Results from a phase I trial of pembrolizumab plus vorinostat in relapsed/refractory B-cell non-Hodgkin lymphoma

Outcomes after programmed death-1 (PD-1) blockade in B-cell lymphomas are disappointing with few durable responses. Histone deacetylase inhibitors exhibit favorable immunomodulatory effects and demonstrate synergistic anti-tumor immune responses with anti-PD-1 therapy in preclinical models. We, therefore, developed a phase I study to evaluate the safety and preliminary efficacy of pembrolizumab with vorinostat in relapsed/refractory B-cell lymphomas. Patients were treated in a dose-escalation cohort using a Rolling 6 design followed by an expansion cohort at the recommended phase II dose (R2PD). Fifty-two patients were enrolled (32 Hodgkin and 20 non-Hodgkin lymphoma [NHL]). Here, we report safety data from the dose escalation cohort, and the toxicity and efficacy within NHL patients. Vorinostat was administered twice daily on days 1-5 and 8-12 (dose-level [DL]1: 100 mg; DL2: 200 mg) and pembrolizumab (200 mg) was administered on day 1 of each 3-week cycle. Of six patients treated at DL1, one had a dose-limiting toxicity (DLT) (Stevens-Johnson syndrome [SJS]), and one of six had a DLT at DL2 (thromboembolism); therefore, DL2 was the RP2D. The patient developing SJS was treated with corticosteroids, infliximab, and cyclosporine but ultimately died of invasive fungal infection from the extensive immunosuppression used to treat the SJS. The most common adverse events were hypertension, diarrhea, and cytopenias. Of 20 NHL patients, nine had follicular lymphoma (FL) and 11 had diffuse large B-cell lymphoma (DLBCL). Five DLBCL patients had primary mediastinal B-cell lymphoma (PMBL). The complete and overall response rates (CR and ORR) were 11% and 22% for FL and 45% and 55% for all DLBCL. Amongst DLBCL, the CR and ORR was 80% and 80% for PMBL and 17% and 33% for non-PMBL. In conclusion, pembrolizumab with vorinostat was tolerable and produced responses in relapsed/refractory B-cell NHL, with particularly notable efficacy in PMBL (clinicaltrials gov. Identifier: NCT03150329).

A step-by-step guide to ileoanal J-pouch MRI interpretation

BACKGROUND

Multidisciplinary management of patients with an ileoanal pouch requires dedicated imaging to identify structural problems of the pouch associated with dysfunction. The purpose of this study is to provide a framework for interpretation of magnetic resonance imaging (MRI) scan of the ileoanal pouch to enable surgeons and radiologists to work cohesively, optimise diagnosis and ultimately improve patient care.

METHODS

We propose a protocol for structured MRI assessment of the ileal pouch, aiming to provide surgeons a systematic report of the anatomy, its variations and pouch complications. This guide consists of studying the characteristics of the bowel, mesentery and anal canal.

RESULTS

The presented checklist is designed to systematically interpret and identify abnormalities of the ileoanal pouch on MRI. It focuses on the characteristics of the bowel (encompassing pre-pouch ileum, pouch and rectal cuff), mesentery and anal canal. The different elements of the checklist are presented in the associated supplementary video.

CONCLUSIONS

A combination of clinical assessment, endoscopic evaluations and imaging is fundamental to achieving accurate diagnosis of ileoanal pouch surgery complications and pouch dysfunction.

Evaluation of a new Perinatal Mental Health Service in a University Maternity Hospital

OBJECTIVES

Specialist Perinatal Mental Health Services (SPMHS) are a new development in Ireland. This service evaluation examined the impact of the introduction of a SPMHS multidisciplinary team (MDT) on prescribing practices and treatment pathways in an Irish maternity hospital.

METHODS

Clinical charts were reviewed to collect data on all referrals, diagnoses, pharmacological and non-pharmacological interventions delivered in a SPMHS over a 3-week period in 2019. The findings were compared to the same 3-week period in 2020 following the expansion of the SPMHS MDT.

RESULTS

In 2019 (n = 32) and 2020 (n = 47), most (75 and 79%, respectively) assessments were antenatal. The proportion of patients prescribed psychotropic medication within the SPMHS was not significantly different from 2019 (31%) to 2020 (23%), though more patients were already prescribed psychotropic medications at the time of referral (22% in 2019 v. 36% in 2020). There was an increase in MDT interventions in 2020 with more input from psychology, clinical nurse specialist (CNS), and social work intervention. Adherence to prescribing standards improved from 2019 to 2020.

CONCLUSION

Prescribing patterns remained unchanged between 2019 and 2020. Improvement was observed in adherence to prescribing standards and there was increased provision of MDT interventions in 2020. Broader diagnostic categories were also used in 2020, possibly suggesting that the service is now providing more individualized care.

Pembrolizumab plus vorinostat induces responses in patients with Hodgkin lymphoma refractory to prior PD-1 blockade

This phase 1 study evaluated the addition of vorinostat to pembrolizumab in patients with relapsed/refractory (RR) classical Hodgkin lymphoma (cHL), diffuse large B-cell lymphoma, and follicular lymphoma. We report the results in cases of cHL. Adult patients with RR cHL who had received ≥1 prior lines of therapy and were ineligible for transplantation were treated in a dose-escalation cohort with 2 dose levels (DLs) and then on an expansion cohort at the recommended phase 2 dose (RP2D) in 21-day cycles. Vorinostat 100 mg twice a day (DL1) and 200 mg twice a day (DL2) was administered orally from days 1 to 5 and 8 to 12; all patients received pembrolizumab 200 mg IV every 3 weeks. The primary end point was safety and determination of RP2D. In total, 32 patients with cHL were enrolled, including 30 at DL2 (RP2D); 78% had received prior anti-programmed cell death 1 (anti-PD-1) therapy, and 56% were PD-1 refractory. Grade ≥3 adverse events (AEs) included hypertension (9%), neutropenia (9%), hypophosphatemia (9%), thrombocytopenia (6%), and lymphopenia (6%). Immune-related AEs included grade 1 or 2 thyroiditis (13%), grade 1 rash (6%), and grade 3 esophagitis/duodenitis (3%). The overall response rate (ORR) was 72% and complete response (CR) rate was 34%. Patients refractory to prior PD-1 blockade (n = 18) had ORR and CR rates of 56% and 11%, respectively. Pembrolizumab and vorinostat was well tolerated with a high ORR rate in RR cHL including in anti-PD-1-refractory disease. This trial was registered at www.clinicaltrials.gov as #NCT03150329.

Healthcare use attributable to COVID-19: a propensity-matched national electronic health records cohort study of 249,390 people in Wales, UK

BACKGROUND

To determine the extent and nature of changes associated with COVID-19 infection in terms of healthcare utilisation, this study observed healthcare contact 1 to 4 and 5 to 24 weeks following a COVID-19 diagnosis compared to propensity-matched controls.

METHODS

Two hundred forty nine thousand three hundred ninety Welsh individuals with a positive reverse transcription-polymerase chain reaction (RT-PCR) test were identified from data from national PCR test results. After elimination criteria, 98,600 positive individuals were matched to test negative and never tested controls using propensity matching. Cohorts were split on test location. Tests could be taken in either the hospital or community. Controls were those who had tested negative in their respective environments. Survival analysis was utilised for first clinical outcomes which are grouped into primary and secondary. Primary outcomes include post-viral-illness and fatigue as an indication of long-COVID. Secondary outcomes include clinical terminology concepts for embolism, respiratory conditions, mental health conditions, fit notes, or hospital attendance. Increased instantaneous risk for positive individuals was quantified using hazard ratios (HR) from Cox regression, while absolute risk (AR) and relative risk were quantified using life table analysis.

RESULTS

Analysis was conducted using all individuals and stratified by test location. Cases are compared to controls from the same test location. Fatigue (HR: 1.77, 95% CI: 1.34-2.25, p =  < 0.001) and embolism (HR: 1.50, 95% CI: 1.15-1.97, p = 0.003) were more likely to occur in all positive individuals in the first 4 weeks; however, anxiety and depression (HR: 0.83, 95% CI: 0.73-0.95, p = 0.007) were less likely. Positive individuals continued to be more at risk of fatigue (HR: 1.47, 95% CI: 1.24-1.75, p =  < 0.001) and embolism (HR: 1.51, 95% CI: 1.13-2.02, p = 0.005) after 4 weeks. All positive individuals are also at greater risk of post-viral illness (HR: 4.57, 95% CI: 1.77-11.80, p = 0.002). Despite statistical association between testing positive and several conditions, life table analysis shows that only a small minority of the study population were affected.

CONCLUSIONS

Community COVID-19 disease is associated with increased risks of post-viral-illness, fatigue, embolism, and respiratory conditions. Despite elevated risks, the absolute healthcare burden is low. Subsequently, either very small proportions of people experience adverse outcomes following COVID-19 or they are not presenting to healthcare.

Brentuximab vedotin plus nivolumab after autologous haematopoietic stem-cell transplantation for adult patients with high-risk classic Hodgkin lymphoma: a multicentre, phase 2 trial

BACKGROUND

After autologous haematopoietic stem-cell transplantation (HSCT), consolidation with brentuximab vedotin in patients with high-risk relapsed or refractory classic Hodgkin lymphoma has been shown to improve progression-free survival compared with placebo. Brentuximab vedotin plus nivolumab is a safe and effective treatment for relapsed or refractory classic Hodgkin lymphoma; therefore, we aimed to evaluate the safety and activity of this drug combination post-autologous HSCT consolidation in patients with high-risk relapsed or refractory classic Hodgkin lymphoma.

METHODS

We did a multicentre phase 2 trial at five centres in the USA. Eligible patients were aged 18 years or older with high-risk relapsed or refractory classic Hodgkin lymphoma, had an ECOG performance status of 0-2, and had adequate organ and bone marrow function. Enrolled patients received brentuximab vedotin (1·8 mg/kg) and nivolumab (3 mg/kg) intravenously starting 30-60 days after autologous HSCT on day 1 of each 21-day cycle for up to 8 cycles. Nivolumab dose reduction was not allowed. Brentuximab vedotin dose reduction to 1·2 mg/kg was permitted. If one drug was discontinued because of a toxic effect, the other could be continued. The primary endpoint was 18-month progression-free survival in all treated patients. This study is registered with ClinicalTrials.gov, number NCT03057795.

FINDINGS

Between May 3, 2017, and July 13, 2019, 59 patients were enrolled and received the study therapy. Patients initiated brentuximab vedotin plus nivolumab for a median of 54 days (IQR 46-58) after autologous HSCT and received a median of 8 cycles (8-8). 34 (58%) of 59 patients were male, 29 (49%) completed 8 cycles of brentuximab vedotin plus nivolumab, and 45 (76%) completed 8 cycles of at least one drug. The median follow-up time was 29·9 months (IQR 24·6-34·8). The 18-month progression-free survival in all 59 patients was 94% (95% CI 84-98). The most common adverse events were sensory peripheral neuropathy (31 [53%] of 59) and neutropenia (25 [42%]), and immune-related adverse events requiring corticosteroids occurred in 17 (29%) of 59 patients. No treatment-related deaths were observed.

INTERPRETATION

Brentuximab vedotin plus nivolumab was highly active post-autologous HSCT consolidation for patients with high-risk relapsed or refractory classic Hodgkin lymphoma, most of whom had previous exposure to either brentuximab vedotin or PD-1 blockade. Combination immunotherapy in this setting should be further studied in patients with classic Hodgkin lymphoma with further refinement of the regimen to mitigate toxic effects, particularly in high-risk patients in whom more intensive therapy to prevent relapse is warranted.

FUNDING

Bristol Myers Squibb, Leukemia and Lymphoma Society, Lymphoma Research Foundation, and National Cancer Institute of the National Institutes of Health.

304 IMPLEMENTING A FRAILTY SPECIFIC PHARMACY PRIORITISATION TOOLKIT IN AN OLDER PERSONS’ REHABILITATION UNIT

Background

Standardised identification of patients for medication review using nurse-delivered, frailty-specific pharmacy prioritisation toolkits should maximise effective use of limited pharmacy resources. A frailty-specific pharmacy prioritisation toolkit was introduced in a 21 bed older persons’ rehabilitation unit to standardise pharmacy referrals and categorise the interventions made.

Methods

The frailty-specific pharmacy prioritisation toolkit was applied to consecutive patients by upskilled rehabilitation nurses to identify patients for weekly senior pharmacist review over a 5-month period from 18th Jan 2022 to 24th May 2022. Regular use of high-risk medication, greater than 10 medications, patients with specific pharmaceutical concerns such as a desire to reduce their medication burden, acute or chronic kidney injury and admission potentially related to medications or admission with non-mechanical falls are included in this toolkit. Pharmacist interventions included recommendations on medications to be weaned or stopped, dose-adjusted, started or restarted and identification of prescribing errors. Age, gender and interventions were recorded onto Excel and data was analysed using descriptive statistics.

Results

The total number of patients screened was 82. Eighty five percent (n=70) fulfilled criteria for a medication review. Mean age (SD) was 77(10.9) years. Female:male ratio was 1.5:1. Review was completed in 50% (n=35) of these cases. In total there were 228 interventions, with a mean (SD) of 6.5 (2.4) per patient. Eighty-four recommendations were made to wean or stop medication and thirty to dose adjust, of which 60% (n=18) were proton pump inhibitor dose reduction. Thirty-eight were to start or restart a medication, 34% (n=13) of which were for bone protection. Eleven prescribing errors were identified.

Conclusion

The pharmacy prioritisation toolkit applied by existing rehabilitation nurses successfully identified patients for medication review. The review rate reflects a need for a twice-weekly senior pharmacy resource.

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.

POS1497-HPR FEASIBILITY OF A PHYSIOTHERAPIST LED, BEHAVIOUR CHANGE INTERVENTION TO IMPROVE PHYSICAL ACTIVITY IN PEOPLE WITH RHEUMATOID ARTHRITIS

Background

Physical activity (PA) is an important component in the management of people with rheumatoid arthritis (RA) (1). Interventions incorporating Behaviour Change (BC) theory are needed to target physically inactive people with RA. The study Physiotherapist-led Intervention to Promote Physical Activity in Rheumatoid Arthritis (PIPPRA) was designed using the Behaviour Change Wheel (BCW) and a pilot study of feasibility undertaken (ClinicalTrials.gov Identifier: NCT03644160).

Objectives

To obtain reliable estimates regarding recruitment rates; participant retention; protocol adherence and possible adverse events, and to producing estimates of the potential effect sizes of the BC intervention on changes in outcomes of physical activity; fatigue; disability and quality of life.

Methods

Participants were recruited at University Hospital (UH) rheumatology clinics and randomly assigned to control group (physical activity information leaflet) or intervention group (four BC physiotherapy sessions in eight weeks). Inclusion criteria were diagnosis of RA (ACR/EULAR 2010 classification criteria), aged 18+ years and classified as insufficiently physically active. Ethical approval was obtained from the UH research ethics committee. Participants were assessed at baseline (T0), 8-weeks (T1), and 24-weeks (T2). Descriptive statistics and t-tests were used to analyse the data with SPSS v22.

Results

320 participants were identified through chart review with direct contact then with people meeting the inclusion criteria at rheumatology clinics. Of the clinic attendees n=183 (57%) were eligible to participate and n=58 (55%) of those consented to participate. The recruitment rate was 6.4 per month and refusal rate was 59%. Due to impact of COVID-19 on the study n=25 (43%) participants completed the study (n=11 (44%) in intervention and n=14 (56%) in control). Of the 25, n= 23 (92%) were female, mean age was 60 years (sd 11.5). Intervention group participants completed 100% of BC sessions 1 & 2, 88% session 3 and 81% session 4. No serious adverse events were reported. Secondary outcome measures data is Table 1.

Table 1.

Mean (sd) for secondary outcome measures in PIPPRA feasibility study

Outcomes and instrumentsInterventionControlBaseline Mean (sd)Time 1 Mean (sd)Time 2 Mean (sd)Baseline Mean (sd)Time 1 Mean (sd)Time 2 Mean (sd)Physical Activity – self report (YPAS1)146.27 (193.73)120.88 (70.80)132.00 (70.65)91.75 (85.86)58.03 (50.61)124.31 (69.75)Physical Activity – objective (Step Count)32,616.9132,190.0027,793.3330,476.1542,117.2534,288.77(11,415.85)(9,291.57)(7,426.92)(12,642.97)(21,714.67)(17,677.90)Pain (VAS2)4.184.904.503.715.104.79(2.40)(1.91)(1.90)(2.55)(2.77)(4.50)Disability (HAQDI3)0.850.941.030.710.711.52(0.57)(0.57)(0.65)(0.56)(0.52)(0.69)Fatigue (BRAF MDQ4)18.1814.82 (13.15)18.55 (11.84)15.71 (12.29)13.93 (15.27)20.21 (10.85)(8.98)Psychological Constructs (TPB5)22.0019.91 (7.76)20.27 (8.63)21.79 (5.67)15.50 (11.43)25.36 (6.86)(4.84)Quality of Life (RA QoL6)15.1814.73 (7.23)17.09 (7.33)18.4311.50 (10.02)14.86 (6.47)(6.08)(5.06)Sleep (PSQI7)11.558.509.9110.219.0910.14(3.56)(3.27)(3.62)(3.47)(4.32)(4.42)

1YPAS – Yale Physical Activity Scale

2VAS – Visual Analogue Scale

3HAQDI – Health Assessment Questionnaire Disability Index

4BRAF MDQ - Bristol Rheumatoid Arthritis Fatigue Multidimensional Questionnaire

5TPB – Theory of Planned Behaviour Questionnaire

6RA QoL – Rheumatoid Arthritis Quality of Life Scale

7PSQI – Pittsburgh Sleep Quality Index

Conclusion

The PIPPRA study designed using the BCW to improve promote physical activity was feasible and safe. This pilot study provides a framework for larger intervention studies and based on these findings a fully powered trial is recommended.

References

[1]Rausch Osthoff A, Niedermann K, Braun J, et al. (2018) EULAR recommendations for physical activity in people with inflammatory arthritis and osteoarthritis. Annals of the Rheumatic Diseases 77:1251-1260.

Disclosure of Interests

None declared

POS1511-HPR “I LEARNT SO MUCH ABOUT MY APPROACH TO BEING ACTIVE”: EXPERIENCES OF PEOPLE WITH RHEUMATOID ARTHRITIS ON THE IMPACT OF A PHYSIOTHERAPIST LED INTERVENTION TO PROMOTE PHYSICAL ACTIVITY

Background

Physical activity is an important component in the management of people with rheumatoid arthritis (RA) [1]. A Physiotherapist-led Intervention to Promote Physical Activity in people with RA (PIPPRA) was undertaken using the Behaviour Change Wheel, with the aim of examining the feasibility of promoting physical activity in RA. This qualitative study involved participants and health care professionals who participated and were involved in a behaviour change pilot RCT intervention.

Objectives

To determine, qualitatively, the acceptability of PIPPRA to participants with RA and health care professionals, in order to capture their reality.

Methods

A qualitative study design of face-to-face semi-structured interviews was undertaken. The interview schedule explored the following areas: experience of the intervention; unintended consequences; experience and suitability of outcome measures used; views regarding the intervention; perceptions of behaviour change and physical activity. Interviews were transcribed verbatim by a professional transcriber. Thematic analysis was used as an analytical approach [2]. The research team searched for patterns, analysed and coded the data, and generated themes and sub-themes. Themes were reviewed by the research team to check if they worked in relation to the coded extracts and the entire data set. The COREQ checklist provided guidance throughout [3].

Results

Fourteen participants [13 female/1 male; mean age of 59 (SD 6.3); mean RA diagnosis of 8.6 (SD 6.8) years; moderate to severe disability (HAQ-DI: 1.4 (SD 0.50)] and 8 healthcare staff [4 female/4 male; mean age of 41 (SD 5.6)] participated. Three main themes were generated from participants:- 1) Positive experience of behaviour change intervention - “I found it very knowledgeable to help you get stronger”; 2) Improvement in self-management - “…….motivate me maybe to go back to doing a little bit more exercise”; 3) Negative impact of COVID-19 on intervention – “I don’t think doing it online again would be really good at all”. Two main themes from health care professionals:- 1) Positive learning experience of behaviour change delivery – “Really made me realise the importance of discussing physical activity with patients”; 2) Positive approach to recruitment – “Very professional team showing the importance of having a study member on site”.

Conclusion

The findings demonstrated that participants had a positive experience of being involved in a behaviour change intervention in order to improve their physical activity and found it acceptable as an intervention. However, if given the choice they would prefer the intervention delivery face to face rather than telehealth. Healthcare professionals also had a positive experience and in particular found it beneficial to their own development, in particular the importance of recommending PA to patients.

References

[1]Rausch Osthoff A, Niedermann K, Braun J, et al. (2018) EULAR recommendations for physical activity in people with inflammatory arthritis and osteoarthritis. Annals of the Rheumatic Diseases 77:1251-1260

[2]Clarke, V. and Braun, V., 2014. Thematic analysis. In Encyclopedia of critical psychology (pp. 1947-1952). Springer, New York, NY

[3]Tong, A., Sainsbury, P. and Craig, J., 2007. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. International journal for quality in health care, 19(6), pp.349-357

Disclosure of Interests

None declared

POS0243 THE EFFECT OF A MEDITERRANEAN DIET ON PHYSICAL FUNCTION AND QUALITY OF LIFE IN PATIENTS WITH RHEUMATOID ARTHRITIS – THE MEDRA STUDY

Background

The immunomodulatory and anti-inflammatory effects of the Mediterranean Diet (MedDiet) suggest a protective role in rheumatic conditions1. A small but increasing body of evidence from randomised controlled trials demonstrates that increased adherence to a MedDiet in patients with Rheumatoid Arthritis (RA) can have a beneficial effect on disease activity, pain levels and physical function2.

Objectives

The primary aim of the MEDRA study was to determine the effects of a MedDiet compared to the current food based dietary guidelines in Ireland (Healthy Eating Guidelines/HEG) on the physical function and quality of life in patients with RA.

Methods

In this randomised controlled trial, 44 patients with RA were randomly allocated to either the MedDiet or the HEG arm of the study. The 12-week dietary intervention study was delivered online by a Registered Dietitian (RD) and included data collection at three time points: baseline, mid-intervention (6 weeks) and post-intervention (12 weeks). Participants in both dietary intervention groups attended three video consultations with the RD, at baseline, weeks 6 and 12, and two follow up reviews by telephone at weeks 3 and 9. All participants were provided resources designed to specifically explain the assigned diet and how it can be successfully adhered to. Primary outcomes were changes in physical function and quality of life measured using the validated Health Assessment Questionnaire - Disability Index (HAQ-DI) and Rheumatoid Arthritis Quality of Life Questionnaire (RAQoL), respectively. Secondary outcomes included changes in physical activity and patient-reported pain levels.

Results

Forty patients with RA completed the study (mean age:47.5 SD10.9 years, females: 87.5%). No significant differences were found in the distribution of age, anthropometric measures, disease duration, physical activity, and quality of life between the two diet groups at baseline. However, the group assigned to the MedDiet had better mean values for quality of life compared to the HEG group; 0.9 ± 0.5 vs. 1.4 ±0.7, p<0.001, respectfully. Compared to baseline, there was a significant improvement in HAQ-DI scores in participants following both the MedDiet (0.9 ±0.5 to 0.5 ± 0.4, p<0.001) and HEG (1.4 ± 0.7 to 1.0 ± 0.6, p<0.001). Significant improvements in RAQoL scores were also seen in both the MedDiet (10.1 ±7.5 to 4.0 ± 4.7, p<0.001) and HEG (11.25 ± 7.2 to 7.9 ± 6.4, p=0.02) groups. At 12 weeks, participants in the MedDiet group reported a significantly better physical function status (mean difference -0.5, 95% CI -0.8 to -0.1, p=0.007) and quality of life (mean difference -3.9, 95% CI -7.5 to -0.2, p=0.04) compared to the HEG group. Participants in the MedDiet group demonstrated a significant increase in physical activity levels (56.7 ± 28.6 to 70.6 ± 33.5, p=0.01). Conversely, a non-significant decrease in physical activity levels was observed in the HEG group from baseline to post-intervention.

Conclusion

The study indicates positive effects of a Mediterranean and low-fat diet as per the Healthy Eating Guidelines on physical function and quality of life in patients with RA. The MedDiet may be superior in improving physical activity levels. Further studies and a larger cohort are needed to confirm these findings.

References

[1]Oliviero, F., Spinella, P., Fiocco, U., Ramonda, R., Sfriso, P. and Punzi, L., 2015. How the Mediterranean diet and some of its components modulate inflammatory pathways in arthritis. Swiss medical weekly, 145(4546).

[2]Forsyth, C., Kouvari, M., D’Cunha, N.M., Georgousopoulou, E.N., Panagiotakos, D.B., Mellor, D.D., Kellett, J. and Naumovski, N., 2018. The effects of the Mediterranean diet on rheumatoid arthritis prevention and treatment: a systematic review of human prospective studies. Rheumatology international, 38(5), pp.737-747.

Acknowledgements

This work was funded by the School of Allied Health Postgraduate scholarship at the University of Limerick.

Disclosure of Interests

None declared

A highly virulent variant of HIV-1 circulating in the Netherlands

We discovered a highly virulent variant of subtype-B HIV-1 in the Netherlands. One hundred nine individuals with this variant had a 0.54 to 0.74 log₁₀ increase (i.e., a ~3.5-fold to 5.5-fold increase) in viral load compared with, and exhibited CD4 cell decline twice as fast as, 6604 individuals with other subtype-B strains. Without treatment, advanced HIV-CD4 cell counts below 350 cells per cubic millimeter, with long-term clinical consequences-is expected to be reached, on average, 9 months after diagnosis for individuals in their thirties with this variant. Age, sex, suspected mode of transmission, and place of birth for the aforementioned 109 individuals were typical for HIV-positive people in the Netherlands, which suggests that the increased virulence is attributable to the viral strain. Genetic sequence analysis suggests that this variant arose in the 1990s from de novo mutation, not recombination, with increased transmissibility and an unfamiliar molecular mechanism of virulence.

OP0191-PARE DEVELOPMENT OF A PUBLIC AND PATIENT INVOLVEMENT (PPI) RESEARCH NETWORK FOR PEOPLE WHO HAVE RHEUMATIC CONDITIONS

Background:

Public and patient involvement (PPI) improves quality and relevance of research (1). PPI is advocated by policy makers and funding bodies and is supported by EULAR (2). Arthritis Research Limerick (ARL) is a partnership between researchers at the University of Limerick and clinicians at University Hospitals Limerick. PPI representatives have been involved in ARL projects, however no formal PPI network had been established prior to 2020. The need for a formal PPI network to collaborate with ARL was identified by both ARL and patient representatives. This need arose from a joint ambition to promote meaningful involvement of the public and patients in ARL projects and to develop a platform through which researchers and PPI representatives could collaboratively set research priorities.

Objectives:

The aim of this project was to create a formal PPI network to engage with people living with rheumatic and musculoskeletal diseases (RMDs) and their families and to identify collaborative research opportunities between ARL and PPI representatives.

Methods:

A face-to-face PPI seminar was planned for October 2020. The seminar consisted of speakers from ARL providing an overview of research projects and a World Café research ideas session. Funding was obtained through a competitive, peer-review funding call from the PPI Ignite group at the University of Limerick to support the PPI seminar. The funding application was a joint application between ARL members and a PPI partner (iCAN - Irish Children’s Arthritis Network). The seminar was advertised through national patient organisations (iCAN and Arthritis Ireland), social media and ARL research networks.

Results:

Due to Covid-19 public health restrictions the PPI seminar was held virtually. The ARL PPI inaugural seminar was attended by N=19 researchers and people living with RMDs. The seminar speakers included ARL researchers and a PPI representative. The World Café event was modified to adapt to the virtual seminar delivery. Research ideas were noted by the seminar organiser and summarised for attendees at the end of the research ideas and priorities session. An ARL PPI mailing list was set-up post seminar as a means of communicating with seminar attendees and will serve as a formal PPI network for ARL. Research updates and opportunities will be communicated via this formal network to people living with RMDs and researchers alike.

Conclusion:

This was the first PPI seminar organised by ARL in collaboration with a PPI seminar, and has led to the creation of a formal PPI network. Delivery mode of the PPI seminar was changed due to Covid-19 public health restrictions. This change may also have impacted engagement and attendance at the PPI seminar, given that virtual events are not accessible to all of the RMD population. Future PPI seminars will consider a hybrid approach of face-to-face and virtual attendance, to enhance accessibility. A formal PPI communication network has been established. Future work will focus future collaborative opportunities between the PPI panel and the ARL group, including project development, co-led research funding applications and joint research dissemination.

References:

[1]INVOLVE. (2012). Briefing notes for researchers: Involving the public in NHS, public health and social care research. Retrieved from www.invo.org.uk 7th January 2020.

[2]de Wit MPT, Berlo SE, Aanerud GJ, et al (2011). European League Against Rheumatism recommendations for the inclusion of patient representatives in scientific projects. Annals of the Rheumatic Diseases 70:722-726

Disclosure of Interests:

None declared

AB0872-HPR IMPACT OF COVID-19 ON A PHYSICAL ACTIVITY FEASIBILITY PILOT STUDY: THE PIPPRA EXPERIENCE

Background:

The PIPPRA (Physiotherapist-led Intervention to Promote Physical Activity in Rheumatoid Arthritis) project is a feasibility project examining the impact of a physical activity behaviour change intervention in people who have rheumatoid arthritis (RA). The PIPPRA study recruitment commenced in October 2019, with participant assessment and intervention commencing in November 2019. In the Republic of Ireland people who have RA are categorised as high risk category for Covid-19, due to immunosuppression [1], although this categorisation contrasts with EULAR’s provisional recommendations [2].

Objectives:

To examine the impact of the Covid-19 pandemic and public health restrictions on a pilot randomised controlled feasibility study in 2020.

Methods:

Participants (aged 18 years+, diagnosis of RA, independently mobile and low levels of physical activity [3]) were recruited from a rheumatology clinic at an urban hospital. Target recruitment was four participants per month for one year (N=48). Assessments were planned at baseline, eight and twenty-four weeks (N=144). Participants were randomised to intervention group or control group. The intervention group received four 1:1 sixty minute sessions with a physiotherapist (N=96). The intervention was delivered over eight weeks. Intervention and control groups received a physical activity information leaflet.

Results:

The Covid-19 pandemic and associated public health restrictions forced the study to be formally paused in April 2020 and the study formally resumed in August 2020. N=48 participants were recruited between October 2019 and March 2020 (six months). N=20 participants have commenced in the study, N=16 are awaiting baseline assessment, N=6 withdrew and N=6 were lost to follow-up prior to baseline. Trial protocol planned for the delivery of N=55 assessments and N=36 intervention sessions for participants who had commenced in the study. N=22 assessments and N=26 intervention sessions were delivered between November 2019 and March 2020. N=5 assessments and N=6 intervention sessions were conducted between August and October 2020. No assessment or intervention delivery occurred in November-December 2020 due to participant hesitancy in attending for assessment and/or intervention with increased public health restrictions. The impact of Covid-19 restrictions resulted in N=33 (60%) deviations from assessment protocol and N=10 (27%) deviations from intervention delivery protocol (Figure 1).

Figure 1.

Deviations from assessment and intervention protocol in the PIPPRA study

Conclusion:

The Covid-19 pandemic has had a significant impact on the delivery of the PIPPRA study. Feasibility study outcomes, including participant retention rate, and study delivery as per protocol, have been affected due to the Covid-19 pandemic. Participant reluctance to attend face-to-face sessions demonstrates the need to consider alternative methods of delivery, e.g. virtual delivery of interventions, where attending in person is not acceptable to participants [4], in future studies.

References:

[1]Health Service Executive. (2019). People at higher risk from COVID-19.Accessed 5th Jan 2020 https://www2.hse.ie/conditions/coronavirus/people-at-higher-risk.html.

[2]Landewé RB et al (2020). EULAR provisional recommendations for the management of rheumatic and musculoskeletal diseases in the context of SARS-CoV-2. Annals of the Rheumatic Diseases 79:851-858.

[3]Godin, G. (2011). The Godin-Shephard leisure-time physical activity questionnaire. The Health & Fitness Journal of Canada, 4(1):18-22.

[4]Inan, OT et al. (2020). Digitizing clinical trials. npj Digit. Med. 3:10.

Disclosure of Interests:

None declared

Bronchiectasis is associated with delayed diagnosis and adverse outcomes in the New Zealand Common Variable Immunodeficiency Disorders cohort study

Common variable immunodeficiency disorders (CVID) are multi-system disorders where target organ damage is mediated by infective, autoimmune and inflammatory processes. Bronchiectasis is probably the most common disabling complication of CVID. The risk factors for bronchiectasis in CVID patients are incompletely understood. The New Zealand CVID study (NZCS) is a nationwide longitudinal observational study of adults, which commenced in 2006. In this analysis, the prevalence and risk factors for bronchiectasis were examined in the NZCS. After informed consent, clinical and demographic data were obtained with an interviewer-assisted questionnaire. Linked electronic clinical records and laboratory results were also reviewed. Statistical methods were applied to determine if variables such as early-onset disease, delay in diagnosis and increased numbers of infections were associated with greater risk of bronchiectasis. One hundred and seven adult patients with a diagnosis of CVID are currently enrolled in the NZCS, comprising approximately 70% of patients known to have CVID in New Zealand. Fifty patients (46·7%) had radiologically proven bronchiectasis. This study has shown that patients with compared to those without bronchiectasis have an increased mortality at a younger age. CVID patients with bronchiectasis had a greater number of severe infections consequent to early-onset disease and delayed diagnosis. Indigenous Māori have a high prevalence of CVID and a much greater burden of bronchiectasis compared to New Zealand Europeans. Diagnostic latency has not improved during the study period. Exposure to large numbers of infections because of early-onset disease and delayed diagnosis was associated with an increased risk of bronchiectasis. Earlier diagnosis and treatment of CVID may reduce the risk of bronchiectasis and premature death in some patients.

The coil-globule transition in self-avoiding active polymers

We perform numerical simulations of an active fully flexible self-avoiding polymer as a function of the quality of the embedding solvent described in terms of an effective monomer-monomer interaction. Specifically, by extracting the Flory exponent of the active polymer under different conditions, we are able to pin down the location of the coil-globule transition for different strengths of the active forces. Remarkably, we find that a simple rescaling of the temperature is capable of qualitatively capturing the dependence of the Θ-point of the polymer on the amplitude of active fluctuations. We discuss the limits of this mapping and suggest that a negative active pressure between the monomers, not unlike the one that has already been found in suspensions of active hard spheres, may also be present in active polymers.

Increased case-finding and uptake of direct-acting antiviral treatment essential for micro-elimination of hepatitis C among people living with HIV: a national record linkage study

OBJECTIVES

Micro-elimination of hepatitis C virus (HCV) in people living with HIV (PLHIV) and co-infected with HCV has been proposed as a key contribution to the overall goal of HCV elimination. While other studies have examined micro-elimination in HIV-treated cohorts, few have considered HCV micro-elimination among those not treated for HIV or at a national level.

METHODS

Through data linkage of national and sentinel surveillance data, we examined the extent of HCV testing, diagnosis and treatment among a cohort of PLHIV in Scotland identified through the national database of HIV-diagnosed individuals, up to the end of 2017.

RESULTS

Of 5018 PLHIV, an estimated 797 (15%) had never been tested for HCV and 70 (9%) of these had undiagnosed chronic HCV. The odds of never having been tested for HCV were the highest in those not on HIV treatment [adjusted odds ratio (aOR) = 7.21, 95% confidence interval (CI): 5.15-10.10). Overall HCV antibody positivity was 11%, and it was at its highest among people who inject drugs (49%). Most of those with chronic HCV (91%) had attended an HCV treatment clinic but only half had been successfully treated (54% for those on HIV treatment, 12% for those not) by the end of 2017. The odds of never having been treated for HCV were the highest in those not on HIV treatment (aOR = 3.60, 95% CI: 1.59-8.15).

CONCLUSIONS

Our data demonstrate that micro-elimination of HCV in PLHIV is achievable but progress will require increased effort to engage and treat those co-infected, including those not being treated for their HIV.

OP0267-HPR “I NEVER THOUGHT EXERCISE COULD HELP IMPROVE MY SLEEP”: EXPERIENCES OF PEOPLE WITH RHEUMATOID ARTHRITIS ON THE IMPACT OF EXERCISE ON SLEEP

Background:

OMERACT has identified sleep quality as one of the key outcomes for people with RA [1]. Poor sleep and reduced total sleep time (TST) are common complaints among people with RA. Poor sleep can in turn lead to deterioration in function, reduce activity levels and also impact mental health. Although sleep and mental health outcomes have been identified as important, they are frequently not measured in clinical trials. Involving key stakeholders, like people with RA, is important when designing exercise interventions as it allows consideration of particular issues that may influence future intervention delivery. This study involved people with RA who participated in a pilot RCT group exercise class to improve sleep quality.

Objectives:

To explore participants experiences of an exercise intervention in improving sleep quality and TST, to capture their reality.

Methods:

A descriptive qualitative study design of face-to-face semi-structured interviews was employed. The interview schedule explored a number of areas: experience of the intervention; outcome measures used; views regarding the intervention; perceptions regarding exercise and sleep and the impact on sleep. Interviews were transcribed verbatim by a professional transcriber. Inductive thematic analysis was used as an analytical approach. Interview transcripts were read, notes made, and ideas formulated to facilitate coding. The research team searched for patterns, analysed and coded the data, and generated themes and sub-themes. Themes were reviewed by the research team to check if they worked in relation to the coded extracts and the entire data set. The COREQ checklist provided guidance.

Results:

Twelve females participated with a mean age of 58 (SD 7.4); mean RA diagnosis of 9.9 (SD 7.4) years; moderate to severe disability (HAQ-DI: 1.5 (SD 0.60). Four main themes were generated: 1) Positive impact of exercise on sleep -“I really didn’t think any type of exercise would help me sleep better if I’m honest.”;2) Positive experiences of exercise intervention to improve sleep-“I learnt so much regarding walking that I didn’t even think about.”;3) Clear mental health benefits –“If you don’t sleep well then it will have a knock-on effect to your mental health”; 4) Achieving empowerment and ownership when exercising -“I feel empowered now and confident that I’m not doing harm to myself”.The findings demonstrated that participants were clearly surprised that exercise could improve sleep.

Conclusion:

In a variety of inflammatory conditions exercise is recommended as an effective intervention for the treatment of sleeping disorders. Although there is a growing consensus that exercise will benefit sleep, research is severely lacking in those with RA. This study demonstrates that participants were clearly surprised that exercise could improve their sleep. Due to the multifactorial nature of RA, engaging in exercise may not only improve sleep quality but also mitigate some of its symptoms.

References:

[1]Kirwan JR, Boonen A, Harrison MJ, Hewlett SE, et al (2011) OMERACT 10 Patient Perspective Virtual Campus: Valuing health; measuring outcomes in rheumatoid arthritis fatigue, RA sleep, arthroplasty, and systemic sclerosis; and clinical significance of changes in health. The Journal of Rheumatology;38:1728–34.

Disclosure of Interests:

None declared

Impact of previous hepatitis B infection on the clinical outcomes from chronic hepatitis C? A population-level analysis

Chronic coinfection with hepatitis C virus (HCV) and hepatitis B virus (HBV) is associated with adverse liver outcomes. The clinical impact of previous HBV infection on liver disease in HCV infection is unknown. We aimed at determining any association of previous HBV infection with liver outcomes using antibodies to the hepatitis B core antigen (HBcAb) positivity as a marker of exposure. The Scottish Hepatitis C Clinical Database containing data for all patients attending HCV clinics in participating health boards was linked to the HBV diagnostic registry and mortality data from Information Services Division, Scotland. Survival analyses with competing risks were constructed for time from the first appointment to decompensated cirrhosis, hepatocellular carcinoma (HCC) and liver-related mortality. Records of 8513 chronic HCV patients were included in the analyses (87 HBcAb positive and HBV surface antigen [HBsAg] positive, 1577 HBcAb positive and HBsAg negative, and 6849 HBcAb negative). Multivariate cause-specific proportional hazards models showed previous HBV infection (HBcAb positive and HBsAg negative) significantly increased the risks of decompensated cirrhosis (hazard ratio [HR]: 1.29, 95% CI: 1.01-1.65) and HCC (HR: 1.64, 95% CI: 1.09-2.49), but not liver-related death (HR: 1.02, 95% CI: 0.80-1.30). This is the largest study to date showing an association between previous HBV infection and certain adverse liver outcomes in HCV infection. Our analyses add significantly to evidence which suggests that HBV infection adversely affects liver health despite apparent clearance. This has important implications for HBV vaccination policy and indications for prioritization of HCV therapy.

Participation in research improves overall patient management: insights from the Global Rheumatic Heart Disease registry (REMEDY)

Background

Rheumatic heart disease (RHD) is a major public health problem in low– and middle–income countries (LMICs), with a paucity of high–quality trial data to improve patient outcomes. Investigators felt that involvement in a recent large, observational RHD study impacted positively on their practice, but this was poorly defined.

Aim

The purpose of this study was to document the experience of investigators and research team members from LMICs who participated in a prospective, multi–centre study, the global Rheumatic Heart Disease Registry (REMEDY), conducted in 25 centres in 14 countries from 2010 to 2012.

Methods

We conducted an online survey of site personnel to identify and quantify their experiences. Telephone interviews were conducted with a subset of respondents to gather additional qualitative data. We asked about their experiences, positive and negative, and about any changes in RHD management practices resulting from their participation in REMEDY as a registry site.

Results

The majority of respondents in both the survey and telephone interviews indicated that participation as a registry site improved their management of RHD patients. Administrative changes included increased attention to follow–up appointments and details in patient records. Clinical changes included increased use of penicillin prophylaxis, and more frequent INR monitoring and contraceptive counselling.

Conclusions

Our study demonstrates that participation in clinical research on RHD can have a positive impact on patient management. Furthermore, REMEDY has led to increased patient awareness and improved healthcare workers’ knowledge and efficiency in caring for RHD patients.

Autologous stem-cell transplantation after second-line brentuximab vedotin in relapsed or refractory Hodgkin lymphoma

Background

We previously demonstrated that brentuximab vedotin (BV) used as second-line therapy in patients with Hodgkin lymphoma is a tolerable and effective bridge to autologous hematopoietic cell transplantation (AHCT). Here, we report the post-AHCT outcomes of patients treated with second-line standard/fixed-dose BV and an additional cohort of patients where positron-emission tomography adapted dose-escalation of second-line BV was utilized.

Patients and methods

Patients on the dose-escalation cohort received 1.8 mg/kg of BV intravenously every 3 weeks for two cycles. Patients in complete remission (CR) after two cycles received two additional cycles of BV at 1.8 mg/kg, while patients with stable disease or partial response were escalated to 2.4 mg/kg for two cycles. All patients, regardless of treatment cohort, proceeded directly to AHCT or received additional pre-AHCT therapy at the discretion of the treating physician based on remission status after second-line BV.

Results

Of the 20 patients enrolled to the BV dose-escalation cohort, 8 patients underwent BV dose-escalation. BV escalation was well-tolerated, but no patients who were escalated converted to CR. Of 56 evaluable patients treated across cohorts, the overall response rate (ORR) to second-line BV was 75% with 43% CR. Twenty-eight (50%) patients proceeded directly to AHCT without post-BV chemotherapy, and a total of 50 patients proceeded to AHCT. Thirteen patients received consolidative post-AHCT therapy with either radiation, BV, or a PD-1 inhibitor. After AHCT, the 2-year progression-free survival (PFS) and overall survival were 67% and 93%, respectively. The 2-year PFS among patients in CR at the time of AHCT (n = 37) was 71% compared with 54% in patients not in CR (p = 0.12). The 2-year PFS in patients who proceeded to AHCT directly after receiving BV alone was 77%.

Conclusions

Second-line BV is an effective bridge to AHCT that produces responses of sufficient depth to provide durable remission in conjunction with AHCT (clinicaltrials.gov: NCT01393717).

HMGCR-associated myositis: a New Zealand case series and estimate of incidence

Statins are one of the most commonly prescribed drugs in New Zealand, with 525 772 or 16.5% of the adult New Zealand population prescribed a statin between June 2013 and July 2014. While generally well-tolerated, statins are known to cause a range of muscle-related side effects, ranging from myalgia to life-threatening rhabdomyolysis. Recently, it has been recognised that in rare instances, statins can induce an immune-mediated necrotising myositis with antibodies against 3-hydroxy-3-methylglutaryl-coenzyme A reductase (HMGCR), the enzymatic target of statins. In 2014, anti-HMGCR antibody testing was introduced to Canterbury Health Laboratories (CHL), with this being the only laboratory in New Zealand performing this test during the period of this case series. This article describes an index case and characterises the clinical features of a subsequent 12-month series. From this series, we estimated the yearly incidence of HMGCR-associated myositis at 1.7/million/year or ~1/90 000 New Zealand statin users.

Comparing cardiovascular risk factors, disease and treatment in participants with rheumatoid arthritis and without arthritis in a population based stud

Rheumatoid Arthritis (RA) is associated with a significant increase in mortality compared to the general population, with cardiovascular disease (CVD) the leading cause of death. The aim of this study is to compare the prevalence and treatment of modifiable CV risk factors and history of CVD in those with RA and those without arthritis in Ireland. Data from the Irish Longitudinal Study on Ageing (TILDA), a population-representative cohort study of people in Ireland aged 50 or over, was used. Participants with RA (n=457) were twice as likely to be obese (OR 2.02, 95% CI 1.99 to 2.06) compared to those without arthritis (n=4,063). Participants with RA were also more likely to be physically inactive (OR 1.73, 95% CI 1.69 to 1.76) and taking antihypertensive medication than those without arthritis. Exercise can have a beneficial impact on CVD and specific interventions to increase physical activity in those with RA may be warranted.

A protein-truncating R179X variant in RNF186 confers protection against ulcerative colitis

Protein-truncating variants protective against human disease provide in vivo validation of therapeutic targets. Here we used targeted sequencing to conduct a search for protein-truncating variants conferring protection against inflammatory bowel disease exploiting knowledge of common variants associated with the same disease. Through replication genotyping and imputation we found that a predicted protein-truncating variant (rs36095412, p.R179X, genotyped in 11,148 ulcerative colitis patients and 295,446 controls, MAF=up to 0.78%) in RNF186, a single-exon ring finger E3 ligase with strong colonic expression, protects against ulcerative colitis (overall P=6.89 × 10(-7), odds ratio=0.30). We further demonstrate that the truncated protein exhibits reduced expression and altered subcellular localization, suggesting the protective mechanism may reside in the loss of an interaction or function via mislocalization and/or loss of an essential transmembrane domain.

Supra-treatment threshold neonatal jaundice: Incidence in HIV-exposed compared to non-exposed neonates at Queen Elizabeth Central Hospital in Blantyre, Malawi

INTRODUCTION

Jaundice is the yellowish pigmentation of the skin, sclera, and mucous membranes resulting from bilirubin deposition. Children born to mothers with HIV are more likely to be born premature, with low birth weight, and to become septic-all risk factors for neonatal jaundice. Further, there has been a change in the prevention of mother-to-child transmission (PMTCT) of HIV guidelines from single-dose nevirapine to a six-week course, all of which theoretically put HIV-exposed newborns at greater risk of developing neonatal jaundice.

AIM

We carried out a study to determine the incidence of severe and clinical neonatal jaundice in HIV-exposed neonates admitted to the Chatinkha Nursery (CN) neonatal unit at Queen Elizabeth Central Hospital (QECH) in Blantyre.

METHODS

Over a period of four weeks, the incidence among non-exposed neonates was also determined for comparison between the two groups of infants. Clinical jaundice was defined as transcutaneous bilirubin levels greater than 5 mg/dL and severe jaundice as bilirubin levels above the age-specific treatment threshold according the QECH guidelines. Case notes of babies admitted were retrieved and information on birth date, gestational age, birth weight, HIV status of mother, type of feeding, mode of delivery, VDRL status of mother, serum bilirubin, duration of stay in CN, and outcome were extracted.

RESULTS

Of the 149 neonates who were recruited, 17 (11.4%) were HIV-exposed. One (5.88%) of the 17 HIV-exposed and 19 (14.4%) of 132 HIV-non-exposed infants developed severe jaundice requiring therapeutic intervention (p = 0.378). Eight (47%) of the HIV-exposed and 107 (81%) of the non-exposed neonates had clinical jaundice of bilirubin levels greater than 5 mg/dL (p < 0.001).

CONCLUSIONS

The study showed a significant difference in the incidence of clinical jaundice between the HIV-exposed and HIV-non-exposed neonates. Contrary to our hypothesis, however, the incidence was greater in HIV-non-exposed than in HIV-exposed infants.

HIV testing in Lanarkshire

INTRODUCTION

The 2008 UK National Guidelines for HIV testing were designed in order to decrease the proportion of people living with undiagnosed HIV infection.

AIMS

Two audits were conducted. The aim of Audit 1 was to determine the proportion of current medical inpatients with an indicator condition that had been tested for HIV. Audit 2 aimed to identify missed opportunities for testing prior to diagnosis among newly diagnosed individuals with HIV.

METHODS

Audit 1 involved a case note review looking for indicator conditions and HIV testing of all inpatients. Audit 2 analysed the hospital case notes of all new Lanarkshire HIV patients in 2010 for previous missed diagnostic opportunities.

RESULTS

In Audit 1, 36% (63/174) of medical inpatients had a current indicator condition. Of the total population, 1.7% (3/174) had what would be an AIDS-defining condition if they had a positive HIV test. However, only 11% (7/63) of individuals were appropriately HIV tested. For Audit 2, 64% (9/14) of newly diagnosed individuals had previous missed opportunities for diagnosis.

CONCLUSION

Increased education of clinical staff around testing guidelines is needed, as we have demonstrated that the 2008 guidelines are not being adhered to.

UK university students’ awareness of stroke early warning signs and the FAST campaign

Background:

The UK FAST (face, arm, speech, time) campaign aimed to increase awareness of stroke early warning signs (EWS) and the need to call 999. Research is needed to investigate the impact of this campaign among UK allied health professional (AHP) students and university students in general.

Methods:

Ethical approval was obtained from the university. A sample of 291 university students completed an online pilot questionnaire. Data regarding awareness of EWS, thrombolysis, the FAST campaign and the need to call 999 were collected, coded and analysed using descriptive statistics and independent sample t tests, a Mann-Whitney U test and multiple regression analyses.

Results:

Two thirds of students were aware of the FAST campaign, and the majority could name all four letters (48%). Overall, 62% could name 3 EWS and 94% knew to call 999. Awareness of the FAST campaign, being aged over 20 years and awareness of thrombolysis were significant predictors of greater EWS knowledge (P<0.001); however, firstaid training and personal experience of stroke were not. AHP students had significantly greater stroke awareness compared to non-AHP students.

Conclusions:

This study reports fairly good knowledge of stroke, suggesting the FAST campaign appears to have been somewhat successful in raising awareness within this sample. Opportunities exist for further development of knowledge, particularly the breadth of EWS known by AHP students.

Implications:

Stroke education in this population needs to be developed further to ensure sufficient knowledge as future potential bystanders and for AHP students as future healthcare professionals. Further research is warranted.