Predicting Marfan Syndrome in Children With Congenital Ectopia Lentis: Development and Validation of a Nomogram

Purpose

To derive an effective nomogram for predicting Marfan syndrome (MFS) in children with congenital ectopia lentis (CEL) using regularly collected data.

Methods

Diagnostic standards (Ghent nosology) and genetic test were applied in all patients with CEL to determine the presence or absence of MFS. Three potential MFS predictors were tested and chosen to build a prediction model using logistic regression. The predictive performance of the nomogram was validated internally through time-dependent receiver operating characteristic curves, calibration curves, and decision curve analysis.

Results

Eyes from 103 patients under 20 years old and with CEL were enrolled in this study. Z score of body mass index (odds ratio [OR] = 0.659; 95% confidence interval [CI], 0.453-0.958), corneal curvature radius (OR = 3.397; 95% CI, 1.829-6.307), and aortic root diameter (OR = 2.342; 95% CI, 1.403-3.911) were identified as predictors of MFS. The combination of the above predictors shows good predictive ability, as indicated by area under the curve of 0.889 (95% CI, 0.826-0.953). The calibration curves showed good agreement between the prediction of the nomogram and the actual observations. In addition, decision curve analysis showed that the nomogram was clinically useful and had better discriminatory power in identifying patients with MFS. For better individual prediction, an online MFS calculator was created.

Conclusions

The nomogram provides accurate and individualized prediction of MFS in children with CEL who cannot be identified with the Ghent criteria, enabling clinicians to personalize treatment plans and improve MFS outcomes.

Translational Relevance

The prediction model may help clinicians identify MFS in its early stages, which could reduce the likelihood of developing severe symptoms and improve MFS outcomes.

Postoperative longitudinal refractive changes in children younger than 8 years with ectopia lentis and Marfan syndrome

PURPOSE

To evaluate the postoperative longitudinal refractive changes in children younger than 8 years with ectopia lentis and Marfan syndrome (MFS).

SETTING

Zhongshan ophthalmic center, Guangzhou, China.

DESIGN

Retrospective cohort study.

METHODS

Medical data of patients diagnosed with ectopia lentis and MFS that underwent surgery younger than 8 years were collected. Refractive errors and ocular biometric parameters were collected preoperatively and at each follow-up visit. Patients were stratified into groups according to age at surgery, and only the eye operated on first was selected. Multivariate analysis was performed to determine the association between refractive shift and potential risk factors.

RESULTS

In total, 54 eyes of 54 patients were enrolled. The median age at surgery was 6.21 years (interquartile range [IQR], 5.25 to 6.85), and the median follow-up was 2.0 years (IQR, 1.2 to 2.8 years). At age 8 years, patients demonstrated a median myopic shift ranged from -1.75 diopters (D) (IQR, -2.75 to -1.00 D) for the 4-year-old group to -0.13 D (IQR, -0.50 to -0.06 D) for the 7-year-old group. Multivariate analysis showed that greater myopic shift was associated with younger age at surgery ( P = .004), male sex ( P = .026), and shorter preoperative axis length ( P = .005).

CONCLUSIONS

A tendency toward increasing postoperative myopic was demonstrated in children with ectopia lentis and MFS, with the greatest myopic shift in the younger age groups. If the goal is to reach emmetropia by age 8 years, the immediate postoperative hypermetropic targets should be 1.75 D for age 4 years, 1 D for age 5 years, 0.5 D for age 6 years, and 0 to 0.25 D for age 7 years.

Quantitative analysis of choriocapillaris flow deficits and choroidal thickness in children with Marfan syndrome

PURPOSE

To evaluate the characteristics and associated factors of choroidal thickness (ChT) and choriocapillaris flow deficit percentage (CC FD%) in children with Marfan syndrome (MFS).

METHODS

This is a cross-sectional study. The ChT of the subfoveal area and other areas 0.5, 1.5, and 2.5 mm away from the fovea were assessed. The CC FD% of quadrant and circular regions with diameters of 0.5, 1.5 and 2.5 mm were assessed with 3×3 mm macular choriocapillaris images. Best-corrected visual acuity (BCVA) and cardiac function factor such as Z score were measured to analyse the associations with ChT and CC FD%.

RESULTS

51 MFS children and 50 healthy controls were enrolled in this study. Compared with the healthy controls, the ChT in the MFS group was thinner in the subfoveal area, temporal 0.5, 1.5 and 2.5 mm (all p<0.001). The CC FD% was higher in circle 0.5, 1.5 and 2.5 mm (all p<0.001). Multivariate regression analysis showed that CC FD% in the circle 2.5 mm when the Z score ≥2 was associated with BCVA (β=9.08 (95% CI 3.96 to 14.20); p=0.005) and Z score (β=4.19 (95% CI 1.28 to 12.00); p=0.012).

CONCLUSIONS

Thinner ChT and a higher CC FD% were observed in children with MFS, and an increased CC FD% in circle 2.5 mm was significantly associated with worse BCVA and cardiac function. These findings may help identify future visual impairment and early cardiac events in MFS children.

Cross-sectional study to assess the psychological morbidity of women facing possible miscarriage

INTRODUCTION

Threatened miscarriage is a common complication of pregnancy. This study aimed to assess psychological morbidity in women with threatened miscarriage, with the goal of identifying early interventions for women at risk of anxiety or depression.

METHODS

Women in their first trimester attending an Early Pregnancy Assessment Clinic were recruited between July 2013 and June 2015. They were asked to complete the 12-item General Health Questionnaire (GHQ-12), the Beck Depression Inventory (BDI), Spielberger's State Anxiety Inventory State form (STAI-S), the Fatigue Scale-14 (FS-14), and the Profile of Mood States (POMS) before consultation. They were also asked to rate anxiety levels before and after consultation using a visual analogue scale (VAS).

RESULTS

In total, 1390 women completed the study. The mean ± standard deviation of GHQ-12 (bi-modal) and GHQ-12 (Likert) scores were 4.04 ± 3.17 and 15.19 ± 5.30, respectively. Among these women, 48.4% had a GHQ-12 (bi-modal) score ≥4 and 76.7% had a GHQ-12 (Likert) score >12, indicating distress. The mean ± standard deviation of BDI, STAI-S, and FS-14 scores were 9.35 ± 7.19, 53.81 ± 10.95, and 2.40 ± 0.51, respectively. The VAS score significantly decreased after consultation (P<0.001). Compared with women without a history of miscarriage, women with a previous miscarriage had higher GHQ-12, BDI, and POMS scores (except for fatigue-inertia and vigour-activity subscales). A higher bleeding score was strongly positively correlated with GHQ-12 (Likert) score. There were weak correlations between pain score and the GHQ-12 (bi-modal) ≥4, BDI >12, and POMS scores (except for confusion-bewilderment subscale which showed a strong positive correlation).

CONCLUSION

Women with threatened miscarriage experience a considerable psychological burden, emphasising the importance of early recognition for timely management.

A Single-Institution Experience of Acute Neuropathic Lumbosacral Pain in Patients Treated with Short Course Hypofractionated Radiotherapy in Locally Advanced Rectal Cancer

PURPOSE/OBJECTIVE(S)

There has been increased interest in the use of short course hypofractionated radiotherapy as part of a total neoadjuvant treatment (TNT) approach in the management of rectal cancer since publication of the RAPIDO trial. However, the literature on short course radiation for rectal cancer has not reported significant acute toxicities in the weeks immediately following the completion of treatment. Anecdotally, a subset of patients has experienced acute neuropathic pain characterized in a lumbosacral distribution. This study investigates acute lumbosacral toxicity for patients receiving hypofractionated short course radiation as part of their definitive treatment for rectal cancer.

MATERIALS/METHODS

We retrospectively analyzed 75 patients with locally advanced rectal adenocarcinoma treated with hypofractionated short course radiation (25 Gy in 5 fractions) at our institution between 2016 and 2022. Acute toxicity caused by radiation was defined as that occurring from the start of radiation treatment to either 30 days post radiation completion, the start of chemotherapy, or date of surgery, whichever occurred first.

RESULTS

Among 75 patients treated with hypofractionated short course preoperative radiation with definitive intent, we identified 10 patients (13.3%) who experienced significant lumbosacral neuropathic pain and initiated a report to their medical providers during the acute toxicity time frame. Commonly, this was described as an achy pain in the bilateral buttocks radiating down to the knees or posterior claves. Patients rated this pain between moderate to extreme and management included steroids after failure of improvement with conservative measures, gabapentin, and conservative treatment with NSAIDs and Tylenol. Average time to onset of acute lumbosacral neuropathic pain was 3.7 days (SD 2.05) from start of RT.

CONCLUSION

We have identified a previously underappreciated acute toxicity of neuropathic lumbosacral pain in short course hypofractionated radiation therapy, which may be due to a lumbosacral plexus toxicity. Further analysis will seek to identify predictive factors such as comorbidities and dose to the lumbosacral plexus, and to determine whether there is a correlation between these observed acute toxicities and long-term outcomes.

Visual prognosis and complications of congenital ectopia lentis: study protocol for a hospital-based cohort in Zhongshan Ophthalmic Center

INTRODUCTION

Congenital ectopia lentis (CEL) is a rare ocular disease characterised by the dislocation or displacement of the lens. Patients with mild lens dislocations can be treated with conservative methods (eg, corrective eyeglasses or contact lenses). In contrast, patients with severe CEL usually require surgical management. However, few studies have focused on the visual prognosis and complications in conservative and surgical management of patients. This study aims to investigate the prognosis and complications in patients with CEL with conservative and surgical management, which is vital for CEL management, especially the choice of surgical timing and surgical method.

METHODS AND ANALYSIS

A cohort study will be conducted at Zhongshan Ophthalmic Center. We plan to recruit 604 participants diagnosed with CEL and aged ≥3 years old. Patients with mild lens subluxation and stable visual conditions will be included in the non-surgical group and follow-up at 1, 2 and 3 years after enrolment. Patients with severe lens subluxation who accept CEL surgery will be included in the surgical group. Different surgical techniques, including phacoemulsification, in-the-bag intraocular lens implantation (with or without capsular tension ring) and trans-scleral fixation, will be used depending on the severity of dislocation. Patients will be followed up at 3 months, and 1, 2 and 3 years postoperatively. Over a 5-year follow-up period, patients will receive a detailed ocular examination, including optometry, biological measurement, specular microscopy, ultrasound biomicroscopy, anterior segment and posterior segment optical coherence tomography (OCT), OCT angiography, echocardiography and questionnaires on vision-related quality of life. The primary outcome is the change of best-corrected visual acuity and the incidence of complications in both groups.

ETHICS AND DISSEMINATION

Ethics approval was obtained from the ethics committee of the Zhongshan Ophthalmic Center (number: 2022KYPJ207). Study findings will be published in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

NCT05654025.

Five-year retrospective review of ultrasoundguided manual vacuum aspiration for first-trimester miscarriage

INTRODUCTION

Manual vacuum aspiration is increasingly accepted as an alternative to medical or surgical evacuation of the uterus after first-trimester miscarriage. This study aimed to assess the efficacy of ultrasound-guided manual vacuum aspiration (USG-MVA) in the management of first-trimester miscarriage.

METHODS

This retrospective analysis included adult women with first-trimester miscarriage who underwent USG-MVA in Hong Kong between July 2015 and February 2021. The primary outcome was the efficacy of USG-MVA in terms of complete evacuation of the uterus, without the need for further medical or surgical intervention. Secondary outcomes included tolerance of the entire procedure, the success rate of karyotyping using chorionic villi, and procedural safety (ie, any clinically significant complications).

RESULTS

In total, 331 patients were scheduled to undergo USG-MVA for first-trimester miscarriage or incomplete miscarriage. The procedure was completed in 314 patients and well-tolerated in all of those patients. The complete evacuation rate was 94.6% (297/314), which is similar to the rate (98.1%) achieved by conventional surgical evacuation in a previous randomised controlled trial in our unit. There were no major complications. Samples from 95.2% of patients were suitable for karyotyping, which is considerably higher than the rate of suitable samples (82.9%) obtained via conventional surgical evacuation in our previous randomised controlled trial.

CONCLUSION

Ultrasound-guided manual vacuum aspiration is a safe and effective method to manage first-trimester miscarriage. Although it currently is not extensively used in Hong Kong, its broader clinical application could avoid general anaesthesia and shorten hospital stay.

Automatic slice thickness measurement on three types of Catphan CT phantoms

OBJECTIVE

To develop an algorithm to measure slice thickness to run on three types of Catphan phantoms with the ability to adapt to any misalignment and rotation of the phantoms.&#xD;Method: Images of Catphan 500, 504, and 604 phantoms were examined. In addition, images with various slice thicknesses ranging from 1.5 to 10.0 mm, distance to the iso-center and phantom rotations were also examined. The automatic slice thickness algorithm was carried out by processing only objects within a circle having a diameter half that of the phantom diameter. A segmentation was performed within an inner circle with dynamic thresholds to produce binary images with wire and bead objects. Region properties were used to distinguish wire ramps and bead objects. At each identified wire ramp, the angle was detected using the Hough transform. Profile lines were then placed on each ramp based on the centroid coordinates and detected angles, and the full-width at half maximum (FWHM) determined for the average pixel profile. The slice thickness was obtained by multiplying the FWHM by the tangent of the ramp angle (23o). &#xD;Results: Automatic measurements work well and have only a small difference (<0.5 mm) from manual measurements. For variations of slice thickness, automatic measurement successfully performs segmentation and correctly locates the profile line on all wire ramps. The results show values that are close (< 3mm) to the nominal thickness on thin slices, but less close for thicker slices. There is a strong correlation (R2 = 0.873) between automatic and manual measurements. Testing the algorithm at various distances from the iso-center and phantom rotation angle also produced accurate results. &#xD;Conclusion: An automated algorithm for measuring slice thickness on three types of Catphan CT phantom images has been developed. The algorithm works well on various thicknesses, distances from the iso-center, and phantom rotations.

Long-term Cardiovascular Risks of Gonadotropin-releasing Hormone Agonists and Antagonists: a Population-based Cohort Study

AIMS

Gonadotropin-releasing hormone (GnRH) agonists and antagonists, critical medications for prostate cancer (PCa) treatment, may differ in cardiovascular safety. This prospective cohort study aimed to compare the long-term cardiovascular risks between GnRH agonists and antagonists.

MATERIALS AND METHODS

Patients with PCa receiving GnRH agonists or antagonists during 2013-2021 in Hong Kong were identified. Patients with <6 months' prescriptions, who were switching between drugs, had missing baseline prostate-specific antigen level or had a prior stroke or myocardial infarction were excluded. Patients were followed up until September 2021. The primary outcome was major adverse cardiovascular events (MACE) as in the PRONOUNCE trial (MACE_PRONOUNCE), i.e. a composite of all-cause mortality, stroke and myocardial infarction. The secondary outcome was MACE_CVM, i.e. a composite of cardiovascular mortality, stroke and myocardial infarction. Inverse probability treatment weighting was used to balance covariates between groups. The Log-rank test was used to compare the cumulative freedom from the primary outcome between groups.

RESULTS

In total, 2479 patients were analysed (162 GnRH antagonist users and 2317 agonist users; median age 75.0 years, interquartile range 68.0-81.6 years). Inverse probability treatment weighting achieved good covariate balance between groups. Over a median follow-up duration of 3.0 years (interquartile range 1.7-5.0 years), 1115 patients (45.0%) had MACE_PRONOUNCE and 344 (13.9%) had MACE_CVM. GnRH agonist users had lower risks of MACE_PRONOUNCE (Log-rank P < 0.001) and MACE_CVM (Log-rank P = 0.027). However, no differences were observed within 1 year of follow-up (MACE_PRONOUNCE: Log-rank P = 0.308; MACE_CVM: Log-rank P = 0.357). Among patients without cardiovascular risk factors at baseline, GnRH agonist users had lower risks of MACE_PRONOUNCE (Log-rank P < 0.001) and MACE_CVM (Log-rank P = 0.001), whereas no differences were observed in those with such risk factor(s) (MACE_PRONOUNCE: Log-rank P = 0.569; MACE_CVM: Log-rank P = 0.615).

CONCLUSIONS

GnRH antagonists may be associated with higher long-term, but not short-term, cardiovascular risks than agonists in Asian patients with PCa, particularly in those without known cardiovascular risk factors.

Implementation of ovarian tissue cryopreservation in Hong Kong

INTRODUCTION

Worldwide, >130 babies have been born from ovarian tissue cryopreservation (OTC) and ovarian tissue transplantation (OTT). Ovarian tissue cryopreservation can improve quality of life among young female cancer survivors. Here, we assessed the feasibility of OTC and subsequent OTT in Hong Kong via xenografts in nude mice.

METHODS

This pilot study was conducted in a university-affiliated tertiary hospital. Fifty-two ovarian tissues were collected from 12 patients aged 29 to 41 years during ovarian surgery, then engrafted into 34 nude mice. The efficacies of slow freezing and vitrification were directly compared. In Phase I, non-ovariectomised nude mice underwent ovarian tissue engraftment. In Phase II, ovariectomised nude mice underwent ovarian tissue engraftment, followed by gonadotrophin administration to promote folliculogenesis. Ovarian tissue viability was assessed by gross anatomical, histological, and immunohistochemical examinations before and after OTC. Follicular density and morphological integrity were also assessed.

RESULTS

After OTC and OTT, grafted ovarian tissues remained viable in nude mice. Primordial follicles were observed in thawed and grafted ovarian tissues, indicating that the cryopreservation and transplantation protocols were both effective. The results were unaffected by gonadotrophin stimulation.

CONCLUSION

This study demonstrated the feasibility of OTC in Hong Kong as well as primordial follicle viability after OTC and OTT in nude mice. Ovarian tissue cryopreservation is ideal for patients who cannot undergo the ovarian stimulation necessary for oocyte or embryo freezing as well as prepubertal girls (all ineligible for oocyte freezing). Our findings support the clinical implementation of OTC and subsequent OTT in Hong Kong.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

The age-dependent association of risk factors with pancreatic cancer

BACKGROUND

Pancreatic cancer presents as advanced disease in >80% of patients; yet, appropriate ages to consider prevention and early detection strategies are poorly defined. We investigated age-specific associations and attributable risks of pancreatic cancer for established modifiable and non-modifiable risk factors.

PATIENTS AND METHODS

We included 167 483 participants from two prospective US cohort studies with 1190 incident cases of pancreatic cancer during >30 years of follow-up; 5107 pancreatic cancer cases and 8845 control participants of European ancestry from a completed multicenter genome-wide association study (GWAS); and 248 893 pancreatic cancer cases documented in the US Surveillance, Epidemiology, and End Results (SEER) Program. Across different age categories, we investigated cigarette smoking, obesity, diabetes, height, and non-O blood group in the prospective cohorts; weighted polygenic risk score of 22 previously identified single nucleotide polymorphisms in the GWAS; and male sex and black race in the SEER Program.

RESULTS

In the prospective cohorts, all five risk factors were more strongly associated with pancreatic cancer risk among younger participants, with associations attenuated among those aged >70 years. The hazard ratios comparing participants with three to five risk factors with those with no risk factors were 9.24 [95% confidence interval (CI) 4.11-20.77] among those aged ≤60 years, 3.00 (95% CI 1.85-4.86) among those aged 61-70 years, and 1.46 (95% CI 1.10-1.94) among those aged >70 years (Pheterogeneity = 3×10-5). These factors together were related to 65.6%, 49.7%, and 17.2% of incident pancreatic cancers in these age groups, respectively. In the GWAS and the SEER Program, the associations with the polygenic risk score, male sex, and black race were all stronger among younger individuals (Pheterogeneity ≤0.01).

CONCLUSIONS

Established risk factors are more strongly associated with earlier-onset pancreatic cancer, emphasizing the importance of age at initiation for cancer prevention and control programs targeting this highly lethal malignancy.

AB0879 Interim analysis of baseline characteristics and 12-week outcomes for a subset of patients with moderate-to-severe plaque psoriasis and psoriatic arthritis from the Psoriasis Study of Health Outcomes

Background

Approximately 30% of patients (pts) with plaque psoriasis (PsO) develop psoriatic arthritis (PsA)1, which is associated with high Psoriasis Area and Severity Index (PASI) and nail involvement. The Psoriasis Study of Health Outcomes (PSoHO) is a 3-year (yr), international, prospective, observational cohort study comparing the effectiveness of anti-IL-17A biologics to all other approved biologics in pts with moderate-to-severe PsO.

Objectives

This interim subset analysis describes the baseline characteristics and Week 12 (W12) effectiveness in pts with moderate-to-severe PsO and PsA in PSoHO.

Methods

Adults with moderate-to-severe PsO for ≥6 months who initiated/switched biologic treatment during routine medical care were enrolled. PsA diagnosis was recorded by the dermatologists based on the medical history and/or information provided by the patient. W12 effectiveness was assessed by the proportion of pts achieving almost clear or clear skin defined by ≥90% improvement in PASI, affected Body Surface Area (BSA), Dermatology Life Quality Index (DLQI), and Patient Global Assessment of Disease Severity (PatGA). Musculoskeletal endpoints were not collected. Data were analysed descriptively, using mean (standard deviation [SD]) or median ([Q1/Q3]) for continuous variables and n, % and 95% confidence limits for categorical variables.

Results

Overall, 1981 pts were enrolled in this study, of whom 461 (23.3%) had a PsA diagnosis and received either anti-IL-17A (n=227; 49.2%) or other biologics (n=234; 50.8%). This subset of pts had a mean age of 48.7 yrs and a median disease duration of 18.9 yrs for PsO and 5.6 yrs for PsA (Table 1).

Table 1.

Baseline characteristics for PsO patients with PsA. Mean (SD) reported for all available data for that measure, unless stated otherwise.

Overall (n=461)Anti-IL-17A (n=227)Other Biologics (n=234)Age, yrs48.7 (12.9)50.9 (12.9)46.6 (12.6)Male, n (%)232 (50.3)112 (49.3)120 (51.3)BMI (kg/m2)29.7 (6.2)29.8 (5.9)29.6 (6.4)Smoking status – Current, n (%)100 (25.4)41 (21.1)59 (29.5)Disease duration (PsA), yrs, median (Q1/Q3)5.6(2.2/13.1)5.6(2.0 / 13.8)5.5(2.3 / 12.8)Disease duration (PsO), yrs, median (Q1/Q3)18.9(9.7 / 28.6)18.9(9.2 / 30.3)18.7(10.1 / 27.3)Any previous biologic therapy, n (%)249 (54.0)123 (54.2)126 (53.8)PASI14.3 (9.3)13.6 (8.1)15.0 (10.3)BSA, %21.7 (19.4)19.8 (17.3)23.5 (21.1)mNAPSI16.6 (22.8)16.5 (25.5)16.7 (20.1)Presence of nail PsO, n (%)217 (47.2)103 (45.4)114 (48.9)PatGA3.5 (1.2)3.5 (1.3)3.6 (1.2)DLQI13.6 (7.9)13.4 (7.8)13.7 (8.0)HADS Depression score >10, n (%)73 (19.3)38 (20.5)35 (18.1)HADS Anxiety score >10, n (%)124 (32.8)62 (33.5)62 (32.1)

BMI = Body Mass Index; BSA = Body Surface Area; DLQI = Dermatology Life Quality Index; HADS = Hospital Anxiety and Depression Scale; HADS >10 indicates significant symptoms of depression/anxiety; mNAPSI = Modified Nail Psoriasis Severity Index; PASI = Psoriasis Area and Severity Index; PatGA = Patient Global Assessment of Disease Severity; Q1/Q3 = Quartile 1/3.

At W12, 62.4% and 42.6% of anti-IL-17A-treated pts achieved PASI90 and PASI100, respectively, compared with 34.2% and 16.8% in the other biologics cohort, respectively (Figure 1). BSA <3% was reached by 70.9% of anti-IL-17A-treated pts and 49.5% in the other biologics cohort, while 71.2% and 44.8%, respectively, reached PatGA 0/1. Among pts with baseline DLQI ≥2, 38.0% and 27.1% of the anti-IL-17A and other biologics cohorts, respectively, reached DLQI 0/1.

Figure 1.

Percentage of patients receiving anti-IL-17A or other biologics who achieved PASI75/90/100, absolute PASI ≤1, BSA <3%, PatGA 0/1 and DLQI 0/1 (baseline DLQI ≥2) at Week 12. Bars represent upper 95% confidence limits.

Conclusion

The effectiveness of blocking IL-17A on skin manifestations and on quality-of-life improvements in pts with PsO and PsA in the real-world study was consistent with observations from clinical trials.

References

[1]Zabotti A, et al. RMD Open 2019;5: e001067

Disclosure of Interests

Lars Erik Kristensen Speakers bureau: Pfizer, AbbVie, Amgen, UCB, Gilead, Biogen, BMS, MSD, Novartis, Eli Lilly, and Janssen pharmaceuticals., Consultant of: Pfizer, AbbVie, Amgen, UCB, Gilead, Biogen, BMS, MSD, Novartis, Eli Lilly, and Janssen pharmaceuticals., Grant/research support from: IIT research grants from Pfizer, AbbVie, UCB, Gilead, Biogen, Novartis, Eli Lilly, and Janssen pharmaceuticals., Frank Behrens Speakers bureau: Amgen, AbbVie, Pfizer, Roche, Chugai, UCB, BMS, Celgene, MSD, Novartis, Biotest, Janssen, Genzyme, Eli Lilly, Boehringer and Sandoz, Consultant of: Amgen, AbbVie, Pfizer, Roche, Chugai, UCB, BMS, Celgene, MSD, Novartis, Biotest, Janssen, Genzyme, Eli Lilly, Boehringer and Sandoz, Grant/research support from: AbbVie, Pfizer, Roche, Chugai, GSK and Janssen, Luis Puig Speakers bureau: Celgene, Janssen, Eli Lilly, Novartis, Pfizer, Consultant of: Abbvie, Almirall, Amgen, Baxalta, Biogen, Boehringer Ingelheim, Bristol Myers Squibb, Celgene, Fresenius-Kabi, Janssen, JS BIOCAD, Leo-Pharma, Eli Lilly, Mylan, Novartis, Pfizer, Regeneron, Roche, Sandoz, Samsung-Bioepis, Sanofi, UCB, Grant/research support from: Abbvie, Almirall, Amgen, Boehringer Ingelheim, Celgene, Janssen, Leo-Pharma, Eli Lilly, Novartis, Pfizer, Regeneron, Roche, Sanofi, UCB, Adam Reich Speakers bureau: Abbvie, Novartis, Janssen, Pfizer, Sandoz, Galderma, Eli Lilly, Consultant of: Abbvie, Novartis, Janssen, Pfizer, Sandoz, Galderma, Eli Lilly, Thorsten Holzkaemper Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company, Alan Brnabic Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company, Khai Ng Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company, Soyi Liu Leage Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company, Christopher Schuster Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company, Andreas Pinter Speakers bureau: AbbVie, Almirall-Hermal, Amgen, Biogen Idec, Biontec, Boehringer-Ingelheim, Celgene, GSK, Eli Lilly, Galderma, Hexal, Janssen, LEO-Pharma, MC2, Medac, Merck Serono, Mitsubishi, MSD, Novartis, Pascoe, Pfizer, Tigercat Pharma, Regeneron, Roche, Sandoz Biopharmaceuticals, Sanofi-Genzyme, Schering-Plough and UCB Pharma, Consultant of: AbbVie, Almirall-Hermal, Amgen, Biogen Idec, Biontec, Boehringer-Ingelheim, Celgene, GSK, Eli Lilly, Galderma, Hexal, Janssen, LEO-Pharma, MC2, Medac, Merck Serono, Mitsubishi, MSD, Novartis, Pascoe, Pfizer, Tigercat Pharma, Regeneron, Roche, Sandoz Biopharmaceuticals, Sanofi-Genzyme, Schering-Plough and UCB Pharma

OP0142 COMPARISON OF ATTAINMENT AND PROTECTIVE EFFECTS OF THE LUPUS LOW DISEASE ACTIVITY STATE IN PATIENTS WITH NEWLY DIAGNOSED VERSUS ESTABLISHED SLE - A MULTICENTRE PROSPECTIVE STUDY

Background

Lupus low disease activity state (LLDAS) attainment has been reported to be associated with reduced damage accrual, flare, and mortality, as well as improved quality of life, in cohorts of SLE patients with established disease. Whether these associations are present in recent-onset disease is less well known.

Objectives

To evaluate the associations of LLDAS attainment with outcomes in patients with recent onset SLE.

Methods

Data from a 13-country longitudinal SLE cohort (ACR/SLICC criteria) were collected prospectively between 2013 and 2020 using standard templates. Organ damage and flare were captured using SLICC Damage Index and SELENA-SLEDAI Flare Index, respectively. LLDAS was defined as Golder et al., 2019 [1]. An inception cohort was defined based on duration since SLE diagnosis<1 year at enrolment. Patient characteristics between inception and non-inception cohorts were compared using Wilcoxon rank-sum (continuous variables) or Pearson’s Chi-squared tests (categorical variables). Survival analyses were performed to examine the association between LLDAS attainment and damage accrual and flare.

Results

The study cohort included 4,106 patients of whom 680 (16%) were recruited within 1 year of SLE diagnosis (inception cohort). Compared to the non-inception cohort, inception cohort patients were significantly younger, had higher disease activity (SLEDAI-2K and physician global assessment), used more glucocorticoids and immunosuppressants but had less organ damage at enrolment and only 88 (13.6%) patients accrued damage during a median 2.2 years follow-up (Table 1).

Table 1.Non-inception cohortInception cohortp-valuen=3426n=680Age at enrolment (years), median [IQR]40 [31, 51]33 [25, 44]<0.001Age at diagnosis (years), median [IQR]28 [21, 38]33 [25, 43]<0.001SLE duration at enrolment (years), median [IQR]10 [5, 16]1 [0, 1]<0.001Study duration (years), median [IQR]2.5 [1.0, 5.4]2.2 [0.9, 3.7]<0.001Females, n (%)3155 (92.1%)623 (91.6%)0.68Asian ethnicity, n (%)3037 (89.1%)595 (88.1%)0.49Prednisolone (PNL) use - ever, n (%)2865 (83.6%)620 (91.2%)<0.001Time adjusted mean (TAM)-PNL, median [IQR]5.0 [2.2, 8.6]6.2 [3.2, 10.3]<0.001Cumulative PNL (g), median [IQR]3.4 [0.5, 9.7]3.8 [1.1, 8.5]0.26Anti-Malarial use - ever, n (%)2669 (77.9%)569 (83.7%)<0.001Immunosupressant use -ever, n (%)2367 (69.1%)521 (76.6%)<0.001AMS (TAM-SLEDAI-2K), median [IQR]2.8 [1.2, 4.6]3.1 [1.6, 5.0]0.002TAM-PGA, median [IQR]0.4 [0.2, 0.7]0.4 [0.3, 0.8]<0.001Mild/moderate/severe flare ever, n (%)1789 (52.2%)391 (57.5%)0.012Organ damage accrual, n (%)629 (20.8%)88 (13.6%)<0.001LLDAS at baseline, n (%)1730 (50.5%)195 (28.7%)<0.001LLDAS-ever (at least once), n (%)2637 (78.2%)492 (73.9%)0.014≥50% time in LLDAS (LLDAS-5), n (%)1612 (50.6%)256 (41.1%)<0.001

Significantly fewer inception cohort patients were in LLDAS at enrolment than the non-inception cohort (29% vs. 51%, p<0.001). However, 74% of inception and 78% of non-inception cohort patients achieved LLDAS at least once during follow-up. Limiting analysis only to patients not in LLDAS at enrolment, time to first LLDAS attainment was assessed: inception cohort patients were 60% more likely to attain their first LLDAS (HR = 1.60 (95%CI: 1.40, 1.82), p<0.001) than non-inception cohort patients. LLDAS attainment was significantly protective against flare in the inception (HR, 95% CI) and non-inception (HR, 95% CI) cohorts. Trends towards protection against damage accrual in association with LLDAS in the inception cohort were not significant.

Conclusion

LLDAS attainment is protective from flare in recent onset SLE. Significant protection from damage accrual was not observed, due to low rates of damage accrual in the first years after SLE diagnosis.

References

[1]Golder, V., et al., Lupus low disease activity state as a treatment endpoint for systemic lupus erythematosus: a prospective validation study. The Lancet Rheumatology, 2019. 1(2): p. e95-e102.

Acknowledgements

We thank all patients participating in the Asia Pacific Lupus Collaboration (APLC) cohort, and all data collectors for their ongoing support for APLC research activities.

The APLC has received unrestricted project grants from AstraZeneca, BMS, Eli Lily, Janssen, Merck Serono, and UCB to support data collection contributing to this work.

Disclosure of Interests

Vera Golder: None declared, Rangi Kandane-Rathnayake: None declared, Worawit Louthrenoo: None declared, Yi-Hsing Chen Speakers bureau: Pfizer, Novartis, Abbvie, Johnson & Johnson, BMS, Roche, Lilly, GSK, Astra& Zeneca, Sanofi, MSD, Guigai, Astellas, Inova Diagnostics, UCB, Agnitio Science Technology, United Biopharma, Thermo Fisher, Consultant of: Pfizer, Novartis, Abbvie, Johnson & Johnson, BMS, Roche, Lilly, GSK, Astra and Zeneca, Sanofi, Guigai, Astellas, Inova Diagnostics, UCB, Agnitio Science Technology, United Biopharma, Thermo Fisher, Gilead, Grant/research support from: Yes. Clinical trials and/or research grants from Pfizer, Norvatis, BMS, Abbevie, Johnson & Johnson, Roche,Sanofi, Guigai, Roche, Boehringer Ingelheim, UCB, MSD, Astra-Zeneca,Astellas, Gilead, Jiacai Cho: None declared, Aisha Lateef: None declared, Laniyati Hamijoyo Speakers bureau: Pfizer, Novartis, Abbot, Shue Fen Luo: None declared, Yeong-Jian Jan Wu Speakers bureau: Pfizer, Lilly, Novartis, Abbvie, Sandra Navarra Speakers bureau: Pfizer, Johnson & Johnson, Novartis, Astellas, Grant/research support from: Astellas, Johnson & Johnson, Leonid Zamora: None declared, Zhanguo Li Speakers bureau: Eli, Lilly, Novartis, GSK, AbbVie, Paid instructor for: Pfizer, Roche, Johnson, Consultant of: Lilly, Pfizer, Grant/research support from: Pfizer, Yuan An: None declared, Sargunan Sockalingam Speakers bureau: Yes. Pfizer, Roche, Novartis, Grant/research support from: Roche and Novartis, Yasuhiro Katsumata Speakers bureau: Chugai Pharmaceutical Co., Ltd., Glaxo-Smithkline K.K., and Sanofi K.K., Masayoshi Harigai Speakers bureau: MH has received speaker’s fee from AbbVie Japan GK, Ayumi Pharmaceutical Co., Boehringer Ingelheim Japan, Inc.,Bristol Myers Squibb Co., Ltd., Chugai Pharmaceutical Co., Ltd., Eisai Co., Ltd., Eli Lilly Japan K.K., GlaxoSmithKline K.K., Kissei Pharmaceutical Co., Ltd., Pfizer Japan Inc., Takeda Pharmaceutical Co., Ltd., and Teijin Pharma Ltd, Consultant of: MH is a consultant for AbbVie, Boehringer-ingelheim, Bristol Myers Squibb Co., Kissei Pharmaceutical Co.,Ltd. and Teijin Pharma., Grant/research support from: MH has received research grants from AbbVie Japan GK, Asahi Kasei Corp., Astellas Pharma Inc., Ayumi Pharmaceutical Co., Bristol Myers Squibb Co., Ltd., Chugai Pharmaceutical Co., Daiichi-Sankyo, Inc.,Eisai Co., Ltd., Kissei Pharmaceutical Co., Ltd., Mitsubishi Tanabe Pharma Co., Nippon Kayaku Co., Ltd., Sekiui Medical, Shionogi & Co., Ltd., Taisho Pharmaceutical Co., Ltd., Takeda Pharmaceutical Co., Ltd., and Teijin Pharma Ltd., Yanjie Hao: None declared, Zhuoli Zhang Speakers bureau: Norvatis, GSK, Pfizer, BMDB Basnayake: None declared, Madelynn Chan Speakers bureau: AbbVie, Novartis, Consultant of: Advisory Board member for Pfizer, Eli-Lilly, Jun Kikuchi: None declared, Tsutomu Takeuchi Speakers bureau: AbbVie AYUMI Pharmaceutical Corp. Bristol-Myers Squibb Chugai Pharmaceutical Co, Ltd. Daiichi Sankyo Co., Ltd. Eisai Co., Ltd. Eli Lilly Japan, Gilead Sciences, Inc. Mitsubishi-Tanabe Pharma Corp. Pfizer Japan Inc. Sanofi K.K., Consultant of: Astellas Pharma, Inc. Chugai Pharmaceutical Co, Ltd. Eli Lilly Japan, Mitsubishi-Tanabe Pharma Corp., Grant/research support from: AbbVie Asahikasei Pharma Corp. Chugai Pharmaceutical Co, Ltd. Mitsubishi-Tanabe Pharma Corp. Sanofi K.K, Sang-Cheol Bae: None declared, Sean O’Neill Paid instructor for: Advisory board member for GSK, Fiona Goldblatt: None declared, Shereen Oon: None declared, Kathryn Gibson Speakers bureau: UCB, Consultant of: Novartis – co-chair for NSW and steering committee member for ARISE meeting Feb 2021

Janssen Pharmaceuticals – advisory board, Grant/research support from: Novartis, Employee of: Eli Lilly, Kristine Ng Speakers bureau: speaker fees and advisory board (Abbvie, Novartis, Janssen), Annie Law: None declared, Nicola Tugnet: None declared, Sunil Kumar: None declared, Cherica Tee: None declared, Michael Tee: None declared, Yoshiya Tanaka Speakers bureau: Daiichi-Sankyo, Eli Lilly, Novartis, YL Biologics, Bristol-Myers, Eisai, Chugai, Abbvie, Astellas, Pfizer, Sanofi, Asahi-kasei, GSK, Mitsubishi-Tanabe, Gilead, Janssen, Grant/research support from: Daiichi-Sankyo, Eli Lilly, Novartis, YL Biologics, Bristol-Myers, Eisai, Chugai, Abbvie, Astellas, Pfizer, Sanofi, Asahi-kasei, GSK, Mitsubishi-Tanabe, Gilead, Janssen, C.S. Lau Shareholder of: Pfizer, Sanofi and Janssen, Mandana Nikpour Speakers bureau: Actelion, GSK, Janssen, Pfizer, UCB, Paid instructor for: UCB, Consultant of: Actelion, Boehringer Ingelheim, Certa Therapeutics, Eli Lilly, GSK, Janssen, Pfizer, UCB, Grant/research support from: Actelion, Astra Zeneca, BMS, GSK, Janssen, UCB, Alberta Hoi Consultant of: AH is on the advisory board for Abbvie and GSK, Grant/research support from: AH has received research support from AstraZeneca, GSK, BMS, Janssen, and Merck Serono, Eric F. Morand Speakers bureau: AstraZeneca, Paid instructor for: Eli Lilly, Consultant of: AstraZeneca, Amgen, Biogen, BristolMyersSquibb, Eli Lilly, EMD Serono, Genentech, Janssen, Grant/research support from: AstraZeneca, BristolMyersSquibb, Eli Lilly, EMD Serono, Janssen

AB0428 TREATMENT PATTERNS OF SYSTEMIC LUPUS ERYTHEMATOSUS PATIENTS IN TAIWAN – A POPULATION-BASED ANALYSIS

Background

Systemic lupus erythematosus (SLE) is a chronic, autoimmune disease of an unknown etiology with a broad spectrum of organ manifestations, and patients with SLE have limited treatment options to NSAIDS, glucocorticoids, hydroxychloroquine and immunosuppressants. There is a lack of real-world evidence related to treatment patterns of SLE patients in Taiwan.

Objectives

To describe the real-world patient demographics, clinical characteristics, and treatment patterns of patients with SLE in Taiwan.

Methods

A retrospective observational study using Taiwan’s National Health Insurance Research Database (NHIRD) from 1/1/2014 to 12/31/2019 was undertaken. Patients holding catastrophic illness certificates for SLE in 2015-2017 were identified. Enrolled patients aged ≥ 18 years were then divided into three groups (mild, moderate, and severe) based on the highest severity patients experienced in the one year following the enrollment date using a published claims-based algorithm (Garris et al 2013) that incorporates the Systemic Lupus Erythematosus Disease Activity Index, Systemic Lupus Activity Measure, British Isles Lupus Assessment Group Index and expert clinical opinion, and indexed upon the first date of entering the severity group. Baseline patient characteristics and treatment patterns during the follow-up period were measured. The types of treatment considered were NSAIDs, glucocorticoids, hydroxychloroquine and immunosuppressants.

Results

A total of 20,181 patients with catastrophic illness certificates for SLE were included in this study. The mean age of all SLE patients was 46.5 years and patients were mostly female (89.1%). The mean Charlson Comorbidity Index (CCI) score of all SLE patients was 1.5 (SD 1.3). Of these patients, 29.3% (n=5,918) had mild SLE activity, 60.7% (n=12,253) moderate and 10.0% (n=2,010) severe. During the one-year follow-up period, moderate to severe patients had numerically higher utilization rate of all types of treatment compared with mild patients (Table 1). Of all oral glucocorticoid users,27.8% of severe patients used high-dose glucocorticoids (> 15 mg/day) compared to <0.1% for mild and 9.7% for moderate patients. More than 70.0% of moderate to severe patients were prescribed 2 or more types of treatment at the same point of time. Of these patients having concomitant treatment of glucocorticoids with immunosuppressants, glucocorticoid dosage increased with the number of immunosuppressant used, especially in severe patients. 80.4% of moderate to severe patients received glucocorticoid-based therapy as the first-line treatment and the median treatment duration was 3.1 months. The median treatment duration of each first-line immunosuppressant ranged from 0.9 to 4.8 months in moderate to severe patients.

Table 1.

SLE treatment utilization during the 1-year follow-up period

Total (n=20,181)`Mild (n=5,918)Moderate (n=12,253)Severe (n=2,010)n%n%n%n%NSAID7,21235.71,40523.74,98340.782441.0Glucocorticoid14,01969.52,01534.110,29784.01,70784.9Hydroxychloroquine13,27865.82,86748.58,97073.21,44171.7Immunosuppressant7,63037.800.06,31951.61,31165.2Methotrexate8984.500.07866.41125.6Azathioprine5,64228.000.04,84339.579939.8Leflunomide1320.700.01171.0150.8Cyclosporin8544.200.07155.81396.9Mycophenolate9594.800.07746.31859.2Cyclophosphamide7903.900.0170.177338.5

Conclusion

The complexity and intensity of therapeutic approaches in SLE were associated with increased disease severity and patients were often resistant to treatment. These findings reflect the disease burden in SLE patients and suggest there is a substantial unmet need in the SLE treatment paradigm for moderate to severe SLE patients.

References

[1]Garris C, et al. J Med Econ. 2013;16:667–677.

Disclosure of Interests

Yu Sheng Chang: None declared, Wen-Nan Huang: None declared, Chao-Hsiun Tang: None declared, Khai Ng Shareholder of: I am a minor shareholder of Eli Lilly & Company, Employee of: I am an employee of Eli Lilly & Company, Po-Ya Chuang Consultant of: I am a paid consultant for Eli Lilly &Company, Wesley Furnback Consultant of: I am a paid consultant for Eli Lilly & Company, Bruce Wang Consultant of: I am a paid consultant for Eli Lilly & Company, Ching-Yun Wei Shareholder of: I am a minor shareholder of Eli Lilly & Company, Employee of: I am an employee of Eli Lilly & Company, Bradley Wang Shareholder of: I am a minor shareholder of Eli Lilly & Company, Employee of: I am an employee of Eli Lilly & Company

, Tamas Treuer Shareholder of: I am a minor shareholder of Eli Lilly & Company, Employee of: I am an employee of Eli Lilly & Company

Osimertinib and anti-HER3 combination therapy engages immune dependent tumor toxicity via STING activation in trans

Over the past decade, immunotherapy delivered novel treatments for many cancer types. However, lung cancer still leads cancer mortality, and non-small-cell lung carcinoma patients with mutant EGFR cannot benefit from checkpoint inhibitors due to toxicity, relying only on palliative chemotherapy and the third-generation tyrosine kinase inhibitor (TKI) osimertinib. This new drug extends lifespan by 9-months vs. second-generation TKIs, but unfortunately, cancers relapse due to resistance mechanisms and the lack of antitumor immune responses. Here we explored the combination of osimertinib with anti-HER3 monoclonal antibodies and observed that the immune system contributed to eliminate tumor cells in mice and co-culture experiments using bone marrow-derived macrophages and human PBMCs. Osimertinib led to apoptosis of tumors but simultaneously, it triggered inositol-requiring-enzyme (IRE1α)-dependent HER3 upregulation, increased macrophage infiltration, and activated cGAS in cancer cells to produce cGAMP (detected by a lentivirally transduced STING activity biosensor), transactivating STING in macrophages. We sought to target osimertinib-induced HER3 upregulation with monoclonal antibodies, which engaged Fc receptor-dependent tumor elimination by macrophages, and STING agonists enhanced macrophage-mediated tumor elimination further. Thus, by engaging a tumor non-autonomous mechanism involving cGAS-STING and innate immunity, the combination of osimertinib and anti-HER3 antibodies could improve the limited therapeutic and stratification options for advanced stage lung cancer patients with mutant EGFR.

781 IMPROVING THE QUALITY OF DO NOT ATTEMPT CARDIO-PULMONARY RESUSCITATION (DNACPR) FORM COMPLETION

Introduction

The completion of a Do Not Attempt Cardio-Pulmonary Resuscitation (DNACPR) form represents an important part of patient care. However, this can be a sensitive process that has gained national media interest. The aim of this Quality Improvement (QI) Project was to improve the quality of DNACPR form completion in a Care of the Elderly Department.

Methods

The QI project ran from May 2019 to January 2021 and was overseen by a multi-disciplinary team (including patient representation). DNACPR forms on the Care of the Elderly wards were audited monthly against 7 standards which correspond to key sections on the DNACPR form. During the data collection process, interventions were implemented using Plan-Do-Study-Act cycles. Interventions included: appointing ‘DNACPR Champions’ to complete monthly audits and provide personalised clinician feedback, the introduction of a new mandatory e-learning module, the creation of an alert system on nerve centre (the Trust’s electronic handover system) and the development of new DNACPR patient information including webpage development, videos and leaflets.

Results

The project has led to sustained improvements in majority of the 7 standards. The biggest improvements were seen in the inclusion of a review date, correct completion of the mental capacity assessment and the use of patient information leaflets. The documentation of discussions with patient and relatives remained below the audit standards and was largely unchanged during the QI project.

Conclusion

A multi-disciplinary and multi-faceted QI approach has shown to improve the quality of DNACPR form completion. Further work is needed to continue this process and a focus on staff training and ward-level processes will be the priority.

Virtual medical research mentoring and collaboration: breaking the bounds of nationality during the COVID-19 pandemic

Funding Acknowledgements

Type of funding sources: None.

OnBehalf

Cardioovascular Analytics Group

Background

Medical research is critical to professional advancement, and mentoring is an important means of early research engagement in medical training. In contrast to international research collaborations, research mentoring programs are often locally limited. With the COVID-19 pandemic causing drifts to virtual classes and conferences, virtual international medical research mentoring may be viable. We hereby describe our experience with a virtual, international mentorship group for cardiovascular research.

Methods

Our virtual international research mentorship group has been running since 2015. The group focuses on risk stratification and outcomes research in cardiovascular medicine and epidemiology. Mentees from any country or region in all stages of medical careers are welcomed. Considering the increasing emphasis of contemporary research on multidisciplinary healthcare and translational research, our team also includes allied healthcare professionals or students, and graduates from natural sciences (Figure 1). With our members’ diverse backgrounds, we firmly adhere to the principle that all members must be given equal opportunities and treatment, regardless of their age, gender, race, nationality, sexual orientation, family background, and institution of study or practice. We make use of virtual platforms and multi-level mentoring (both senior and peer mentoring), and emphasize active participation, early leadership, open culture, accessible research support, and a distributed research workflow (i.e. an accessible-distributed model).

Results

Since establishment, our group has expanded to include 63 active members from 14 countries (Figure 2), leading a total of 109 peer-reviewed original studies and reviews published. We observed no significant difficulty in communication between team members, nor conflicts due to differences in nationality or ethnicity. Most studies involve cross-country and ethnicity collaborations, and inter-disciplinary and inter-regional knowledge exchanges are frequent. Multi-level mentoring ensured mentoring quality without compromising bonding and communication.

Conclusion

An accessible-distributed model of virtual international medical research collaboration and multi-level mentoring is viable, efficient, and caters to the needs of contemporary healthcare. We hope that others will build similar models and improve medical research mentoring globally.

POS0028 DEFINING THE PREVALENCE OF UNMET NEED IN SLE: DATA FROM A LARGE MULTINATIONAL LONGITUDINAL SLE COHORT

Background:

The recent prospectively validated definition of the lupus low disease activity state (LLDAS) allows characterisation of patients not achieving a treatment goal, providing impetus for an analysis of unmet needs in SLE using formal definitions. Other recently described definitions of high disease burden include disease activity over time, high disease activity status (HDAS) episodes, and the combination of high disease activity, serological activity and glucocorticoid (GC) use (HDAS+SA+GC).

Objectives:

To determine the prevalence of formal categories of unmet need, and the association of these with adverse outcomes, in SLE.

Methods:

Data from a 13-country longitudinal SLE cohort (ACR/SLICC criteria) were collected between 2013 and 19 using standard templates. Unmet need was defined as (i) patients never attaining LLDAS defined as in Golder et al., 2019 [1], (ii) having persistently active disease (time adjusted mean SLEDAI-2K (AMS) > 4), (iii) ever exhibiting high disease activity status (HDAS; SLEDAI-2K ≥10[2]), or (iv) ever exhibiting all of SLEDAI≥10, serological activity, and glucocorticoid use (HDAS+SA+GC)[3]. Health-related quality of life (HRQoL) was assessed using SF36 (v2) surveys and damage accrual using SLE Damage Index (SDI).

Results:

3,384 SLE patients were followed for 30,313 visits over median [IQR] 2.4 [0.4, 4.3] years. 53% of all visits were not in LLDAS; 813 patients (24%) never achieved LLDAS during observation. Median AMS was 3.0 [1.4, 4.9] and 34% of patients had AMS > 4 throughout the study. 25% of patients had at least one episode of HDAS, representing 8% of visits. 702 patients (21%) had at least one episode of HDAS+SA+GC, representing 8% of visits. Each of never-LLDAS, AMS>4, ever-HDAS, and ever-HDAS+SA+GC were associated with significantly greater number of physician visits, higher mean glucocorticoid dose, lower HRQoL and higher mortality. 31%, 58% and 83% of never-LLDAS, AMS>4, and ever-HDAS patients respectively were also HDAS+SA+GC on at least one occasion.

Conclusion:

Data from a multinational longitudinal SLE cohort indicate that unmet need, defined by LLDAS-never, AMS>4, HDAS, or HDAS+SA+GC, is prevalent in SLE, and that these definitions are associated with poor outcomes.

References:

[1]Golder, V., et al., Lupus low disease activity state as a treatment endpoint for systemic lupus erythematosus: a prospective validation study. The Lancet Rheumatology, 2019. 1(2): p. e95-e102.

[2]Koelmeyer, R., et al., High disease activity status suggests more severe disease and damage accrual in systemic lupus erythematosus. Lupus Sci Med, 2020. 7(1).

[3]van Vollenhoven, R.F., et al., Belimumab in the treatment of systemic lupus erythematosus: high disease activity predictors of response. Annals of the Rheumatic Diseases, 2012. 71(8): p. 1343-1349.

Acknowledgements:

The APLC acknowledges all the Data Collectors and Patients for their valuable contributions to research.

Disclosure of Interests:

Rangi Kandane-Rathnayake: None declared, Worawit Louthrenoo: None declared, Alberta Hoi Consultant of: Abbvie and GSK, Grant/research support from: AstraZeneca, GSK, BMS, Janssen, and Merck Serono, Vera Golder: None declared, Yi-Hsing Chen Speakers bureau: Pfizer, Novartis, Abbvie, Johnson & Johnson, BMS, Roche, Lilly, AstraZeneca, Sanofi, MSD, Guigai, Astellas, Inova Diagnostics, UCB, Agnitio Science Technology, United Biopharma, Thermo Fisher, Consultant of: Pfizer, Novartis, Abbvie, Johnson & Johnson, BMS, Roche, Lilly, AstraZeneca, Sanofi, MSD, Guigai, Astellas, Inova Diagnostics, UCB, Agnitio Science Technology, United Biopharma, Thermo Fisher, Gilead, Grant/research support from: Pfizer, Norvatis, BMS, Abbevie, Johnson & Johnson, Roche, Sanofi, Guigai, Roche, Boehringer Ingelheim, UCB, MSD, Astra-Zeneca, Astellas, Gilead, Shue Fen Luo: None declared, Yeong-Jian Jan Wu Speakers bureau: Pfizer, Lilly, Novartis, Abbvie, Aisha Lateef: None declared, Jiacai Cho: None declared, Laniyati Hamijoyo Speakers bureau: Pfizer, Novartis, Abbot, Chak Sing Lau Shareholder of: Pfizer, Sanofi, and Janssen, Sandra Navarra Speakers bureau: Pfizer, Johnson & Johnson, Novartis, Astellas, Grant/research support from: Astellas, Johnson & Johnson, Leonid Zamora: None declared, Zhanguo Li Speakers bureau: Eli, Lilly, Novartis, GSK, AbbVie, Paid instructor for: Pfizer, Roche, Johnson., Consultant of: Lilly, Pfizer, Grant/research support from: Pfizer, Yuan An: None declared, Sargunan Sockalingam Speakers bureau: Pfizer, Roche, Novartis, Grant/research support from: Roche and Novartis, Yasuhiro Katsumata Speakers bureau: Chugai Pharmaceutical Co., Ltd., Glaxo-Smithkline K.K., and Sanofi K.K., masayoshi harigai Speakers bureau: AbbVie Japan GK, Ayumi Pharmaceutical Co., Boehringer Ingelheim Japan, Inc.,Bristol Myers Squibb Co., Ltd., Chugai Pharmaceutical Co., Ltd., Eisai Co., Ltd., Eli Lilly Japan K.K., GlaxoSmithKline K.K., Kissei Pharmaceutical Co., Ltd., Pfizer Japan Inc., Takeda Pharmaceutical Co., Ltd., and Teijin Pharma Ltd., Consultant of: AbbVie, Boehringer-ingelheim, Bristol Myers Squibb Co., Kissei Pharmaceutical Co.,Ltd. and Teijin Pharma., Grant/research support from: AbbVie Japan GK, Asahi Kasei Corp., Astellas Pharma Inc., Ayumi Pharmaceutical Co., Bristol Myers Squibb Co., Ltd., Chugai Pharmaceutical Co., Daiichi-Sankyo, Inc.,Eisai Co., Ltd., Kissei Pharmaceutical Co., Ltd., Mitsubishi Tanabe Pharma Co., Nippon Kayaku Co., Ltd., Sekiui Medical, Shionogi & Co., Ltd., Taisho Pharmaceutical Co., Ltd., Takeda Pharmaceutical Co., Ltd., and Teijin Pharma Ltd., Yanjie Hao: None declared, Zhuoli Zhang Speakers bureau: Norvatis, GSK, Pfizer, Jun Kikuchi: None declared, Tsutomu Takeuchi Speakers bureau: AbbVie AYUMI Pharmaceutical Corp. Bristol-Myers Squibb Chugai Pharmaceutical Co, Ltd. Daiichi Sankyo Co., Ltd. Eisai Co., Ltd. Eli Lilly Japan, Gilead Sciences, Inc. Mitsubishi-Tanabe Pharma Corp. Pfizer Japan Inc. Sanofi K.K., Consultant of: Astellas Pharma, Inc. Chugai Pharmaceutical Co, Ltd. Eli Lilly Japan, Mitsubishi-Tanabe Pharma Corp., Grant/research support from: AbbVie, Asahikasei Pharma Corp. Chugai Pharmaceutical Co, Ltd. Mitsubishi-Tanabe Pharma Corp. Sanofi K.K., BMDB Basnayake: None declared, Fiona Goldblatt: None declared, Madelynn Chan Speakers bureau: AbbVie, Novartis, Consultant of: Pfizer, Eli-Lilly, Kristine Ng Speakers bureau: Abbvie, Novartis, Janssen, Sang-Cheol Bae: None declared, Shereen Oon: None declared, Sean O’Neill Consultant of: GSK, Kathryn Gibson Speakers bureau: UCB, Consultant of: Novartis, Janssen, Grant/research support from: Novartis, Sunil Kumar: None declared, Nicola Tugnet: None declared, Yoshiya Tanaka Speakers bureau: Daiichi-Sankyo, Eli Lilly, Novartis, YL Biologics, Bristol-Myers, Eisai, Chugai, Abbvie, Astellas, Pfizer, Sanofi, Asahi-kasei, GSK, Mitsubishi-Tanabe, Gilead, Janssen, Grant/research support from: Abbvie, Mitsubishi-Tanabe, Chugai, Asahi-Kasei, Eisai, Takeda, Daiichi-Sankyo, Mandana Nikpour Speakers bureau: Actelion, GSK, Janssen, Pfizer, UCB, Paid instructor for: UCB, Consultant of: Actelion, Boehringer Ingelheim, Certa Therapeutics, Eli Lilly, GSK, Janssen, Pfizer, UCB, Grant/research support from: Actelion, Astra Zeneca, BMS, GSK, Janssen, UCB, Eric F. Morand Speakers bureau: AstraZeneca, Paid instructor for: Eli Lilly, Consultant of: AstraZeneca, Amgen, Biogen, BristolMyersSquibb, Eli Lilly, EMD Serono, Genentech, Janssen, Grant/research support from: AstraZeneca, BristolMyersSquibb, Eli Lilly, EMD Serono, Janssen.

Prospective evaluation of dietary and lifestyle pattern indices with risk of colorectal cancer in a cohort of younger women

BACKGROUND

Although colorectal cancer (CRC) incidence in the USA is declining overall, its incidence is increasing among those younger than 50 years of age. The reasons underlying the increasing trend are largely unknown, although behavioral changes, such as unhealthy diet and lifestyle factors, may be partially responsible.

DESIGN

A prospective cohort study included 94 217 women aged 26-45 years at baseline. Validated anthropometric measures and lifestyle information were self-reported biennially. Exposures were four recommendation-based dietary indices-the prime diet quality score and three plant-based dietary indices; and two mechanism-based indices-the empirical dietary and lifestyle index for hyperinsulinemia (EDIH and ELIH). We calculated hazard ratios (HRs) and 95% confidence intervals (CIs) for overall CRC and for early-onset (before age 50) and after age 50 CRC separately.

RESULTS

We documented 332 cases of CRC during 24 years of follow-up (2 113 655 person-years), with an average age of 52 ± 7 years at diagnosis. Hyperinsulinemic dietary and lifestyle patterns were associated with a higher risk of CRC. Multivariable-adjusted HRs (95% CIs) comparing participants in the highest versus lowest quartile were: 1.67 for EDIH (95% CI: 1.15-2.44, P-trend = 0.01) and 1.51 for ELIH (95% CI: 1.10-2.08, P-trend = 0.01). Moreover, per 75% increment in rank, ELIH appeared to be a stronger risk factor for early-onset CRC (HR = 1.86, 95% CI: 1.12-3.07) than after age 50 CRC (HR = 1.20, 95% CI: 0.83-1.73, P-heterogeneity = 0.16). The four recommendation-based indices were not significantly associated with overall, early-onset, or after age 50 CRC risk (per 75% increment in rank, HRs ranged from 0.75 to 1.28).

CONCLUSION

Dietary and lifestyle patterns contributing to hyperinsulinemia were associated with greater CRC risk in younger women. Moreover, the hyperinsulinemic lifestyle showed a suggestively stronger positive association with early-onset CRC risk, compared with after age 50 CRC. Our findings suggest that dietary and lifestyle interventions to reduce insulinemic potential may be effective for CRC prevention among younger women.

Treatment of patients with Mayer-Rokitansky- Küster-Hauser syndrome in a tertiary hospital

INTRODUCTION

Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome is an uncommon congenital malformation characterised by agenesis or hypoplasia of the vagina and uterus. Here, we describe the treatment of patients with MRKH syndrome in a tertiary hospital.

METHODS

This retrospective study included patients with MRKH syndrome attending the Paediatric and Adolescent Gynaecology Clinic in a tertiary hospital. Their clinical manifestations, examinations, and methods for neovagina creation were recorded. Among patients who underwent vaginal dilation (VD), therapy duration, vaginal width and length at baseline and after VD, complications, and sexual activity and dyspareunia outcomes were evaluated.

RESULTS

Forty nine patients with MRKH syndrome were identified. Their mean age at presentation was 17.9 years; 69.4% and 24.5% of patients presented for primary amenorrhoea treatment and vaginoplasty, respectively. Forty eight patients had normal renal imaging findings and 46 XX karyotypes. Seventeen (34.7%) patients underwent VD as first-line therapy; three did not complete the therapy. Two had surgical vaginoplasty, whereas five achieved adequate vaginal length by sexual intercourse alone; 25 had not yet requested VD. The mean duration of VD was 16±10.2 (range, 4-35) weeks. The widths and lengths of the vagina at baseline and after VD were 1.1±0.28 cm and 1.3±0.7 cm, and 3.1±0.5 cm and 6.9±0.9 cm, respectively. The overall success rate of VD was 92.3%. Vaginal spotting was the most common complication (21%); only one patient reported dyspareunia.

CONCLUSIONS

Mayer-Rokitansky-Küster-Hauser syndrome is an uncommon condition that requires multidisciplinary specialist care. Vaginal dilation is an effective first-line approach for neovagina creation.

COVID-19 in patients with lung cancer

BACKGROUND

Patients with lung cancers may have disproportionately severe coronavirus disease 2019 (COVID-19) outcomes. Understanding the patient-specific and cancer-specific features that impact the severity of COVID-19 may inform optimal cancer care during this pandemic.

PATIENTS AND METHODS

We examined consecutive patients with lung cancer and confirmed diagnosis of COVID-19 (n = 102) at a single center from 12 March 2020 to 6 May 2020. Thresholds of severity were defined a priori as hospitalization, intensive care unit/intubation/do not intubate ([ICU/intubation/DNI] a composite metric of severe disease), or death. Recovery was defined as >14 days from COVID-19 test and >3 days since symptom resolution. Human leukocyte antigen (HLA) alleles were inferred from MSK-IMPACT (n = 46) and compared with controls with lung cancer and no known non-COVID-19 (n = 5166).

RESULTS

COVID-19 was severe in patients with lung cancer (62% hospitalized, 25% died). Although severe, COVID-19 accounted for a minority of overall lung cancer deaths during the pandemic (11% overall). Determinants of COVID-19 severity were largely patient-specific features, including smoking status and chronic obstructive pulmonary disease [odds ratio for severe COVID-19 2.9, 95% confidence interval 1.07-9.44 comparing the median (23.5 pack-years) to never-smoker and 3.87, 95% confidence interval 1.35-9.68, respectively]. Cancer-specific features, including prior thoracic surgery/radiation and recent systemic therapies did not impact severity. Human leukocyte antigen supertypes were generally similar in mild or severe cases of COVID-19 compared with non-COVID-19 controls. Most patients recovered from COVID-19, including 25% patients initially requiring intubation. Among hospitalized patients, hydroxychloroquine did not improve COVID-19 outcomes.

CONCLUSION

COVID-19 is associated with high burden of severity in patients with lung cancer. Patient-specific features, rather than cancer-specific features or treatments, are the greatest determinants of severity.

Critical care usage after major gastrointestinal and liver surgery: a prospective, multicentre observational study

BACKGROUND

Patient selection for critical care admission must balance patient safety with optimal resource allocation. This study aimed to determine the relationship between critical care admission, and postoperative mortality after abdominal surgery.

METHODS

This prespecified secondary analysis of a multicentre, prospective, observational study included consecutive patients enrolled in the DISCOVER study from UK and Republic of Ireland undergoing major gastrointestinal and liver surgery between October and December 2014. The primary outcome was 30-day mortality. Multivariate logistic regression was used to explore associations between critical care admission (planned and unplanned) and mortality, and inter-centre variation in critical care admission after emergency laparotomy.

RESULTS

Of 4529 patients included, 37.8% (n=1713) underwent planned critical care admissions from theatre. Some 3.1% (n=86/2816) admitted to ward-level care subsequently underwent unplanned critical care admission. Overall 30-day mortality was 2.9% (n=133/4519), and the risk-adjusted association between 30-day mortality and critical care admission was higher in unplanned [odds ratio (OR): 8.65, 95% confidence interval (CI): 3.51-19.97) than planned admissions (OR: 2.32, 95% CI: 1.43-3.85). Some 26.7% of patients (n=1210/4529) underwent emergency laparotomies. After adjustment, 49.3% (95% CI: 46.8-51.9%, P<0.001) were predicted to have planned critical care admissions, with 7% (n=10/145) of centres outside the 95% CI.

CONCLUSIONS

After risk adjustment, no 30-day survival benefit was identified for either planned or unplanned postoperative admissions to critical care within this cohort. This likely represents appropriate admission of the highest-risk patients. Planned admissions in selected, intermediate-risk patients may present a strategy to mitigate the risk of unplanned admission. Substantial inter-centre variation exists in planned critical care admissions after emergency laparotomies.

The leucine-rich region of Flightless I interacts with R-ras to regulate cell extension formation

Flightless I (FliI) is a calcium-dependent, actin severing and capping protein that localizes to cell matrix adhesions, contributes to the generation of cell extensions, and colocalizes with Ras. Currently, the mechanism by which FliI interacts with Ras to enable assembly of actin-based cell protrusions is not defined. R-Ras, but not K-ras, H-ras, or N-ras, associated with the leucine-rich region (LRR) of FliI. Mutations of the proline-rich region of R-ras (P202A, P203A) prevented this association. Knockdown of Ras GTPase-activating SH3 domain-binding protein (G3BP1) or Rasgap¹²⁰ by small interfering RNA inhibited the formation of cell extensions and prevented interaction of R-ras and G3BP1 in FliI wild-type (WT) cells. Pull-down assays using G3BP1 fusion proteins showed a strong association of R-ras with the C-terminus of G3BP1 (amino acids 236-466), which also required the LRR of FliI. In cells that expressed the truncated N-terminus or C-terminus of G3BP1, the formation of cell extensions was blocked. Endogenous Rasgap¹²⁰ interacted with the N-terminus of G3BP1 (amino acids 1-230). We conclude that in cells plated on collagen FliI-LRR interacts with R-ras to promote cell extension formation and that FliI is required for the interaction of Rasgap¹²⁰ with G3BP1 to regulate R-ras activity and growth of cell extensions.

Predicted vitamin D status and colon cancer recurrence and mortality in CALGB 89803 (Alliance)

Background

Observational studies suggest that higher levels of 25-hydroxyvitamin D3 (25(OH)D) are associated with a reduced risk of colorectal cancer and improved survival of colorectal cancer patients. However, the influence of vitamin D status on cancer recurrence and survival of patients with stage III colon cancer is unknown.

Patients and methods

We prospectively examined the influence of post-diagnosis predicted plasma 25(OH)D on outcome among 1016 patients with stage III colon cancer who were enrolled in a National Cancer Institute-sponsored adjuvant therapy trial (CALGB 89803). Predicted 25(OH)D scores were computed using validated regression models. We examined the influence of predicted 25(OH)D scores on cancer recurrence and mortality (disease-free survival; DFS) using Cox proportional hazards.

Results

Patients in the highest quintile of predicted 25(OH)D score had an adjusted hazard ratio (HR) for colon cancer recurrence or mortality (DFS) of 0.62 (95% confidence interval [CI], 0.44-0.86), compared with those in the lowest quintile (Ptrend = 0.005). Higher predicted 25(OH)D score was also associated with a significant improvement in recurrence-free survival and overall survival (Ptrend = 0.01 and 0.0004, respectively). The benefit associated with higher predicted 25(OH)D score appeared consistent across predictors of cancer outcome and strata of molecular tumor characteristics, including microsatellite instability and KRAS, BRAF, PIK3CA, and TP53 mutation status.

Conclusion

Higher predicted 25(OH)D levels after a diagnosis of stage III colon cancer may be associated with decreased recurrence and improved survival. Clinical trials assessing the benefit of vitamin D supplementation in the adjuvant setting are warranted.

ClinicalTrials.gov Identifier

NCT00003835.