Indigenous peoples and local communities as partners in the sequencing of global eukaryotic biodiversity

The aim to sequence, catalog, and characterize the genomes of all of Earth's eukaryotic biodiversity is the shared mission of many ongoing large-scale biodiversity genomics initiatives. Reference genomes of global flora and fauna have the potential to inform a broad range of major issues facing both biodiversity and humanity, such as the impact of climate change, the conservation of endangered species and ecosystems, public health crises, and the preservation and enhancement of ecosystem services. Biodiversity is dramatically declining: 28% of species being assessed by the IUCN are threatened with extinction, and recent reports suggest that a transformative change is needed to conserve and protect what remains. To provide a collective and global genomic response to the biodiversity crisis, many biodiversity genomics initiatives have come together, creating a network of networks under the Earth BioGenome Project. This network seeks to expedite the creation of an openly available, "public good" encyclopedia of high-quality eukaryotic reference genomes, in the hope that by advancing our basic understanding of nature, it can lead to the transformational scientific developments needed to conserve and protect global biodiversity. Key to completing this ambitious encyclopedia of reference genomes, is the ability to responsibly, ethically, legally, and equitably access and use samples from all of the eukaryotic species across the planet, including those that are under the custodianship of Indigenous Peoples and Local Communities. Here, the biodiversity genomics community is subject to the provisions codified in international, national, and local legislations and customary community norms, principles, and protocols. We propose a framework to support biodiversity genomic researchers, projects, and initiatives in building trustworthy and sustainable partnerships with communities, providing minimum recommendations on how to access, utilize, preserve, handle, share, analyze, and communicate samples, genomics data, and associated Traditional Knowledge obtained from, and in partnership with, Indigenous Peoples and Local Communities across the data-lifecycle.

18F-Fluorodeoxyglucose Positron Emission Tomography Parameters can Predict Long-Term Outcome Following Trimodality Treatment for Oesophageal Cancer

AIMS

¹⁸F-fluorodeoxyglucose positron emission tomography/computed tomography (¹⁸FDG-PET/CT) is routinely used for the pre-treatment staging of oesophageal or gastro-oesophageal junction cancers (EGEJC). The aim of this study was to identify objective ¹⁸FDG-PET/CT-derived parameters that can aid in predicting the patterns of recurrence and prognostication in patients with EGEJC.

PATIENTS AND METHODS

EGEJC patients referred for consideration of preoperative chemoradiation therapy were identified and clinicopathological data were collected. ¹⁸FDG-PET/CT imaging data were reviewed and correlated with treatment outcomes. Maximum standardised uptake value (SUV_max), metabolic tumour volume (MTV) and total lesion glycolysis were assessed and association with recurrence-free survival (RFS), locoregional recurrence-free survival (LR-RFS), oesophageal cancer-specific survival (ECSS) and overall survival were evaluated using receiver operating characteristic curves, as well as Cox regression and Kaplan-Meier models.

RESULTS

In total, 191 EGEJC patients completed trimodality treatment and 164 with ¹⁸FDG-PET/CT data were included in this analysis. At the time of analysis, 15 (9.1%), 70 (42.7%) and two (1.2%) patients were noted to have locoregional, distant and both locoregional and distant metastases, respectively. The median RFS was 30 months (9.6-50.4) and the 5-year RFS was 31.1%. The 5-year overall survival and ECSS were both noted to be 34.8%. Pre-treatment MTV₂₅ > 28.5 cm³ (P = 0.029), MTV₄₀ > 12.4 cm³ (P = 0.018) and MTV₅₀ > 10.2 cm³ (P = 0.005) predicted for worse LR-RFS, ECSS and overall survival for MTV definition of voxels ≥25%, 40% and 50% of SUV_max.

CONCLUSION

¹⁸FDG-PET/CT parameters MTV and total lesion glycolysis are useful prognostic tools to predict for LR-RFS, ECSS and overall survival in EGEJC. MTV had the highest accuracy in predicting clinical outcomes. The volume cut-off points we identified for different MTV thresholds predicted outcomes with significant accuracy and may potentially be used for decision making in clinical practice.

Social individuation: Extending the scale of emotional development - Short (SED-S) for adolescent reference ages

BACKGROUND

The SED-S is a standardized diagnostic instrument for assessing emotional development (ED) in people with a disorder of intellectual development. The SED-S defines five ED stages covering emotional reference ages up to 12 years in eight domains (5 items per domain). Stage 6 will extend the scale for early adolescent reference ages.

AIMS

The aim of this study is to define the SED-S items for stage 6 ('Social Individuation').

METHODS AND PROCEDURES

Experts in developmental psychology phrased 56 items (7 items/domain) describing typical behaviors for emotional reference ages 13th-18th year (145th-216th month) in English, German and Dutch. Twenty-eight independent experts assessed the items' content validity and observability on a Likert scale (0 = good to 3 = unacceptable). Two items/domain with the lowest ratings were excluded to finally select 5 items/domain for SED-S stage 6.

OUTCOMES AND RESULTS

The ratings were good with results ranging from 0.06 to 0.78 for validity and 0.06-1.78 for observability. After exclusion of the 2 lowest ranking items/domain, a set of 40 items was selected.

CONCLUSIONS AND IMPLICATIONS

The SED-S is extended to allow the assessment of emotional reference ages up to 18 years. Further research should evaluate the scale's psychometric properties. WHAT THIS PAPER ADDS?: The current version of the SED-S covers emotional reference ages up to 12 years (144 months). Extending the SED-S for emotional reference ages up to 18 years (145th-216th months of life) in Dutch, German and English allows better differentiation in the higher ED range and expands the applicability of the scale. Specifically, it makes it possible to apply the SED-S in people with borderline intellectual functioning. Accounting for the level of ED may provide valuable information about the behaviors and needs of individuals with higher reference ages and may support targeted treatment options in a population highly vulnerable to behavioral or mental disorders.

1029 EVEN LIMITED GERIATRICIAN INVOLVEMENT REDUCES LENGTH OF STAY FOR ALL-AGE ACUTE GENERAL SURGERY PATIENTS

Background

More than half of patients undergoing emergency general surgery are older than 651. The Emergency Laparotomy and Frailty (ELF) study identified that frail patients (CFS ≥5) were vulnerable to adverse outcomes and longer hospital stays and should be reviewed by a geriatrician2. The 2021 National Emergency Laparotomy Audit (NELA) found that only 27% were reviewed by a geriatrician1. Local problem A local hospital had no routine geriatrician input to perioperative care of older people admitted under the care of general surgeons.

Method/Intervention

In one month prior to intervention, we noted CFS recorded once and a geriatrician involved in only 3 patients over the age of 65 (n = 35). We introduced a service comprising twice-weekly geriatrician-led multi-disciplinary team (MDT) meetings of all-age patients followed by selected patient ward rounds. This equated to 2.5 Programmed Activity’s (PA) per week. After another month we measured the number of patients having CFS recorded, those who had geriatrician involvement and length of stay. We also surveyed members of the MDT.

Results

All 31 patients aged over 65 received geriatrician input with 93.5% having a CFS recorded. Length of stay of all-age patients (n = 75) was reduced from 12.8 to 8.8 days, with the most significant reduction of 6.5 days in over 65’s (16.7 to 10.2); >200 bed days saved for older people. The MDT comments included: ‘improved MDT communication’, ‘early identification of discharge barriers’ and ‘pro-active approach’.

Conclusion

NELA highlights that consistent geriatrician input remains generally poor. Even a limited geriatrician-led service can be highly effective at guaranteeing review of appropriate patients in line with recommendations from NELA. Alongside targeted patient review geriatricians can support and lead decision making of all-age patients. This cost-effective strategy can reduce length of stay for young and old alike and gained excellent feedback from the MDT.

POS1361 THE CANADIAN RESEARCH GROUP OF RHEUMATOLOGY IN IMMUNO-ONCOLOGY (CanRIO): A NATIONWIDE MULTI-CENTER PROSPECTIVE COHORT

Background

Immune Checkpoint Inhibitors (ICI) have altered the landscape of cancer therapy. However, toxicities are common and up to 80% of patients will develop immune-related adverse events (irAE), including rheumatic irAEs (Rh-irAE), which can often limit their cancer treatment. Our knowledge of clinical manifestations and optimal management of patients with Rh-irAE continues to evolve as these agents are being used to treat a wider variety of cancers. Currently available data is limited to retrospective case series and case reports. There is also scarce data on the use of ICI in patients with pre-existing autoimmune disease (PAD) as these patients are often excluded from clinical trials.

Objectives

To describe the clinical presentation, management and early outcomes of patients exposed to ICI with Rh-irAE or PAD recruited and followed prospectively from multiple sites across Canada.

Methods

Adult patients with Rh-irAE from cancer immunotherapy (CTLA-4, PD-1 or PDL-1 inhibitors) or those with PAD exposed to cancer immunotherapy are prospectively recruited across 9 academic sites in Canada. Standardized clinical and biologic data are also collected. We describe clinical characteristics and management of patients recruited between January 2020 and October 2021, stratified based on the presence or absence of PAD.

Results

103 patients were recruited from 9 sites. From those, 85 had Rh-irAE, 47 had pre-existing musculoskeletal and rheumatic diseases, and 20 had other PAD. The most frequent Rh-irAE were joint manifestations (n = 73). Other Rh-irAE included muscle symptoms (n = 7), connective tissue disease (n = 6), vasculitis (n=2) and sarcoid (n = 3). Prednisone was the most common treatment (n = 53). Intraarticular corticosteroids were used in 7 patients. Eleven patients required conventional synthetic disease-modifying anti-rheumatic drugs (DMARD) and only one required biologic DMARD to control the Rh-irAE. Anti-PD-1 therapies were the most used ICI (56.3%), followed by combination therapy (35.9%). Response to index immunotherapy at 6 months was available for 21 patients. Most patients had partial response (57.1%) and only 4 patients had tumor progression (19.1%). The ICI was permanently discontinued due to an irAE in 21 patients (38.1% with PAD and 61.9% without PAD). There were no deaths related to Rh-irAE.

Conclusion

The initial sample of the CanRIO prospective national cohort suggests that demographic characteristics and tumor representation in people with PAD and without PAD is similar. Patients with PAD are less likely to receive combination therapy (n= 12 vs. n=25) and are less likely to have tumor progression on ICI (n=1) compared to those without PAD (n=3). Selection bias is noted in this initial sample since half of recruited patients have PAD. The CanRIO cohort provides valuable insight into real-world spectrum and management of Rh-irAE secondary to immunotherapy for cancer.

Disclosure of Interests

Shahin Jamal Grant/research support from: CanRIO has received financial support from BMS and Organon, Lourdes Gonzalez Arreola: None declared, Julia Tan: None declared, Carrie Ye: None declared, Janet Roberts: None declared, Aurore Fifi-Mah: None declared, Marie Hudson: None declared, Sabrina Hoa: None declared, Janet Pope: None declared, Ines Colmegna: None declared, C. Thomas Appleton: None declared

702 COMMUNICATION CHALLENGES BETWEEN DOCTORS & RELATIVES DURING THE COVID-19 PANDEMIC: SIMPLE INTERVENTIONS WITH MEANINGFUL IMPACT

Background

& Aims Visiting restrictions during the COVID-19 pandemic resulted in reduced and inconsistent communication with the next-of-kin of elderly inpatients. This project aimed to improve communication between doctors and patients’ relatives in accordance with the GMC Good Medical Practice guidelines which outline that doctors ‘must be considerate to those close to the patient and be sensitive and responsive in giving them information and support’.

Methods

We created a virtual whiteboard on an elderly care ward in an inner London hospital documenting patient demographics, details of named next-of-kin and when they had been contacted. We aimed to update next-of-kin within 48-hours of ward admission and subsequently twice weekly. The outcome was measured via identical ‘pre- and post-intervention’ questionnaires recording the next-of-kin’s satisfaction with communication from the doctors. Questionnaires included 11 questions utilising a 5-point Likert scale for satisfaction. Results were anonymised and analysed using Microsoft Excel.

Results

Satisfaction with communication improved in 10 of the 11 domains of the questionnaire following intervention. Cumulative satisfaction scores post-intervention (N = 13) in comparison to pre-intervention (N = 25) were closer to the total possible satisfaction score per question for these 10 domains. The mean cumulative satisfaction score across all domains was 60% post-intervention compared with 44% pre-intervention. Satisfaction following intervention was particularly improved in the domains of frequency of communication (60% post-intervention.

32.8% pre-intervention) and how adequately questions and concerns were addressed (69.2% post-intervention; 45.6% pre-intervention).

Conclusion

During the COVID-19 pandemic healthcare professionals have had to adapt in communicating with patients’ next-of-kin. Our Introduction of robust standards and a virtual whiteboard to track communication resulted in improved satisfaction and proved useful in adapting to remote communication. We propose that similar practice and standards are extended across additional wards to encourage widespread optimal and consistent communication between doctors and patients’ relatives, an integral part of patient care.

OP0018 PREDICTING RESPONSES TO ANTI-TNF TREATMENTS IN RHEUMATOID ARTHRITIS PATIENTS FROM GENETIC AND CLINICAL DATA USING A MACHINE LEARNING APPROACH

Background:

Tumor necrosis factor (TNF) inhibitors are key therapies in rheumatoid arthritis (RA). However, a third of patients fail to respond to these agents, and there are no reliable predictors for response. Predictive models, potentially based on clinical and genomic data, are vital to personalizing therapy. The Dialogue for Reverse Engineering Assessments and Methods (DREAM) RA Responder Challenge invited research teams to create models for patient response to anti-TNF therapy. The winning model relied heavily on limited genetic input and was unable to correctly predict responses in a large number of individuals.

Objectives:

We compared non-linear and linear analytic methods to predict response and non-response to anti-TNF treatment for RA patients in the DREAM database, using moth clinical variables and a large number of potential genome-wide predictors.

Methods:

DREAM data on anti-TNF treated RA patients were accessed through Synapse (synapse.sagebase.org). Analogously to the DREAM challenge, we were provided with the clinical and genomic data of 2706 patients with at least moderate disease activity according to their composite disease activity scores for 28 joints (DAS28). In contrast to the previous analysis that focused on single nucleotide polymorphisms (SNPs) based on existing knowledge of RA, we used the full genome-wide dataset of 2.5 million SNPs. We first reduced this to 284 SNPs by considering the marginal p-value of 0.001 for each SNP based on whether or not it predicted response. Then, we removed SNPs with borderline significant p-values if they were in linkage disequilibrium with the most significant SNPs. Instead of predicting a binary outcome of responder or non-responder, we trained both linear (e.g. least absolute shrinkage and selection operator, or LASSO) and non-linear models (e.g. Random Forest) to predict a continuous outcome, the change in DAS28 from baseline to 3-12 months after initiation of anti-TNF therapy. We split the patients into training (N=2031) and testing (N=675) subsets and used the predicted response scores to evaluate the true binary response labels for the test patients.

Results:

The best performing method was Random Forest (RF), a non-linear model that uses decision trees to progressively separate subjects into groups based on the most predictive features. Support Vector Regression (SVR) also out-performed linear methods. Compared to only clinical covariates such as age and sex, adding SNPs improved the prediction from an area under the receiver operating curve (AUROC) of 0.63 to 0.67, i.e., 0.04 improvement. This AUROC of 0.67 was 0.046 greater than the DREAM challenge winner.

Conclusion:

Non-linear methods such as RF and SVR gave larger predictive improvements compared to linear methods. This may imply some interaction between SNPs and clinical covariatesas potential predictors of response to anti-TNF therapy in RA. We are further investigating these 284 SNPs and their interactions in this regard.

References:

[1]Guan, Y., Zhang, H., Quang, D., Wang, Z., Parker, S., Pappas, D. A., Kremer, J. M., & Zhu, F. (2019). Machine Learning to Predict Anti-Tumor Necrosis Factor Drug Responses of Rheumatoid Arthritis Patients by Integrating Clinical and Genetic Markers. Arthritis & rheumatology (Hoboken, N.J.), 71(12), 1987–1996. https://doi.org/10.1002/art.41056

[2]Sieberts, S. K., Zhu, F., García-García, J., Stahl, E., Pratap, A., Pandey, G., Pappas, D., Aguilar, D., Anton, B., Bonet, J., Eksi, R., Fornés, O., Guney, E., Li, H., Marín, M. A., Panwar, B., Planas-Iglesias, J., Poglayen, D., Cui, J., Falcao, A. O., … Mangravite, L. M. (2016). Crowdsourced assessment of common genetic contribution to predicting anti-TNF treatment response in rheumatoid arthritis. Nature communications, 7, 12460. https://doi.org/10.1038/ncomms12460

Figure.

Disclosure of Interests:

None declared

POS1268 COVID-19 VACCINE HESITANCY AMONG RHEUMATOLOGY PATIENTS RECEIVING INFLUENZA VACCINE

Background:

Adults with rheumatic diseases are a COVID-19 vulnerable population with potential increased risk for severe infection. COVID-19 vaccines are a key strategy to ending the pandemic. Unfortunately, fears about vaccines, some of which are propagated by misinformation, are common and may prevent or inappropriately delay vaccination. Refusal or uncertainty to get a vaccine despite its availability is known as vaccine hesitancy.

Objectives:

This study aims at defining causes of COVID-19 vaccine hesitancy among rheumatology patients.

Methods:

Between November and December 2020, a cross-sectional survey was completed by rheumatology patients presenting to a large Canadian tertiary-care center for influenza immunization. COVID-19 risk factors, previous COVID-19 infection, the likelihood of getting a future COVID-19 vaccine (scale 0-10), and contextual, individual, and vaccine-specific potential determinants of vaccine hesitancy were assessed. Patients were classified into 5 groups based on how likely they were to get a future COVID-19 vaccine (0= not likely at all; 2.5= unlikely; 5= intermediate; 7.5= likely; 10= highly likely). A machine learning approach (XgBoost) was used to fit univariate models for a multi-class correlation.

Results:

157 rheumatology patients completed the survey. Most were females (n=112, 71%) with a mean age of 54.6 (standard deviation 17.9). The majority (73%) had tertiary-education, and 46% were employed at the time of the survey. The most common rheumatology diagnoses were rheumatoid arthritis (n=90, 58%), systemic lupus erythematosus/vasculitis (n=41, 26%) and spondyloarthropathies (n=39, 25%). Most patients were on immunosuppressors (n=93, 59%). Only half (n=85, 54%) were highly likely to accept a future COVID vaccine, 17% (n=26) likely, 19% (n=30) intermediate, 6% (n=10) unlikely, and 4% (n=6) not likely at all. One hundred thirty-five patients (86%) previously received the flu vaccine, whereas 6% (n=10) previously rejected it. Only three patients were previously diagnosed with COVID-19 (2%) one of whom was hospitalized. Eighty-seven patients (56%) considered that the COVID-19 vaccine should be mandatory, and 101 (65%) that they should receive it. Most respondents were somewhat concerned about receiving a future COVID-19 vaccine (n=116, 76%) despite that 65% believed that vaccines benefits outweighed their risks. Almost all, (n=145, 96%) believed that governmental decisions about vaccines are in the best interest of the population, while less than half (n=70, 45%) were confident that pharmaceutical companies would provide safe and effective vaccines. One hundred participants (65%) denied feeling social pressure to get the vaccine, and 55% (n=81) were willing to pay for the vaccine. Feeling social pressure about getting a COVID-19 vaccine, having severe concerns about receiving a future COVID-19 vaccine, distrust in pharmaceutical companies, lower education, and doubts of whether vaccines benefits outweigh their risks, were negatively associated with COVID vaccine acceptance.

Conclusion:

Forty six percent of rheumatology patients being immunized against influenza showed at least some hesitancy towards COVID-19 vaccination. Multiple contextual, individual, and vaccine-related factors may contribute. Targeted educational strategies, including producing and communicating data on vaccine safety, may help promote vaccine uptake in this potentially vulnerable population.

Disclosure of Interests:

None declared

Risk factors and impact of early anastomotic biliary complications after liver transplantation: UK registry analysis

Background

Biliary leaks and anastomotic strictures are common early anastomotic biliary complications (EABCs) following liver transplantation. However, there are no large multicentre studies investigating their clinical impact or risk factors. This study aimed to define the incidence, risk factors and impact of EABC.

Methods

The NHS registry on adult liver transplantation between 2006 and 2017 was reviewed retrospectively. Adjusted regression models were used to assess predictors of EABC, and their impact on outcomes.

Results

Analyses included 8304 liver transplant recipients. Patients with EABC (9·6 per cent) had prolonged hospitalization (23 versus 15 days; P < 0·001) and increased chance for readmission within the first year (56 versus 32 per cent; P < 0·001). Patients with EABC had decreased estimated 5-year graft survival of 75·1 versus 84·5 per cent in those without EABC, and decreased 5-year patient survival of 76·9 versus 83·3 per cent; both P < 0.001. Adjusted Cox regression revealed that EABCs have a significant and independent impact on graft survival (leak hazard ratio (HR) 1·344, P = 0·015; stricture HR 1·513, P = 0·002; leak plus stricture HR 1·526, P = 0·036) and patient survival (leak HR 1·215, P = 0·136, stricture HR 1·526, P = 0·001; leak plus stricture HR 1·509; P = 0·043). On adjusted logistic regression, risk factors for EABC included donation after circulatory death grafts, graft aberrant arterial anatomy, biliary anastomosis type, vascular anastomosis time and recipient model of end-stage liver disease.

Conclusion

EABCs prolong hospital stay, increase readmission rates and are independent risk factors for graft loss and increased mortality. This study has identified factors that increase the likelihood of EABC occurrence; research into interventions to prevent EABCs in these at-risk groups is vital to improve liver transplantation outcomes.

Scale of emotional development-short: Reliability and validity in two samples of children with an intellectual disability

BACKGROUND

Intellectual disability (ID) is often accompanied by more significant delays in emotional development than in cognitive development. Diagnostic assessment can provide insight into emotional functioning. However, few standardized assessment instruments are available.

AIMS

Examine the reliability and validity of the Scale of Emotional Development-Short (SED-S) in children with ID.

METHODS AND PROCEDURES

This methodological instrument validation study was conducted in the Netherlands and Switzerland with children (N = 118) older than 3 and younger than 18 years with ID ranging from profound to mild. Measures included: demographic and medical data, SED-S, and the Vineland. Coherence and reliability of the SED-S were determined using Cronbach's alpha, and validity was examined using Goodman and Kruskal's γ, Kruskal-Wallis H, and Mann-Whitney U tests.

OUTCOMES AND RESULTS

The reliability of the SED-S was high, the convergent validity was good, and divergent validity was indicated in relation to autism spectrum disorder (ASD), visual and/or auditory impairment, and adaptive functioning.

FURTHER RESEARCH

Research is needed to better understand the implications of ASD and visual and/or auditory impairment on emotional development and their association with (normal) intelligence. Children with ID may also benefit from (more) detailed guidelines for imbalanced profiles on the SED-S.

FRI0106 RISK FACTORS FOR SERIOUS INFECTIONS IN PATIENTS WITH RA INITIATING TREATMENT WITH BIOLOGIC DMARDS: A REAL-WORLD POPULATION-BASED OBSERVATIONAL STUDY

Background:

Patients with RA are at increased risk of infection compared with the general population, but it is unclear whether this is due to the underlying disease or to immunosuppressive medications used to manage the disease.1Some biologic DMARDs (bDMARDs) have been associated with an increased risk of serious infection.2A large cohort study found no increased risk of serious infection in patients initiating abatacept compared with patients initiating other bDMARDs.3It is clinically important to identify which patients are at a higher risk of infections at the time of initiating treatment with a bDMARD. However, studies that assess risk factors for infection and derive corresponding risk scores of infection, especially at the time of bDMARD treatment initiation, are lacking or based on too few patients.4

Objectives:

To identify the risk factors for serious infections among patients with RA initiating treatment with a bDMARD in a real-world observational setting.

Methods:

The Truven MarketScan®Commercial and Supplemental Medicare databases were used to identify patients diagnosed with RA who initiated treatment with a bDMARD between January 2007 and December 2015. Patients were followed from treatment initiation until the occurrence of a serious infection requiring hospitalisation, the end of enrolment or 31 December 2015, whichever came first. The Cox proportional hazards model was used to estimate the hazard ratios (HRs) of serious infection associated with baseline risk factors including demographics, the presence of co-morbidities, prior hospitalised infections and medications. An infection risk score was developed using the independent risk factors found to be significant in the model.

Results:

The study cohort included 84,308 patients initiating treatment with a bDMARD, mainly etanercept (36.7%), adalimumab (29.3%), infliximab (12.4%), rituximab (7.3%) and abatacept (6.8%). During a mean follow-up of 6.6 months, 1724 patients were hospitalised for a serious infection (incidence rate 3.7/100 persons per year). The baseline risk factors significantly and independently associated with serious infections were age, prior hospitalisation for infection, hypertension, diabetes, lymphoma, asthma, chronic obstructive pulmonary disease, cardiovascular disease, other autoimmune disease, corticosteroid use and antibiotic use. The infection risk score, with a possible range of 0 to 15, had a mean (SD) value of 2.6 (1.9) with range 0–12.5. The HR (95% CI) of serious infection was 1.43 (1.40–1.45) for every unit increase in the risk score. Relative to patients with a score of 0, the HR (95% CI) of serious infection for a risk score of 5 was 5.9 (5.3–6.5), and for a risk score of 10 was 34.5 (28.5–41.6).

Conclusion:

In this large, real-world cohort of patients with RA who were initiating treatment with a bDMARD, several patient characteristics were found to independently predict the subsequent risk of serious infection. The risk score, based on easily available patient characteristics, can be a simple and useful tool for the clinician to identify patients at higher risk of infection at the time of bDMARD initiation for the treatment of RA.

References:

[1]Doran MF, et al.Arthritis Rheum2002;46:2287–93.

[2]Singh JA.Curr Rheumatol Rep2016;18:61.

[3]Montastruc F, et al.Semin Arthritis Rheum2019;48:1053–8.

[4]Jani M, et al.Curr Opin Rheumatol2019;31:285–92.

Acknowledgments:

Joanna Wright (editorial assistance, Caudex; funding: Bristol-Myers Squibb).

Disclosure of Interests:

Samy Suissa Grant/research support from: AstraZeneca, Bayer, Boehringer Ingelheim, Bristol-Myers Squibb, Novartis, Consultant of: AstraZeneca, Bayer, Boehringer Ingelheim, Bristol-Myers Squibb, Novartis (advisory board meetings), Speakers bureau: AstraZeneca, Bayer, Boehringer Ingelheim, Bristol-Myers Squibb, Novartis, Paul Brassard: None declared, Alyssa L. Dominique Shareholder of: Bristol-Myers Squibb, Employee of: Bristol-Myers Squibb, Teresa Simon Shareholder of: Bristol-Myers Squibb, Employee of: Bristol-Myers Squibb, Marie Hudson: None declared

An evidence-based strategy to screen for pulmonary arterial hypertension in systemic sclerosis

BACKGROUND

Clinical practice guidelines recommend screening all systemic sclerosis (SSc) patients for pulmonary arterial hypertension (PAH) with yearly echocardiograms. There is a paucity of evidence to support these guidelines.

RESEARCH QUESTION

Can a prediction model identify SSc patients with a very low probability of PAH and therefore not requiring annual screening echocardiogram?

STUDY DESIGN AND METHODS

We performed a case-control study of 925 unselected SSc subjects nested in a multi-centered, longitudinal cohort. The probability of PAH for each subject was calculated using the results of multivariate logistic regression models. A cut-off was identified for the estimated probability of PAH below which no subject developed PAH (100% sensitivity).

RESULTS

Study subjects were predominantly female (87.5%), with mean (SD) age 58.6 (11.7) years and disease duration of 18.2 (12.2) years. Thirty-seven subjects developed PAH during 5407.97 person-years of observation (incidence rate 0.68 per 100 person-years). Shortness of breath (SOB), diffusing capacity for carbon monoxide (DLCO) and NT-proBNP were independent predictors of PAH. All SSc-PAH cases had a probability of PAH of >1.1%. Subjects below this cut-off, none of whom had PAH, accounted for 46.2% of the study population.

INTERPRETATION

A simple prediction model identified subjects at very low probability of PAH who could potentially forego annual screening echocardiogram. This represents almost half of SSc subjects in a general SSc population. This study, which is the first evidence-based study for the rational use of follow-up echocardiograms in an unselected SSc cohort, requires validation. The scoring system is freely available online at http://pahtool.ladydavis.ca.

On the relevance of cocaine detection in a fingerprint

The finding that drugs and metabolites can be detected from fingerprints is of potential relevance to forensic science and as well as toxicology and clinical testing. However, discriminating between dermal contact and ingestion of drugs has never been verified experimentally. The inability to interpret the result of finding a drug or metabolite in a fingerprint has prevented widespread adoption of fingerprints in drug testing and limits the probative value of detecting drugs in fingermarks. A commonly held belief is that the detection of metabolites of drugs of abuse in fingerprints can be used to confirm a drug has been ingested. However, we show here that cocaine and its primary metabolite, benzoylecgonine, can be detected in fingerprints of non-drug users after contact with cocaine. Additionally, cocaine was found to persist above environmental levels for up to 48 hours after contact. Therefore the detection of cocaine and benzoylecgonine (BZE) in fingermarks can be forensically significant, but do not demonstrate that a person has ingested the substance. In contrast, the data here shows that a drug test from a fingerprint (where hands can be washed prior to donating a sample) CAN distinguish between contact and ingestion of cocaine. If hands were washed prior to giving a fingerprint, BZE was detected only after the administration of cocaine. Therefore BZE can be used to distinguish cocaine contact from cocaine ingestion, provided donors wash their hands prior to sampling. A test based on the detection of BZE in at least one of two donated fingerprint samples has accuracy 95%, sensitivity 90% and specificity of 100% (n = 86).

NCEPOD and alcohol-related liver disease, what are the views of those who deliver the service? A survey of consultants and trainees in North Eastern England

BACKGROUND

National Confidential Enquiry into Patient Outcome and Death (NCEPOD) 'Measuring the Units' (June 2013) identified significant organisational and attitudinal deficits in hospital care of patients with alcohol-related liver disease (ARLD), care being recognised as good in less than 50% of patients.

METHOD

We surveyed over 700 consultants and trainees in acute medical and intensive therapy specialties to examine their perceptions of the NCEPOD findings.

RESULTS

A total of 178 responded. In keeping with the NCEPOD findings, their perception was of lack of 24-hour access to specialty advice for patients with liver disease and inequity of access to high-dependency units. Their explanations include lack of resources, therapeutic nihilism and prejudicial judgements that would not be made of other patient groups.

CONCLUSION

There is an urgent need for robust mechanisms to ensure equity of access to specialist liver advice and intensive therapy unit resources, and to counter negative and prejudicial attitudes to these patients.

Mammalian target of rapamycin is activated in the kidneys of patients with scleroderma renal crisis

Objectives:

Scleroderma renal crisis is a rare but serious complication affecting 2%–15% of patients with systemic sclerosis. Despite treatment with angiotensin-converting enzyme inhibitors, outcomes for scleroderma renal crisis patients are still poor. The cellular signaling mechanisms in scleroderma renal crisis are not yet known. Mammalian target of rapamycin, comprised of the subunits mTORC1 and mTORC2, has been shown to be activated in vascular lesions of renal transplant patients with anti-phospholipid antibody syndrome. Given the similarities between the pathophysiology of scleroderma renal crisis and anti-phospholipid antibody syndrome, we hypothesized that the mammalian target of rapamycin pathway would also be activated in the renal vasculature of patients with scleroderma renal crisis.

Methods:

We retrospectively analyzed renal biopsies of five patients with scleroderma renal crisis in the Canadian Scleroderma Research Group cohort. Immunostaining was performed using anti-P-S6RP antibodies to evaluate the phosphorylation of mTORC1, and anti-Rictor and anti-S473 to determine activation of mTORC2.

Results:

Four of the five patients showed mTORC1 activation in arteriolar endothelial cells, and three of the five patients showed mTORC1 activation in the arterial endothelial cells. Two of four samples showed Rictor expression in the arteriolar and arterial endothelial cells, showing mTORC2 activation. There was no expression of mTORC1 or mTORC2 in samples from two healthy controls.

Conclusion:

We demonstrate that both mTORC1 and mTORC2 are activated in renal biopsies with typical histologic features of scleroderma renal crisis. Dual mammalian target of rapamycin inhibitors are currently available and in development. These findings could inform further research into novel treatment targets for scleroderma renal crisis.

Identical and Nonidentical Twins: Risk and Factors Involved in Development of Islet Autoimmunity and Type 1 Diabetes

OBJECTIVE

There are variable reports of risk of concordance for progression to islet autoantibodies and type 1 diabetes in identical twins after one twin is diagnosed. We examined development of positive autoantibodies and type 1 diabetes and the effects of genetic factors and common environment on autoantibody positivity in identical twins, nonidentical twins, and full siblings.

RESEARCH DESIGN AND METHODS

Subjects from the TrialNet Pathway to Prevention Study (N = 48,026) were screened from 2004 to 2015 for islet autoantibodies (GAD antibody [GADA], insulinoma-associated antigen 2 [IA-2A], and autoantibodies against insulin [IAA]). Of these subjects, 17,226 (157 identical twins, 283 nonidentical twins, and 16,786 full siblings) were followed for autoantibody positivity or type 1 diabetes for a median of 2.1 years.

RESULTS

At screening, identical twins were more likely to have positive GADA, IA-2A, and IAA than nonidentical twins or full siblings (all P < 0.0001). Younger age, male sex, and genetic factors were significant factors for expression of IA-2A, IAA, one or more positive autoantibodies, and two or more positive autoantibodies (all P ≤ 0.03). Initially autoantibody-positive identical twins had a 69% risk of diabetes by 3 years compared with 1.5% for initially autoantibody-negative identical twins. In nonidentical twins, type 1 diabetes risk by 3 years was 72% for initially multiple autoantibody-positive, 13% for single autoantibody-positive, and 0% for initially autoantibody-negative nonidentical twins. Full siblings had a 3-year type 1 diabetes risk of 47% for multiple autoantibody-positive, 12% for single autoantibody-positive, and 0.5% for initially autoantibody-negative subjects.

CONCLUSIONS

Risk of type 1 diabetes at 3 years is high for initially multiple and single autoantibody-positive identical twins and multiple autoantibody-positive nonidentical twins. Genetic predisposition, age, and male sex are significant risk factors for development of positive autoantibodies in twins.

Implementation of a 'care bundle' improves the management of patients admitted to hospital with decompensated cirrhosis

BACKGROUND

Since 1970, there has been a 400% increase in liver-related deaths due to the increasing prevalence of chronic liver disease in the United Kingdom (UK). The 2013 UK National Confidential Enquiry into Patient Outcome and Death report found that only 47% of patients who died from alcohol-related liver disease received 'good care' during their hospital stay.

AIM

To develop a 'care bundle' for patients with decompensated cirrhosis, aiming to ensure that evidence-based treatments are delivered within the first 24 h of hospital admission.

METHODS

This work gives practical advice about how to implement the bundle and examines its effects on patient care at three National Health Service Hospital Trusts in the UK by collecting data on patient care before and after introduction of the bundle.

RESULTS

Data were collected on 228 patients across three centres (59% male, median age 53 years). Alcohol-related liver disease was the aetiology of chronic liver disease in 85% of patients. The overall mortality rate during hospital admission was 15%. The audits demonstrated improvements in patient care for patients with a completed care bundle who were significantly more likely to have a diagnostic ascitic performed within the first 24 h (P = 0.020), have an accurate alcohol history documented (P < 0.0001) and be given antibiotics as prophylaxis against infection following a variceal haemorrhage (P = 0.0096). In Newcastle, the bundle completion rate increased from 25% to 90% during the review periods.

CONCLUSIONS

The introduction of a care bundle was associated with increased rates of diagnostic paracentesis and antibiotic prophylaxis with variceal haemorrhage in patients with decompensated cirrhosis.

Single-specificity anti-Ku antibodies in an international cohort of 2140 systemic sclerosis subjects: clinical associations

Autoantibodies directed against the Ku autoantigen are present in systemic sclerosis (SSc) and have been associated with myositis overlap and interstitial lung disease (ILD). However, there is a paucity of data on the clinical correlates of anti-Ku antibodies in the absence of other SSc-specific antibodies. The aim of this study was to assess the clinical correlates of single-specificity anti-Ku in SSc.An international (Canada, Australia, USA, Mexico) cohort of 2140 SSc subjects was formed, demographic and clinical variables were harmonized, and sera were tested for anti-Ku using a line immunoassay. Associations between single-specificity anti-Ku antibodies (i.e., in isolation of other SSc-specific antibodies) and outcomes of interest, including myositis, ILD, and survival, were investigated.Twenty-four (1.1%) subjects had antibodies against Ku, and 13 (0.6%) had single-specificity anti-Ku antibodies. Subjects with single-specificity anti-Ku antibodies were more likely to have ILD (58% vs 34%), and to have increased creatine kinase levels (>3× normal) at baseline (11% vs 1%) and during follow-up (10% vs 2%). No difference in survival was noted in subjects with and without single-specificity anti-Ku antibodies.This is the largest cohort to date focusing on the prevalence and disease characteristics of single-specificity anti-Ku antibodies in subjects with SSc. These results need to be interpreted with caution in light of the small sample. International collaboration is key to understanding the clinical correlates of uncommon serological profiles in SSc.

Sex and time to diagnosis in systemic sclerosis: an updated analysis of 1,129 patients from the Canadian scleroderma research group registry

OBJECTIVES

A previous study found that time to diagnosis was significantly longer from onset of Raynaud's phenomenon for women compared to men with diffuse systemic sclerosis (SSc) and that, in limited SSc, it was more than twice as long for women than men. That study was limited, however, by the small number of men in disease subtype subgroups. The objective of the present study was to investigate the association of sex with time to diagnosis of SSc using a substantially larger patient sample.

METHODS

Association between sex and time to diagnosis was assessed overall and stratified based on diffuse versus limited disease using Kaplan-Meier curves and Cox proportional hazards models.

RESULTS

There were 1,129 patients in the study (median age=56.0 years; 978 [86.6%] women). Time to diagnosis was significantly longer for women (median=1.1 years) than men (median 0.8= years; p=0.037) with diffuse SSc following onset of Raynaud's phenomenon. There were no significant or substantive sex differences in time to diagnosis after Raynaud's onset in limited SSc or from onset of first non-Raynaud's disease manifestation in diffuse or limited SSc.

CONCLUSIONS

Time to diagnosis was significantly longer for women compared to men with diffuse SSc following onset of Raynaud's phenomenon, but the difference was small and unlikely to be clinically significant. There were no differences in time to diagnosis following Raynaud's onset in limited disease or following onset of first non-Raynaud's disease manifestation in diffuse or limited disease. Overall, sex does not appear to influence time to diagnosis meaningfully.

Prevalence and clinical profiles of 'autoantibody-negative' systemic sclerosis subjects

OBJECTIVES

To determine the prevalence of autoantibody negative systemic sclerosis (SSc) and to identify the clinical correlates thereof.

METHODS

Clinical data and sera from 874 SSc subjects were collected and autoantibodies were tested in a central laboratory using 1) indirect immunofluorescence (IIF), 2) commercially available ELISA, addressable laser bead immunoassay (ALBIA), and line immunoassay (LIA), and 3) a sensitive immunoprecipitation (IP) assay.

RESULTS

Fifteen (15; 1.7%) subjects were autoantibody negative by IIF, ELISA, ALBIA, LIA and IP, and 16 (1.8%) were antinuclear antibody (ANA) positive by IIF but otherwise negative by ELISA, ALBIA, LIA and IP. Thirty-seven (37; 4.2%) were ANA positive by IIF, autoantibody negative by commercially available immunoassays, but had autoantibodies identified by IP (including Th/To in 20). Autoantibody-negative subjects had generally less severe disease than positive subjects.

CONCLUSIONS

Autoantibody-negative SSc is rare (<2%) and appears to be associated with a favourable prognosis.

Abstract P6-08-04: Prognostic significance of quality-of-life scores in early stage and relapsed breast cancer: Results from seven randomized trials of the International breast cancer study group

We performed an individual patient meta-analysis to investigate the prognostic value of patient self-reported quality-of-life (QL) scores at baseline, and at several times prior to and following disease relapse on subsequent overall survival (OS) in seven randomized trials of the International Breast Cancer Study Group.

Patients with early stage breast cancer who participated in randomized trials that compared adjuvant therapies, and who had subsequent disease relapse, completed QL assessments for physical well-being, mood, appetite, nausea and vomiting, arm swelling, flushing, coping effort, and utility at study entry, prior to and after disease relapse. We tested the relationships between baseline QL scores and OS using Cox regression analyses. We performed landmark analyses to assess the relationships between pre-relapse QL scores with OS using QL assessments at 1, 2 and 3 months prior to disease relapse, at the time of relapse and at two subsequent QL assessments where these were available. All Cox models were stratified by trial and included other factors related to QL and/or outcome.

Among 8,024 patients, 3,834 (48%) had disease relapse after a median follow-up time of 12 years. Amongst these patients, QL score at baseline, and at 1, 2, and 3 months prior disease relapse were not significantly prognostic for OS. At disease relapse, scores for physical well-being (hazards ratio [HR] per 10 unit increase of QL score for death, 1.05; P = 0.003), mood (HR 1.05; P = 0.007), appetite (HR 1.08; P&lt;0.001), and utility (HR 1.13; P = 0.008) were prognostic for subsequent OS. Nausea and vomiting (HR 1.05; P = 0.11), arm swelling (HR 1.00; P = 0.20), flushing (HR 1.01; P = 0.73), and coping effort (HR 1.02; P = 0.29) were not prognostic for subsequent OS. At post-relapse assessments at median times of 1 (HR 1.07; P&lt;0.001), 6 (HR 1.08; P&lt;0.001) and 10 months (HR 1.13; P&lt;0.001) after disease relapse, scores for physical well-being showed increasing prognostic significance. Scores for mood, nausea and vomiting, appetite, coping effort and utility showed patterns similar to those for physical wellbeing, but scores for arm swelling and flushing were not prognostic for subsequent OS.

These findings confirm and extend those of Coates et al. (J Clin Oncol 2000;18:3768 - 3774) based on two of the trials included in the present analysis. At baseline and prior to relapse, QL scores did not have any prognostic significance for subsequent OS. At and after disease relapse, QL scores substantially predicted for subsequent OS, with stronger association for QL scores later in the course of relapsed disease. Patient perception of the severity of underlying illness after relapse might be a potential reason that determines the reported QL scores and thus contributes to their prognostic significance.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P6-08-04.

The frequency of and associations with hospitalization secondary to lupus flares from the 1000 Faces of Lupus Canadian cohort

Objectives

Hospitalization is a major factor in health care costs and a surrogate for worse outcomes in chronic disease. The aim of this study was to determine the frequency of hospitalization secondary to lupus flare, the causes of hospitalization, and to determine risk factors for hospitalization in patients with systemic lupus erythematosus (SLE).

Methods

Data were collected as part of the 1000 Canadian Faces of Lupus, a prospective cohort study, where annual major lupus flares including hospitalizations were recorded over a 3-year period.

Results

Of 665 patients with available hospitalization histories, 68 reported hospitalization related to a SLE flare over 3 years of follow-up. The average annual hospitalization rate was 7.6% (range 6.6–8.9%). The most common reasons for hospitalization were: hematologic (22.1%), serositis (20.6%), musculoskeletal (MSK) (16.2%), and renal (14.7%). Univariate risk factors for lupus hospitalization included (OR [95% CI]; p < 0.05): juvenile-onset lupus (2.2 [1.1–4.7]), number of ACR SLE criteria (1.4 [1.1–1.7], baseline body mass index (BMI) (1.1 [1.0–1.1]), psychosis (3.4 [1.2–9.9]), aboriginal race (3.2 [1.5–6.7]), anti-Smith (2.6 [1.2–5.4]), erythrocyte sedimentation rate >25 mm/hr (1.9 [1.1–3.4]), proteinuria >0.5 g/d (4.2 [1.9–9.3], and SLAM-2 score (1.1 [1.0–1.2]). After multivariate regression only BMI, number of ACR criteria, and psychosis were associated with hospitalization for lupus flare.

Conclusions

The mean annual rate of hospitalization attributed to lupus was lower than expected. Hematologic, serositis, MSK and renal were the most common reasons. In a regression model elevated BMI, more ACR criteria and psychosis were associated with hospitalization.

Targeted case finding for hepatitis B using dry blood spot testing in the British-Chinese and South Asian populations of the North-East of England

Chronic infection with the hepatitis B virus (HBV) is a frequent cause of cirrhosis and liver cancer. Targeted HBV screening is recommended by the Centre for Disease Control (CDC) and Prevention for subjects born in countries with >2% HBV prevalence. However, there are no UK guidelines. Here, we applied the (CDC) recommendations to the British-Chinese and British-South Asian community of North-East (NE) England. British-Chinese and South Asian subjects were invited to attend for HBV education and screening sessions held in community centres. Hepatitis B surface antigen (HBsAg) and hepatitis B core total antibody (HBcAb) were tested with dry blood spot tests. South Asians were also tested for hepatitis C antibody (HCVAb). A total of 1126 subjects (606 Chinese and 520 South Asian) were screened. Sixty-two (5.5%) were HBsAg positive. Ten of these reported a previous diagnosis of HBV. The prevalence of HBsAg positivity was 4.6% when previously diagnosed individuals were excluded. The HBsAg prevalence was significantly higher in the Chinese subjects compared with South Asians (8.7% VS. 1.7% P < 0.001). In Chinese subjects, HBsAg positivity was highest in subjects born in Vietnam (17.4%), followed by China (11%), Hong Kong (7.8%) and the UK (6.7%). Subjects from Pakistan had the highest HBsAg and HCV Ab prevalence in the South Asians (3.1% and 1.8%, respectively). Ten percentage of HBsAg positive patients who had follow-up assessment had active disease requiring antiviral treatment. Undiagnosed HBV infection was above the 2% threshold for screening suggested by the CDC in the British-Chinese and Pakistani community of NE England, which provides evidence for a UK HBV-targeted screening programme.