESTION

What are the benefits and harms of receiving a polycystic ovary syndrome (PCOS) diagnosis in a community sample of women, including impact on psychosocial wellbeing, lifestyle choices and behaviour?

SUMMARY ANSWER

Although some women benefit considerably from the diagnosis, such as through increased awareness and reassurance, women with minimal symptoms may experience more harm than benefit, including long-lasting anxiety and altered life plans.

WHAT IS KNOWN ALREADY

Disease labels can validate symptoms and play a vital role in understanding and coping with illness; however, they can also cause harm by evoking illness schemas about severity and permanence. Regarding PCOS, the diagnostic criteria have expanded over time to include women with milder phenotypes (such as those without signs of androgen excess). This has occurred despite limited investigation of the benefits and harms of the diagnosis and has increased the number of women diagnosed.

STUDY DESIGN SIZE DURATION

Semi-structured interviews were conducted face-to-face or by telephone with 26 participants from April-July 2018 to explore women's experiences with the diagnosis, including the benefits and harms of receiving the diagnosis and the impact on their life.

PARTICIPANTS/MATERIALS SETTING METHODS

In total, 26 women in the community self-reporting a diagnosis of PCOS (reporting mild to severe symptoms) made by a medical doctor, aged 18-45 years and living in Australia were recruited through social media. Data were analysed thematically using Framework analysis.

MAIN RESULTS AND THE ROLE OF CHANCE

The study identified a range of both positive and negative effects of a PCOS diagnosis in the immediate, short and long-term, which were influenced by symptom severity, expectations and experience. For women with previously unexplained and bothersome symptoms, it was a relief to receive a diagnosis, and this resulted in an increased understanding about the importance of a healthy lifestyle. By contrast, women with milder symptoms often reported feeling shocked and overwhelmed by the diagnosis, consequently experiencing anxiety about the associated long-term risks. The majority of women, regardless of symptom severity, experienced prolonged worry and anxiety about infertility, resulting for some in risk taking with contraception, unintended pregnancies, pressure to conceive early or altered life plans. With time, many women developed positive coping strategies and perceived the diagnosis to be valuable, including those who felt they had experienced minimal benefit or even harm.

LIMITATIONS REASONS FOR CAUTION

PCOS diagnosis was self-reported and the sample was highly educated.

WIDER IMPLICATIONS OF THE FINDINGS

Fear of infertility was salient for many women, underscoring the need for accurate information, counselling and reassurance of fertility potential. Given the risk of significant consequences, health professionals should use a tailored approach to PCOS diagnosis to increase the benefits of appropriate and timely diagnosis for women affected by significant symptoms, while reducing the harms of unnecessarily labelling healthy women for whom the benefits of a diagnosis are small.

STUDY FUNDING/COMPETING INTERESTS

The study was funded by the University of Sydney Lifespan Research Network and an NHMRC Program Grant (APP1113532). B.W.M. reports consultancy for ObsEva, Merck, Merck KGaA and Guerbet. No further competing interests exist.

TRIAL REGISTRATION NUMBER

N/A.

Critical comparison of methods for fault diagnosis in metabolomics data

Platforms like metabolomics provide an unprecedented view on the chemical versatility in biomedical samples. Many diseases reflect themselves as perturbations in specific metabolite combinations. Multivariate analyses are essential to detect such combinations and associate them to specific diseases. For this, usually targeted discriminations of samples associated to a specific disease from non-diseased control samples are used. Such targeted data interpretation may not respect the heterogeneity of metabolic responses, both between diseases and within diseases. Here we show that multivariate methods that find any set of perturbed metabolites in a single patient, may be employed in combination with data collected with a single metabolomics technology to simultaneously investigate a large array of diseases. Several such untargeted data analysis approaches have been already proposed in other fields to find both expected and unexpected perturbations, e.g. in Statistical Process Control. We have critically compared several of these approaches for their sensitivity and their correct identification of the specifically perturbed metabolites. Also a new approach is introduced for this purpose. The newly introduced Sparse Mean approach, which we find here as most sensitive and best able to identify the specifically perturbed metabolites, turns metabolomics into an untargeted diagnostic platform. Aside from metabolomics, the proposed approach may greatly benefit fault diagnosis with untargeted analyses in many other fields, such as Industrial Process Control, food Adulteration Detection, and Intrusion Detection.

Development and pilot testing of a Decision Aid (DA) for women with early-stage breast cancer considering contralateral prophylactic mastectomy

OBJECTIVE

Describe the development, acceptability and feasibility of a Decision Aid (DA) for women with early-stage breast cancer (BC) at average contralateral breast cancer (CBC) risk considering contralateral prophylactic mastectomy (CPM).

METHODS

The DA was developed using the International Patient Decision Aid Standards (IPDAS) and the Ottawa Decision Support Framework. It provides evidence-based information about CPM in a booklet format combining text, graphs and images of surgical options. Twenty-three women with a history of early-stage breast cancer were interviewed in person or over the phone using a 'think aloud approach'. Framework analysis was used to code and analyse data.

RESULTS

Twenty-three women participated in the study. Mean age of participants was 58.6 years and time since diagnosis ranged from 14 months to 21 years. Five women had CPM and eighteen had not. Women strongly endorsed the DA. Many felt validated by a section on appearance and found information on average risk of recurrence and metastases helpful, however, noted the importance of discussing personal risk with their surgeon. Many requested more information on surgery details (time taken, recovery) and costs of the different options.

CONCLUSION

The DA was acceptable to women, including the format, content and proposed implementation strategies. Practical and financial issues are important to women in considering treatment options.

PRACTICE IMPLICATIONS

Women appreciate information about CPM at diagnosis and emphasised the importance of discussing potential downsides of the procedure in addition to benefits. The DA was considered acceptable to facilitate such discussions.

Diagnosing diffuse lung disease in children in a middle-income country: the role of open lung biopsy

SETTING

A tertiary care hospital situated in a middle-income country with a high burden of tuberculosis (TB) and human immunodeficiency virus (HIV) infection.

OBJECTIVE

To determine the diagnostic yield of open lung biopsy (OLB) in children with diffuse lung disease (DLD), comparing findings in HIV-infected and non-HIV-infected children.

DESIGN

This 9-year retrospective study included 51 children with DLD (oxygen-dependent or on artificial ventilation), who required an OLB where the diagnosis remained uncertain after extensive investigations.

RESULTS

The median age was 7 months, median body weight was 6.6 kg (61% were severely malnourished) and 30% were HIV-infected (62% on antiretroviral treatment). The diagnostic yield of the OLB was 86% (n = 44) and was significantly higher in HIV-infected (77%) than in non-HIV-infected (48%) children (P = 0.01). Pneumonia was the most common diagnosis (n = 25, 57%), with common agents being cytomegalovirus (CMV), viruses other than CMV, Pneumocystis jiroveci pneumonia and previously undiagnosed TB (10%). Mycobacterium tuberculosis as a cause of DLD was not suspected before the OLB, as all investigations for TB were negative. Non-infectious causes of DLD were established in 10% of cases.

CONCLUSION

The OLB is a useful diagnostic tool to diagnose idiopathic DLD, including TB, in young children.

Development of Smaller Artificial Ventricles and Valves Made by Vacuum Forming

Implantable prosthetic ventricles and trileaflet valves made by vacuum forming have been developed and implant tested. All components are made from Pellethane®. Recognizing the need for smaller as well as larger ventricles, designs with effective stroke volumes of 50, 85, 100 and 130 cc have been tested with several valve types. The pneumatically driven Utah ventricular assist device (UVAD) can be used as a total artificial heart (TAH) or ventricular assist device (VAD) by using the appropriate inflow and outflow adapters. In vitro durability testing has demonstrated ventricular lifetime beyond two years and valve lifetime to nearly one and one half years. The polymer valves have lower regurgitation than mechanical valves.

Animal implantation experience includes 21 TAH implants and 16 left ventricular assist device (LVAD) implantations. TAH survival ranges from 2 to 210 days. LVAD animals have lived up to 116 days before elective termination. The animal were healthy and grew normally. The devices exhibit a “Starling's Law” response. One TAH animal survived 72 days before successful explantation followed by transplantation. At autopsy, this animal had no renal infarcts. Hematology data has demonstrated the existence of little or no intravascular hemolysis (PF Hb < 5 mg%).

The “Philadelphia” version of the UVAD vacuum formed ventricles are small enough to be implanted without thrombus provoking connectors. Eight animals have received this TAH and survived up to 120 days. Vacuum forming offers a rapid and inexpensive way to produce reliable and effective total artificial hearts and valves for widespread, temporary clinical application in any size adult human.

Learning from games: stakeholders' experiences involved in local health policy

Since public health problems are complex and the related policies need to address a wide range of sectors, cross-sectoral collaboration is beneficial. One intervention focusing on stimulating collaboration is a 'policy game'. The focus on specific problems facilitates relationships between the stakeholders and stimulates cross-sectoral policymaking. The present study explores stakeholders' learning experiences with respect to the collaboration process in public health policymaking. This was achieved via their game participation, carried out in real-life stakeholder networks in the Netherlands, Denmark and Romania. The policy game (In2Action) was developed and implemented as a 1-day role-play. The data consisted of: (i) observations and evaluation notes during the game and (ii) participant questionnaire after the game. All three countries showed similar results in learning experience during the collaboration processes in local policymaking. Specific learning experiences were related to: (i) the stakeholder network, (ii) interaction and (iii) relationships. The game also increased participant's understanding of group dynamics and need for a coordinator in policymaking. This exploratory study shows that the game provides participants with learning experiences during the collaboration process in policymaking. Experiencing what is needed to establish cross-sectoral collaboration is a first step towards enhancing knowledge exchange and more effective public health policies.

Decision-making about mammographic screening: pursuing informed choice

For decades, persuasive techniques have been used to communicate to women about breast cancer screening with the aim of maximizing screening uptake. However, more recently this has shifted to an approach which recognizes that it is important for women to be aware of harms, such as overdiagnosis, as well as benefits of breast screening. There is a lack of consensus in the literature around whether benefits clearly outweigh harms for population-based breast cancer screening. In light of this, the gold standard for communication about breast cancer screening is now to try and support informed decision-making - that is, to help women understand both the advantages and disadvantages of screening, allowing them to make individual decisions about their screening participation that reflect their informed preferences. In this review, we summarize relevant research to identify theoretical and practical aspects of improving communication and decision-making about breast cancer screening, and discuss future implications.

Doppler-guided goal-directed fluid therapy does not affect intestinal cell damage but increases global gastrointestinal perfusion in colorectal surgery: a randomized controlled trial

AIM

Individualized, goal-directed fluid therapy (GDFT), based on Doppler measurements of stroke volume, has been proposed as a treatment strategy in terms of reducing complications, mortality and length of hospital stay in major bowel surgery. We studied the effect of Doppler-guided GDFT on intestinal damage as compared with standard postoperative fluid replacement.

METHOD

Patients undergoing elective colorectal resection for malignancy were randomized either to standard intra- and postoperative fluid therapy or to standard fluid therapy with additional Doppler-guided GDFT. The primary outcome was intestinal epithelial cell damage measured by plasma levels of intestinal fatty acid-binding protein (I-FABP). Global gastrointestinal perfusion was measured by gastric tonometry, expressed as regional (gastric) minus arterial CO₂ -gap (P_r-a CO₂ -gap).

RESULTS

I-FABP levels were not significantly different between the intervention group and the control group (respectively, 440.8 (251.6) pg/ml and 522.4 (759.9) pg/ml, P = 0.67). Mean areas under the curve (AUCs) of intra-operative P_r-a CO₂ -gaps were significantly lower in the intervention group than in the control group (P = 0.01), indicating better global gastrointestinal perfusion in the intervention group. Moreover, the mean intra-operative P_r-a CO₂ -gap peak in the intervention group was 0.5 (1.0) kPa, which was significantly lower than the mean peak in the control group, of 1.4 (1.4) kPa (P = 0.03).

CONCLUSION

Doppler-guided GDFT during and in the first hours after elective colorectal surgery for malignancy increases global gastrointestinal perfusion, as measured by P_r-a CO₂ -gap.

Mild intracellular acidification by dexamethasone attenuates mitochondrial dysfunction in a human inflammatory proximal tubule epithelial cell model

Septic acute kidney injury (AKI) associates with poor survival rates and often requires renal replacement therapy. Glucocorticoids may pose renal protective effects in sepsis via stimulation of mitochondrial function. Therefore, we studied the mitochondrial effects of dexamethasone in an experimental inflammatory proximal tubule epithelial cell model. Treatment of human proximal tubule epithelial cells with lipopolysaccharide (LPS) closely resembles pathophysiological processes during endotoxaemia, and led to increased cytokine excretion rates and cellular reactive oxygen species levels, combined with a reduced mitochondrial membrane potential and respiratory capacity. These effects were attenuated by dexamethasone. Dexamethasone specifically increased the expression and activity of mitochondrial complex V (CV), which could not be explained by an increase in mitochondrial mass. Finally, we demonstrated that dexamethasone acidified the intracellular milieu and consequently reversed LPS-induced alkalisation, leading to restoration of the mitochondrial function. This acidification also provides an explanation for the increase in CV expression, which is expected to compensate for the inhibitory effect of the acidified environment on this complex. Besides the mechanistic insights into the beneficial effects of dexamethasone during renal cellular inflammation, our work also supports a key role for mitochondria in this process and, hence, provides novel therapeutic avenues for the treatment of AKI.

Diagnosing eosinophilic asthma using a multivariate prediction model based on blood granulocyte responsiveness

BACKGROUND

The identification of inflammatory asthma phenotypes, using sputum analysis, has proven its value in diagnosis and disease monitoring. However due to technical limitations of sputum analysis, there is a strong need for fast and noninvasive diagnostics. This study included the activation state of eosinophils and neutrophils in peripheral blood to phenotype and monitor asthma.

OBJECTIVES

To (i) construct a multivariable model using the activation state of blood granulocytes, (ii) compare its diagnostic value with sputum eosinophilia as gold standard and (iii) validate the model in an independent patient cohort.

METHODS

Clinical parameters, activation of blood granulocytes and sputum characteristics were assessed in 115 adult patients with asthma (training cohort/Utrecht) and 34 patients (validation cohort/Oxford).

RESULTS

The combination of blood eosinophil count, fractional exhaled nitric oxide, Asthma Control Questionnaire, medication use, nasal polyposis, aspirin sensitivity and neutrophil/eosinophil responsiveness upon stimulation with formyl-methionyl-leucyl phenylalanine was found to identify sputum eosinophilia with 90.5% sensitivity and 91.5% specificity in the training cohort and with 77% sensitivity and 71% specificity in the validation cohort (relatively high percentage on oral corticosteroids [OCS]).

CONCLUSIONS

The proposed prediction model identifies eosinophilic asthma without the need for sputum induction. The model forms a noninvasive and externally validated test to assess eosinophilic asthma in patients not on OCS.

The RESET Mindset Model applied on decreasing antibiotic usage in dairy cattle in the Netherlands

Background

Prudent use of antibiotics is important to prevent antibiotic resistance in humans and in animals. For this reason politicians demanded a decrease of total antibiotic use and of use of critically important antibiotics in animal husbandry in the Netherlands. In the dairy sector the use of antibiotics almost halved in the years 2009–2015, with a decrease of the use of critically important antibiotics to very low levels.

Theory of behaviour change

To realize a sustainable decrease in antibiotic usage, the mindset towards the subject was considered crucial. Based on several models from social psychology, the RESET Mindset Model was used. This model contains the most important cues to change human behaviour, being Rules and regulations, Education and information, Social pressure, Economics, and Tools. To change behaviour of groups in order to reach a tipping point, it is of utmost importance to not choose among the different cues, but to use them all.

Changing antibiotic usage in dairy cattle

In order to decrease antibiotic usage in dairy cattle in the Netherlands several actions, obliged as well as voluntary, were undertaken. An independent veterinary medicine authority was founded that became active for all animal sectors. In the dairy sector a national database on antibiotic usage called MediRund was developed, which made transparency and benchmarking on antibiotic usage at the national and the herd level possible. Several other activities are described, such as herd health and treatment plans, selective dry cow therapy, and the strong limitation on the use of critically important antibiotics. Antibiotic usage at the herd level, referred to as the ‘antibiotic number’, became an important and socially accepted herd level parameter.

RESET the dairy farmer’s mindset on antibiotic usage

The actions undertaken worked through different cues, all part of the RESET Mindset Model. As such, different types of dairy farmers sensitive to different types of cues were motivated to change their behaviour.

Conclusion

Antibiotic usage in dairy cattle in the Netherlands decreased significantly by intense cooperation between the most important stakeholders in the dairy chain, taking communication seriously and applying the RESET Mindset Model.

Dairy farmers' perceptions toward the implementation of on-farm Johne's disease prevention and control strategies

Implementation of specific management strategies on dairy farms is currently the most effective way to reduce the prevalence of Johne's disease (JD), an infectious chronic enteritis of ruminants caused by Mycobacterium avium subspecies paratuberculosis (MAP). However, dairy farmers often fail to implement recommended strategies. The objective of this study was to assess perceptions of farmers participating in a JD prevention and control program toward recommended practices, and explore factors that influence whether or not a farmer adopts risk-reducing measures for MAP transmission. Semi-structured interviews were conducted with 25 dairy farmers enrolled in a voluntary JD control program in Alberta, Canada. Principles of classical grounded theory were used for participant selection, interviewing, and data analysis. Additionally, demographic data and MAP infection status were collected and analyzed using quantitative questionnaires and the JD control program database. Farmers' perceptions were distinguished according to 2 main categories: first, their belief in the importance of JD, and second, their belief in recommended JD prevention and control strategies. Based on these categories, farmers were classified into 4 groups: proactivists, disillusionists, deniers, and unconcerned. The first 2 groups believed in the importance of JD, and proactivists and unconcerned believed in proposed JD prevention and control measures. Groups that regarded JD as important had better knowledge about best strategies to reduce MAP transmission and had more JD risk assessments conducted on their farm. Although not quantified, it also appeared that these groups had more JD prevention and control practices in place. However, often JD was not perceived as a problem in the herd and generally farmers did not regard JD control as a "hot topic" in communications with their herd veterinarian and other farmers. Recommendations regarding how to communicate with farmers and motivate various groups of farmers according to their specific perceptions were provided to optimize adoption of JD prevention and control measures and thereby increase success of voluntary JD control programs.

Neurostimulation in alcohol dependence: The effect of repetitive transcranial magnetic stimulation on brain function and craving

Background

Alcohol dependence has long been related to impaired processing and handling of negative emotions. This is the first study to compare emotion regulation (ER) at a behavioral and neural level in alcohol dependent patients (ADPs) and healthy controls (HCs). It also examines the effects of high-frequency repetitive transcranial magnetic stimulation (rTMS) on ER abilities and related craving levels in ADPs.

Method

Thirty-six ADPs and 32 HCs matched on age, sex, and education, were included in a within-subject fixed-order study with one functional magnetic resonance imaging (fMRI) session and one rTMS plus fMRI session, with high-frequency (10 Hz) rTMS over the right dorsolateral prefrontal cortex (dlPFC). An fMRI emotion regulation task (ERT) was administered during both sessions and craving was measured before and after each ERT.

Results

ADPs were impaired in the regulation of negative emotion and showed a higher activation of ER related brain areas compared to HCs. Furthermore, active rTMS improved ER abilities in both ADPs and HCs, but was accompanied by a decrease in anterior cingulate and left dlPFC activity only in ADPs. In addition, the ERT-induced increase in craving levels in ADPs was trend-significantly reduced by active rTMS, with a large effect size.

Conclusions

ADPs are impaired in the regulation of negative emotion and show enhanced neural activity in the ER brain circuit. High-frequency rTMS improves ER in ADPs and HCs and normalizes neural activity and tends to reduce craving in ADPs. Future studies are needed to test the long-term effects of (multiple session) rTMS on ER, craving, and drinking.

Disclosure of interest

The authors have not supplied their declaration of competing interest.