Mortality and mental health funding-do the dollars add up? Eating disorder research funding in Australia from 2009 to 2021: a portfolio analysis

Background

Eating Disorders (EDs) are among the deadliest of the mental disorders and carry a sizeable public health burden, however their research and treatment is consistently underfunded, contributing to protracted illness and ongoing paucity of treatment innovation.

Methods

We compare absolute levels and growth rates of Australian mental health research funding by illness group for the years 2009-2021, with a specific focus on eating disorders analysed at the portfolio level.

Findings

Actual and adjusted data obtained from Australia's three national medical research funding bodies (NHMRC, ARC and MRFF) shows eating disorders receive a disproportionately low allocation of mental health research funding despite having amongst the highest mortality rates. Forty-one category one research grants totalling $AUD28.1 million were funded for eating disorders over the period. When adjusted for inflation, this equates to $2.05 per affected individual, compared with $19.56 for depression, $32.11 for autism, and $176.19 for schizophrenia. Half of all research funded for eating disorders was 'basic' research (e.g., illness underpinning), with little investment in the development of innovative treatment models, novel therapeutics or translation, well reflected by recovery rates of less than 50% in individuals with Anorexia Nervosa.

Interpretation

Significant discrepancy remains between research funding dollars and disease burden associated with the mental health disorders. The extent to which eating disorders are underfunded may in part be attributable to inaccuracies in epidemiological and burden of disease data.

Funding

This work was in-part funded by the Australian Government Department of Health and the National Eating Disorder Research & Translation Strategy. The funder was not directly involved in informing the development of the current study.

Exploring the psychometric properties of the Intellectual Disability versions of the Short Warwick-Edinburgh Mental Wellbeing Scale and Kidscreen10, self-reported by adolescents with intellectual disability

BACKGROUND

There are no validated self-report measures that can be used to assess health and wellbeing in adolescents with intellectual disability (ID).

METHOD

The aim of this study was to explore the psychometric properties of two newly adapted self-report health-related quality of life (HRQoL) and mental wellbeing measures: the Intellectual Disability versions of the Short Warwick-Edinburgh Mental Wellbeing Scale (ID-SWEMWBS) and Kidscreen10 (ID-Kidscreen10). For this, we used data from a sample of 427 adolescents (aged 11-19) with ID recruited from special school settings.

RESULTS

Confirmatory factor analysis (CFA) was conducted to validate the factor structure of both measures. Internal consistency was assessed using Cronbach's alpha and test-retest reliability was analysed using intra-class correlation coefficients. The internal consistency measured using Cronbach's alpha was found to be in the range of 0.70-0.78, test-retest reliabilities were expressed using intra-class correlation coefficients that were found to be high for both measures (ID-SWEMWBS, 0.758; ID-Kidscreen10, 0.723), and the CFA supported the unidimensional structure of both measures.

CONCLUSIONS

The results of this study indicate that the ID-SWEMWBS and ID-Kidscreen10 have very good psychometric properties and can be used as self-report measures to assess HRQoL and mental wellbeing in adolescents with ID.

Public perceptions of people with eating disorders: Commentary on results from the 2022 Australian national survey of mental health-related stigma and discrimination

Mental illness is highly prevalent in the community. As such, significant attention has been paid in recent years to raising awareness of the mental health disorders (including eating disorders). This includes efforts to normalise help-seeking, campaigns to reduce stigma and discrimination, targeted research funding and advocacy for improved and accessible mental health service provision. But have these initiatives changed public attitude? The 2022 National Survey of Mental Health-Related Stigma and Discrimination is the first of four national surveys canvassing the general public's perceptions of people with mental health disorders (including stigmatising and discriminatory beliefs) conducted since 1995 to include eating disorders. It finds significant prejudice against those with mental health disorders still exists within the community, particularly among younger Australians. For eating disorders, this is primarily related to attributions of blame and personal weakness. Findings from the survey are discussed in this commentary.

Worse scores but similar patterns of disease activity: interpreting outcomes in women with axial spondyloarthropathy

OBJECTIVE

The aim of this study was to evaluate the impact of sex on disease activity in axial spondylitis (axSpA).

METHOD

Data were extracted from the Ankylosing Spondylitis Registry of Ireland (ASRI). In this cross-sectional study, patients were analysed on the basis of sex, with a series of comparison analyses performed.

RESULTS

Overall, 886 participants were enrolled in the ASRI [232 (26.2%) women, 644 (72.6%) men]. Females recorded significantly worse Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) (4.57 vs 3.83, p < 0.01) and Ankylosing Spondylitis Quality of Life questionnaire (ASQoL) (7.51 vs 6.12, p < 0.01) scores than males. There was a stronger correlation in the Bath Ankylosing Spondylitis Functional and Metrology Indices (BASFI and BASMI) in females (r_s = 0.619, p < 0.01) than in males (r_s = 0.572, p < 0.01). Analysis of factors in BASDAI revealed that the higher total scores in females compared to males were due not to any single component, but to worse scores in all six components of the BASDAI combined. Ranking of components by severity between sexes revealed identical ranking in four of the six components of the BASDAI.

CONCLUSIONS

Women with axSpA reported significantly worse disease activity, quality of life, and functional ability than men. However, the BASDAI capturedsimilar patterns of disease activity. Limitation of spinal mobility in women with axSpA corresponded to greater impairment in functional ability. Further evaluation of disease monitoring tools is required to ensure that disease activity is accurately captured in men and women with axSpA.

Involving adolescents with intellectual disability in the adaptation of self-reported subjective well-being measures: participatory research and methodological considerations

BACKGROUND

The measurement of subjective well-being is challenging with samples of adolescents with intellectual disability (ID) given the cognitive and linguistic difficulties they face in comprehending standardised measures, and as such is primarily based on proxy reports. The lack of appropriate tools needs to be addressed so that adolescents with ID can self-report on their own well-being. The current study reports on the use of participatory research methods to adapt and modify two standardised self-report measures of subjective well-being suitable for completion by adolescents with ID.

METHOD

Two special schools were recruited for this study. At each school, staff (n = 15) and pupils aged 11-17 years (n = 35) participated. A series of co-design workshops were conducted to adapt two standardised subjective well-being measures: Kidscreen-10 and short-form Warwick-Edinburgh Mental Well-being Scale.

RESULTS

Specific aspects for measure adaption were identified: simplifying the item wording and phrasing; inclusion of pictorial communication symbols and visual prompts to represent the meaning of items; changing of tense of questions from past to present; asking questions rather than statements; reducing 5-point Likert scales to 3-point or dichotomous; presenting one item at a time during administration; and developing alternate formats of the survey to ensure inclusivity.

CONCLUSIONS

This paper illustrates the value of using participatory research methods when working alongside adolescents with ID and offers methodological, as well as practical, guidance in the context of adapting subjective self-report measures for this target group, serving as a guide to fellow researchers and clinicians interested in modifying or developing self-report measures for adolescents with ID.

POS1001 CURRENT SMOKING IS ASSOCIATED WITH LOWER RISK OF UVEITIS AND PERIPHERAL ARTHRITIS IN MALES WITH AXIAL SPONDYLOARTHRITIS

Background

The associations between smoking and extra-axial manifestations of axial spondyloarthritis (axSpA) are inadequately described. Previous observational studies have demonstrated smoking as protective against some but not other manifestations. However, the impact of sex on these associations is unknown.

Objectives

Using a large descriptive epidemiological dataset, we performed a sex-stratified analysis of the association between smoking status and extra-axial manifestations in axSpA.

Methods

This study was carried out within the framework of ASRI (Ankylosing Spondylitis Registry of Ireland), a descriptive epidemiological study of the axSpA population of Ireland. A standardised clinical assessment was performed on each patient, collecting demographic and clinical data. Smoking status was characterised as current, previous or never. The number of cigarettes per day, plus number of years smoking was also collected. Data on the following extra-axial manifestations was collected: arthritis, enthesitis, dactylitis, acute anterior uveitis (AAU), psoriasis (PsO), inflammatory bowel disease (IBD). Standardised measures of disease severity were also collected. Separate logistic regression models were used to define the association between extra-axial manifestations and smoking, controlling for potential confounders. SPSS was used for statistical analysis.

Results

Smoking data was available for 913 out of the 917 axSpA individuals with data in ASRI (mean age 46 (SD 13) years, disease duration 19 (SD 12) years, 72% male, 97% Caucasian). Twenty eight percent (n=259) were current smokers, 29% (n=268) were past smokers and 42% (n=386) were never smokers. Of the current smokers, the mean number of cigarettes per day was 12 (SD 7) and number of years smoking was 22 (SD 12). Thirty one percent had peripheral arthritis, 7% had dactylitis, 18% had enthesitis, 34% had AAU, 17% had psoriasis and 11% had IBD.

Current smokers had a significantly lower prevalence of arthritis and uveitis than past or non-smokers (see Table 1). A sex-stratified analysis was performed. There was no association between smoking status and any extra-axial manifestation in females. However, current smoking was associated with lower prevalence of arthritis in males compared to past or non-smokers (22% v 36% v 42%, p=0.002). A similar pattern was seen for uveitis, where male current smokers had a lower prevalence than non-smokers (24% v 38%, p=0.01). In contrast, psoriasis was more prevalent in men who were current smokers compared to non-smokers (18% v 12%, p=0.01), with no difference seen in females. There was no association with number of cigarettes smoked or number of years smoking.

Table 1.

Association between smoking status and extra-axial manifestations in axSpA.

AxSpA cohortCurrent smokerPast smokerNon-smokerArthritis30.9%22.4%a35.5%b33.3%bDactylitis6.7%5.5%a6.7% a7.4% aEnthesitis18.1%17.4% a16.2% a19.9% aUveitis34.3%27.4%a35.0%b38.6%bPsoriasis16.7%18.5% a19.3% a13.8% aInflammatory bowel disease10.7%9.9% a13.2% a9.5% a

Different subscript letters denote significant (p<0.05) differences between groups. Significant values highlighted in bold.

There was no association between smoking status and disease severity by subjective or objective measures, either for the cohort as a whole or by sex.

When compared to non- or ex-smokers and controlled for potential confounders including sex, age, biologic use, the association remained only between current smokers and lower risk of uveitis (OR 0.68, 95% CI 0.49 to 0.96) and arthritis (OR 0.62, 95% CI 0.43 to 0.88), in separate logistic regression models. The association between current smoking and increased prevalence of psoriasis in males did not remain significant once controlled for confounders (OR 1.10, 96% CI 0.73 to 1.65).

Conclusion

We demonstrated that current smoking is independently associated with a lower risk of uveitis and arthritis in males with axSpA, but not females. More research is needed to further investigate this paradoxical finding.

Disclosure of Interests

None declared

The toll of unemployment in axial spondyloarthropathy: high prevalence and negative impact on outcomes captured in a national registry

OBJECTIVE

Axial spondyloarthropathy (axSpA) is an inflammatory arthritis of the axial skeleton. Persistent disease activity can result in significant disability and affect the ability to maintain employment. This study aimed to determine the prevalence of unemployment in axSpA and the impact on patient outcomes.

METHOD

Data from the Ankylosing Spondylitis Registry of Ireland (ASRI) were cleaned, and information on employment, demographics, and disease characteristics was extracted. Patients were analysed on the basis of employment and categorized as employed or unemployed.

RESULTS

Of the 759 participants included in the analysis, 23.5% (178) were unemployed, higher than national averages of 6.2-13.1% during the study period. Unemployed participants reported significantly worse Bath Ankylosing Spondylitis Disease Activity Index (BASDAI; 5.1 vs 3.6), Metrology Index (BASMI; 4.8 vs 3.4), Functional Index (BASFI; 5.2 vs 3.0), Health Assessment Questionnaire (HAQ; 0.82 vs 0.40), and Ankylosing Spondylitis Quality of Life (ASQoL; 9.4 vs 5.4) scores compared to employed (all p < 0.01). Male gender (odds ratio, 95% confidence interval: 2.65, 1.46-4.83), worse BASMI (1.16, 1.02-1.33), and worse HAQ scores (2.18, 1.13-4.19) were significantly associated with unemployment.

CONCLUSION

The prevalence of unemployment in axSpA patients is higher than in the general population, and is associated with worse quality of life, poorer levels of function, and higher levels of disease activity. Predictors of unemployment in axSpA were male gender, worse spinal mobility, and poorer level of function. Recognition of patients at risk of unemployment will improve opportunities for intervention and maintain participation in the workforce.

POS0995 EFFECT OF SEX IN CO-EXISTENT FIBROMYALGIA AND ENTHESITIS IN SPONDYLOARTHRITIS: ANCILLARY ANALYSIS OF THE ASAS-PerSpA STUDY

Background:

Enthesitis is a common feature of axial spondyloarthropathy (axSpA) and psoriatic arthritis (PsA). Up to 25% of individuals with axSpA and PsA have a co-existing diagnosis of fibromyalgia syndrome (FMS). The anatomic overlap between tender points in FMS and sites of entheses is a challenge when differentiating between active SpA and FMS. Literature investigating the co-existence of enthesitis and FMS in individuals with SpA is sparse, in particular the effect of sex. The ASAS Peripheral involvement in Spondyloarthritis (PerSpA) study aims to characterize peripheral musculoskeletal in individuals with SpA across the world.

Objectives:

(1)To characterise the co-existence of enthesitis and FMS in individuals with SpA.

(2)To explore the effect of sex on the presence of FMS and enthesitis.

Methods:

All individuals from the cross-sectional multinational ASAS-PerSpA study with a diagnosis of axSpA, peripheral SpA (pSpA) or PsA according to their rheumatologist were included. The Fibromyalgia Rapid Screening Tool (FiRST) was used to make the diagnosis of FMS. The baseline descriptive and clinical differences between sexes were performed using T-tests and crosstabs. Sex-stratified comparisons within the following categories were conducted using chi-square analysis and ANOVA as appropriate: (1) enthesitis & fibromyalgia; (2) enthesitis only; (3) fibromyalgia only; (4) neither.

Results:

Baseline characteristics of the 4465 included patients are outlined in Table 1, stratified by sex. Enthesitis occurred in 44% (n=1984) of the population and was more common in females than males (48% vs 42%, p<0.01). The majority affected had intermittent episodes of enthesitis (55%, n=1088), with the Achilles tendon and plantar fascia the two most common sites in both sexes. Enthesitis was more often confirmed on imaging in females than males (44% v 35%, p<0.01). The most common treatment for enthesitis was non-steroidal anti-inflammatories (97%, n=1318), with no difference when stratified by sex. FMS occurred in 19% (n=775) of patients and was more common in females than males (28% vs 13%, p<0.01).

Table 1.

Participant characteristics, stratified by sex. Values are mean (SD), median (25th, 75th) or n (%). P-values are independent T-tests or Mann-Whitney as appropriate.

VariableTotalMaleFemaleP valueN446527241741Age, years45 (14)43 (14)46 (13)<0.01Disease duration, years11 (6, 20)12 (6, 21)11 (5, 19)0.01Delay to diagnosis, years3 (1, 9)3 (1, 9)3 (1, 10)0.11HLA-B27 positive2066 (66)1457 (73)609 (54)<0.01Radiographic sacroiliitis2517 (61)1788 (70)729 (46)<0.01Sacroiliitis on MRI1817 (65)1128 (68)689 (60)<0.01axSpA ASAS criteria2910 (65)1953 (72)957 (55)<0.01pSpA ASAS criteria555 (12)250 (9)305 (18)<0.01CASPAR criteria1043 (23)508 (19)535 (31)<0.01BMI, kg/m226 (23, 29)26 (23, 29)26 (23, 30)0.24Axial involvement3428 (76.8)2243 (82.3)1185 (68.1)<0.01Peripheral involvement2541 (56.9)1404 (51.5)1137 (65.3)<0.01Enthesitis1984 (44.4)1149 (42.2)835 (48.0)<0.01Uveitis738 (17)482 (18)256 (15)0.01Psoriasis1212 (27)615 (23)597 (34)<0.01Inflammatory bowel disease275 (6)150 (6)125 (7)0.02

Enthesitis and FMS occurred together in 10% of the cohort, was more common in women than men (see Figure 1) and was associated with a significantly (p<0.01) longer delay to diagnosis of 1.8 years and a higher BMI of 2.1 kg/m2 than people with enthesitis only. Objective confirmation of enthesitis was similar in those with and without FMS (38% vs 38%, p=0.92).

The presence of FMS added to the burden of disease in those with enthesitis as assessed by BASDAI (6.4 vs 3.6, p<0.01) and ASDAS-CRP (3.5 vs 2.5, p<0.01), with no difference between sexes (p>0.05).

Conclusion:

In this large cross-sectional multinational analysis, FMS affected 19% of individuals with SpA. The co-existence of enthesitis and FMS occurred in 16% of females compared to 6% of males. The presence of FMS increased the burden of disease in those with enthesitis, as assessed by BASDAI and ASDAS-CRP, with no difference between men and women.

Disclosure of Interests:

Gillian Fitzgerald: None declared, Sinead Maguire Grant/research support from: Recipient of Gilead Inflammation Fellowship, Finbar Barry O’Shea: None declared, Clementina López-Medina: None declared, Maxime Dougados: None declared, Nigil Haroon Speakers bureau: Received honorarium from AbbVie, Eli Lilly, Jannsen, Novartis, UCB, Consultant of: AbbVie, Eli Lilly, Jannsen, Novartis, UCB, Grant/research support from: AbbVie, Eli Lilly, Jannsen, Novartis, UCB.

OP0051 LOOKING BEYOND BASDAI TOTAL SCORES: ANALYSIS OF THE BASDAI ON THE BASIS OF SEX

Background:

Females with axial spondyloarthropathy (axSpA) average scores on patient reported outcomes (PROs) than males. However, this does not necessarily correlate to worse clinical findings. The Ankylosing Spondylitis Registry of Ireland (ARSI) is a national registry on patients with axSpA in Ireland and a source of epidemiological data.

Objectives:

The purpose of this study was to compare the scores of each sex across the individual components of the BASDAI to understand why females report worse scores than males.

Methods:

Analysis of the ASRI was preformed using IBM SPSS version 26. Patients were analyzed on the basis of gender. Comparison of baseline characteristics and mean BASMI, BASFI, HAQ and ASQoL were tested for significance using an independent two tailed t-test and a Mann Whitney U test. Mean total BASDAI score and mean score for each component of the BASDAI were compared and tested for significance with the same statistical tests. A chi-squared test for independence was used to determine significance in variation of HLA-B27 status and radiographic findings.

Results:

A total of 857 patients were included in the analysis. Patient population was 24.9% (213) female and 75.1% (644) male with a mean age of 45.9 years and mean disease duration of 19.4 years (means: BASDAI 4.02, BASMI 4, BASFI 3.67, HAQ 0.53, ASQoL 6.48). Females had worse BASDAI(4.6 vs 3.83, p<0.01), HAQ(0.6 vs 0.51, p=0.03) and ASQoL scores (7.62 vs 6.12, p<0.01) than males. BASFI scores were worse in females which did not reach significance (3.89 vs 3.63, p=0.26). However, females had significantly better BASMI scores than males (3.51 vs 4.16, p<0.01). Within the BASDAI, females scored significantly worse than males across all components (Fatigue: 5.56 vs 4.51, p<0.01; Spinal pain: 5.51 vs 4.63, p<0.01; Other pain: 3.82 vs 3.19, p=0.01; Discomfort: 4.05 vs 3.29, p<0.01; EMS: 4.55 vs 3.94, p=0.01), however duration of EMS did not reach significance (3.54 vs 3.12, p=0.07)(graph 1). Within the BASDAI, females recorded highest mean scores for fatigue (5.56), while males recorded highest mean scores for spinal pain(4.63). Lowest mean scores for both genders was for EMS duration (3.54 vs 3.12). Ranking of the BASDAI components by mean scores show similarity in the ranking of discomfort, EMS, other pain and EMS duration(Table 1).

Table 1.

Ranking in order of severity by mean score

FemalesMales1 -most severeFatigueSpinal pain2Spinal PainFatigue3EMSEMS4DiscomfortDiscomfort5Other painOther pain6 -least severeEMS durationEMS durationGraph 1.

Breakdown of BASDAI scores in Females compared to Males

Conclusion:

AxSpA females have consistently worse PROs but have better spinal mobility than males. Despite females recording worse BASDAI scores than males, the pattern of active disease is similar in 4 of the 6 components of the BASDAI. However, fatigue is the most problematic symptom in females with active axSpA while spinal pain is the most problematic symptom for males. This variation by gender should be kept in consideration when evaluating a patient with suspected active axSpA.

References:

Disclosure of Interests:

Sinead Maguire Grant/research support from: Recipient of the Gilead Inflammation Fellowship, Phil Gallagher: None declared, Finbar Barry O’Shea: None declared

POS0999 HIGH CORRELATIONS BETWEEN QUESTION 1 & 2 OF THE BASFI: AN OPPORTUNITY TO STREAMLINE THE BASFI

Background:

The Bath Ankylosing Spondylitis Functional Index (BASFI) is a useful tool to quantitatively characterise functional ability in a patient with axial spondyloarthropathy (axSpA). Whether first presentation, decompensated, or routine follow-up, BASFI can help establish a more accurate understanding of disease progression, or response. As with any questionnaire, relevance and absence of redundancy is required. This analysis questions the redundancy of the first two questions of the BASFI:

1) How difficult is it to put socks on your feet?

2) How difficult is it to pick a pen up off the floor?

Objectives:

To compare variation in reporting of questions one and two of the BASFI, to establish redundancy or exclusivity of these questions.

Methods:

IBM SPSS version 26 was used for data analysis. Data from axSpA patients who attended the Rheumatology department during the study period were included in the analysis where BASFI scores were available. Both variables (pen scores and sock scores) were assessed with a Shapiro-Wilk’s test for normal distribution. The variables were also assessed for the presence of a monotonic relationship by visual inspection of a scatterplot of the variables. Once a monotonic relationship was established a Spearman’s rank order correlation between the sock score and pen scores for each participant was analysed.

Results:

In total data from 82 axSpA patients were included in this analysis. Population was made up of 28% (23) females, 72% (59) males with mean BASDAI score 4.33 and mean BASFI score 3.88(Table 1). Both variables were not normally distributed as assessed by Shapiro-Wilk’s test (p <0.05) necessitating a Spearman’s rank-order correlation for analysis. Preliminary analysis variables demonstrated the relationship between the variables to be monotonic as determined by visual inspection of the scatterplot (graph 1) with no outliers detected. There was a statistically significant, strong positive correlation between sock scores and pen scores in this axSpA population, rpartial(80) =0.809 significant at the p < 0.01 level.

Table 1.

Descriptive output of data

% (n)n82Females28% (23)Males72% (59)Age45.03BASDAI4.33BASFI3.88Pen score3.93Sock score2.88Sock score greater7.3% (6)Pen score greater50% (41)Same scores42.7% (35)

Conclusion:

There is a strong positive correlation between sock (question 1) and pen scores (question 2) as captured by the BASFI. It appears that both questions are capturing a similar functional limitation in patients with axSpA. In order to minimise redundancy and improve the relevance of the BASFI our results support the removal of one of these questions to simplify the BASFI. From a practical perspective, putting on socks (question 1) would be a more commonly encountered daily activity than picking up a

pen from the floor(question 2). As such, we would suggest removal of question 2 from the BASFI.

Table 1 & Figure 1

Graph 1.

Spread of Data points demonstrating a monotonic relationship with no outliers

Disclosure of Interests:

Michael MacLean: None declared, Sinead Maguire Grant/research support from: Recipient of the Gilead Inflammation Fellowship, Finbar Barry O’Shea: None declared.

POS0949 HIGH PREVALENCE OF ABDOMINAL OBESITY IN FEMALES WITH AXIAL SPONDYLOARTHROPATHY

Background:

Worldwide prevalence of obesity has been steadily increasing, despite significant public health campaigns to raise health awareness. In axial spondyloarthropathy (axSpA) obesity has been shown to be associated with higher levels of disease activity and decreased response to treatment. The waist to hip ratio (WtHpR) is a tool to screen for abdominal obesity. Abdominal deposition of adipose tissue is associated with increased risk of cardiovascular disease, type II diabetes and premature death. Abdominal obesity is more commonly found in males, while females are more prone to gluteal-femoral fat deposition. The Ankylosing Spondylitis Registry of Ireland (ASRI) is a source of epidemiological data of axSpA patients in Ireland.

Objectives:

To capture the prevalence of abdominal obesity in a large cohort of axSpA patients and assess for variation in prevalence between sexes.

Methods:

Participants were analysed on the basis of sex and presence of obesity by BMI and WtHpR. Obesity was defined by body mass index (BMI) with a result of >30 categorised as obese as per CDC definitions. Abdominal obesity was assessed by WtHpR and defined as per WHO guidelines. Categorical variables were recorded as frequencies, with a chi2 test for independence used to test for statistical significance. Numerical variables were recorded as means within each group and an independent t-test or Mann Whitney U test was used to test for statistical significance between groups. A p-value of <0.05 was deemed significant. IBM SPSS version 26 was used for statistical analysis of the patient population captured within the ASRI.

Results:

At the time of analysis, physical measurements were available on 692 patients in the ASRI made up of 96.2% (666) Caucasians with 22.3% (154) females and 77.7% (538) males. The average age was 45.9 years with a mean disease duration of 18.8 years (mean scores: BASDAI 4.09, BASFI 3.71, BASMI 3.99, HAQ 0.54, ASQoL 6.72). 80.9% (560) of patients had radiographic sacroiliitis while 49.1% (340) had sacroiliitis on MRI.

Overall 29.5% (215) patients were obese based on BMI results, while 37.5% (274) were centrally obese as per the WtHpR. Analysis on the basis of sex revealed no significant variation in mean BMI (28.1 vs 27.7, p=0.45) or prevalence of obesity as assessed by BMI (29.9% vs 28.6%, p=0.49) between males and females(table 1). As expected analysis of WtHpR revealed higher mean ratios in males compared to females (0.96 vs 0.89, p<0.01), however there was a significantly higher prevalence of abdominal obesity in females (29.9% vs 68.2%, p<0.01).

Table 1.

Assessment of Obesity by Sex

MalesFemalesp valuen77.7% (538)22.3% (154)Weight (kg)84.9872.76<0.01BMI28.0827.690.45Underweight0.9% (5)0.06% (1)0.49Normal Weight29.2% (157)36.4% (56)Overweight39.2% (211)34.4% (53)Obese29.9% (161)28.6% (44)Waist Circumference (cm)97.4390.03<0.01Hip Circumference (cm)102.11101.270.56Waist to Hip Ratio0.9560.8901<0.01Normal Weight23.8% (128)17.5% (27)<0.01Overweight46.3% (249)14.3% (22)Obese29.9% (161)68.2% (105)

Conclusion:

There is a high prevalence of abdominal obesity as assessed by WtHpR in axSpA, this is especially high in females with axSpA. Use of WtHpR should be considered when screening for obesity in this population.

Disclosure of Interests:

Sinead Maguire Grant/research support from: Recipient of the Gilead Inflammation fellowship grant, Phil Gallagher: None declared, Fiona Wilson: None declared, Finbar Barry O’Shea: None declared

POS0964 CHARACTERISTICS AND BURDEN OF DISEASE IN PATIENTS WITH RADIOGRAPHIC VERSUS NON-RADIOGRAPHIC AXIAL SPONDYLOARTHRITIS IN THE ANKYLOSING SPONDYLITIS REGISTRY OF IRELAND COHORT

Background:

Axial spondyloarthritis (axSpA) is an umbrella term for types of inflammatory arthritis that primarily affect the spine and the sacroiliac joints. It is comprised of patients with both radiographic (r-axSpA) and non-radiographic features (nr-axSpA). R-axSpA was historically known as Ankylosing Spondylitis. Previous studies have shown the burden of disease to be largely similar in patients with radiographic versus non-radiographic axial spondyloarthritis in cohorts both in the US and Europe [1]. The Ankylosing Spondylitis Registry of Ireland (ASRI) was formed with the objective to measure the burden of axial spondyloarthritis in the population and identify early predictors of a poor outcome. All patients in the registry are 18 years or older and meet Assessment of Spondyloarthritis International Society (ASAS) criteria for a diagnosis of SpA.

Objectives:

To compare the characteristics and burden of disease in patients with radiographic versus non-radiographic axial spondyloarthritis in the ASRI cohort.

Methods:

Patients with radiographic axial spondyloarthritis (r-axSpA) were defined as those with x-ray evidence of sacroiliitis. Patients with non-radiographic axial spondyloarthritis (nr-axSpA) were defined as having MRI evidence of sacroiliitis but no x-ray evidence of sacroiliitis. A standardised clinical assessment was performed on each patient and structured interviews provided patient-reported data. For each patient the following scores were captured: Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Bath Ankylosing Spondylitis Functional Index (BASFI), Bath Ankylosing Spondylitis Metrology Index (BASMI), Health Assessment Questionnaire (HAQ) assesses the self-reported functional status for performing activities of daily living, and the Ankylosing Spondylitis Quality of Life (ASQoL) questionnaire. Categorical variables were summarized as percentages with frequency counts, and continuous variables with a mean and standard deviation. Statistical comparisons between subgroups were evaluated using 2 sample t-tests for continuous variables and chi-square tests for categorical variables.

Results:

764 patients were available for analysis. Analysis of radiographic status showed 88.1% (n=673) of patients with r-axSpA and 11.9% (n=91) with nr-axSpA. Patients with nr-axSpA were younger (41.3 vs. 46.6 years, p<0.01), had shorter disease duration (14.8 vs. 20.2 years, p<0.01), lower proportion of males (66.6% vs. 78.4%, p=0.02) with lower rates of HLA-B27 positivity (73.6% vs. 90.5%, p<0.01). The nr-axSpA group had lower BASDAI (3.37 vs. 4.05, p=0.01), BASFI (2.46 vs. 3.88, p<0.01), BASMI (2.33 vs. 4.34, p<0.01), ASQoL (5.2 vs. 6.67, p=0.02), and HAQ scores (0.38 vs. 0.57, p<0.01). There were no significant differences in the prevalence of extra-articular manifestations.

Conclusion:

This study provides evidence that the burden of disease is less in patients with non-radiographic axial spondyloarthritis than radiographic axial spondyloarthritis, as demonstrated by better BASDAI, BASFI, BASMI, HAQ and ASQoL scores.

References:

[1]López-Medina C, et al. Characteristics and burden of disease in patients with radiographic and non-radiographic axial Spondyloarthritis: a comparison by systematic literature review and meta-analysis. RMD Open, 2019. 5(2) p1108.

Table 1.r-axSpAnr-axSpAp valuen67391Age (years)46.6 (+/-12.4)41.3 (+/-12.4)<0.01Disease duration (years)20.2 (+/-12.4)14.8 (+/-11.7)<0.01Delay to diagnosis (years)8.41 (+/-8.6)6.34 (+/-7.2)0.03Males78.8% (528)65.9% (60)0.02Females21.5% (145)34.1% (31)0.02HLA-B27+90.50%(440 of 486 available results)73.60%(53 of 72 available results)<0.01BASDAI4.05 (+/-2.39)3.37 (+/-2.31)0.01BASFI3.88 (+/-3.00)2.46 (+/-2.39)<0.01BASMI4.34 (+/-2.08)2.33 (+/-1.42)<0.01ASQoL6.67 (+/-5.55)5.2 (+/-5.53)0.02HAQ0.57 (+/-0.54)0.38 (+/-0.44)<0.01Psoriasis17.8% (120)15.4% (14)0.31IBD11% (74)8.8% (8)0.58Uveitis33.9% (228)34.1% (31)0.54

Disclosure of Interests:

Sean Quinn: None declared, Sinead Maguire: None declared, Finbar Barry O’Shea: None declared, Lorraine O’Neill: None declared, Eamonn Molloy: None declared, Ursula Fearon Speakers bureau: Abbvie, Grant/research support from: Janssen, Abbvie, Pfizer, UCB, Phil Gallagher: None declared, Douglas Veale Speakers bureau: AbbVie, BMS, Celgene, Pfizer, MSD, Roche, Consultant of: AbbVie, Actelion, BMS, Novartis, Pfizer, MSD, Roche, Regeneron/Sanofi, Grant/research support from: AbbVie, Pfizer, MSD, Novartis, Roche, Janssen.

POS0942 THE NEGATIVE IMPACT OF UNDIAGNOSED DEPRESSION IN AXIAL SPONDYLOARTHROPARTHY: RESULTS OF A SCREENING STUDY

Background:

Previous research in axial spondyloarthropathy(axSpA) has shown this population to have a high prevalence of depression. This co-morbidity has been previously shown to impact disease activity in patients with rheumatic disease.

Objectives:

The purpose of this study was to screen for early signs of depression using two validated tools, the Patient Health Questionaire-9 (PHQ-9) and the Hospital Anxiety and Depression Scale for depression (HADs-D) in patients with known axSpA.

Methods:

AxSpA patients attending the Rheumatology department in St James’ Hospital between February and October 2020 were invited to take a self-administered survey which included the PHQ-9 and the HADs-D. Scores from the HADs-D yielded a numerical result which was then categorised as normal, borderline or abnormal. PHQ-9 numerical results were categorised as normal, mild, moderate, moderate/severe or severe. Patients with a known diagnosis of depression were excluded. In addition to baseline demographics, patient reported outcomes from the clinic visit were also recorded.

Data analysis was performed using IBM SPSS version 26. Continuous variables were recorded as means, categorical variables as frequencies with percentages. A one-way analysis of variance analysis (ANOVA) was used to determine significance of variation in outcomes between patient outcomes as determined by the HADs-D and PHQ-9. A p-value of <0.05 was deemed significant. Consent was obtained prior to participation. Approval was received from the St James’/Tallaght Hospital Joint Ethics Committee.

Results:

In total 71 axSpA patients took part in the survey. The population was 70.4%(50) males and 29.5%(21) female, with an average age 47.9 years and mean disease duration 19.7 years (mean outcomes: BASDAI 4.08, BASFI 3.62, BASMI 3.54, ASQoL 6.79). Overall, 7 (9.9%) participants recorded abnormal HADs-D scores, while 17 (23.9%) recorded moderate to severe PHQ-9 scores indicative of underlying depression. AxSpA females had higher mean HADs-D scores (7.5 vs 4.8, p=0.01) than males, with abnormal scores in 19%(4) of females and 6% (3) of males. No significant differences were found in PHQ-9 scores between genders.

Analysis revealed significantly worse BASDAI (6.27 vs 3.42, p<0.01) and AQoL scores (12.57 vs 5.26, p<0.01) in axSpA patients with abnormal compared to normal HADs-D scores. No significant differences were noted in BASFI, BASMI or baseline demographics. A similar pattern was noted on analysis of PHQ-9 scores, with significantly worse BASDAI (7.9 vs 2.55, p<0.01), BASFI (8.05 vs 2.33, p<0.01) and ASQoL (19.5 vs 2.62, p<0.01) noted in those scoring as severe compared to normal. No significant differences were detected in BASMI scores or baseline demographics.

Conclusion:

A high percentage of axSpA patients recorded high HADs-D and PHQ-9 scores concerning for undiagnosed depression. These patients were noted to have significantly worse disease activity and quality of life as compared to patients with normal scores. Clinicians treating axSpA should consider screening for depression in this population.

Disclosure of Interests:

Sinead Maguire Speakers bureau: Speaker fee from Jassen, Grant/research support from: Recipient of the Gilead Inflammation Fellowship Grant, Finbar Barry O’Shea: None declared

Evaluation of microcalcification contrast in clinical images for digital mammography and synthetic mammography

PURPOSE

The aim of this work was to compare, in a clinical study, digital mammography and synthetic mammography imaging by evaluating the contrast in microcalcifications of different sizes.

METHODS

A retrospective review of microcalcifications from 46 patients was undertaken. A Hologic 3-Dimensions mammography system and a HD Combo protocol was used for simultaneous acquisition of the digital and synthetic images. Microcalcifications were classified in accordance with their size, and patient breast images were classified in accordance with their density as adipose, moderately dense and dense. The contrast of the microcalcifications was measured and the contrast ratio between synthetic and digital images was compared. An additional qualitative assessment of the images was presented to correlate the conspicuity of the microcalcifications with the suppression of the structure noise.

RESULTS

Microcalcifications in adipose background always exhibit a comparable or better contrast on synthetic images, regardless their size. For moderately dense background, synthetic images show a better contrast in 91.2 % of cases for small microcalcifications and in 90.9 % of cases for large microcalcifications. For a dense background, better contrast is seen in 89.5 % of cases for small microcalcifications, and in 85.7 % of cases for large microcalcifications. The contrast ratio increases with increasing breast glandularity. The suppression of structure noise also contributes to the enhancement of microcalcifications in the synthetic images.

CONCLUSIONS

Synthetic mammography imaging is superior to digital mammography imaging in terms of microcalcification contrast, regardless their size and breast density.

Assessment of structural chromosomal instability phenotypes as biomarkers of carboplatin response in triple negative breast cancer: the TNT trial

BACKGROUND

In the TNT trial of triple negative breast cancer (NCT00532727), germline BRCA1/2 mutations were present in 28% of carboplatin responders. We assessed quantitative measures of structural chromosomal instability (CIN) to identify a wider patient subgroup within TNT with preferential benefit from carboplatin over docetaxel.

PATIENTS AND METHODS

Copy number aberrations (CNAs) were established from 135 formalin-fixed paraffin-embedded primary carcinomas using Illumina OmniExpress SNP-arrays. Seven published [allelic imbalanced CNA (AiCNA); allelic balanced CNA (AbCNA); copy number neutral loss of heterozygosity (CnLOH); number of telomeric allelic imbalances (NtAI); BRCA1-like status; percentage of genome altered (PGA); homologous recombination deficiency (HRD) scores] and two novel [Shannon diversity index (SI); high-level amplifications (HLAMP)] CIN-measurements were derived. HLAMP was defined based on the presence of at least one of the top 5% amplified cytobands located on 1q, 8q and 10p. Continuous CIN-measurements were divided into tertiles. All nine CIN-measurements were used to analyse objective response rate (ORR) and progression-free survival (PFS).

RESULTS

Patients with tumours without HLAMP had a numerically higher ORR and significantly longer PFS in the carboplatin (C) than in the docetaxel (D) arm [56% (C) versus 29% (D), PHLAMP,quiet = 0.085; PFS 6.1 months (C) versus 4.1 months (D), Pinteraction/HLAMP = 0.047]. In the carboplatin arm, patients with tumours showing intermediate telomeric NtAI and AiCNA had higher ORR [54% (C) versus 20% (D), PNtAI,intermediate = 0.03; 62% (C) versus 33% (D), PAiCNA,intermediate = 0.076]. Patients with high AiCNA and PGA had shorter PFS in the carboplatin arm [3.4 months (high) versus 5.7 months (low/intermediate); and 3.8 months (high) versus 5.6 months (low/intermediate), respectively; Pinteraction/AiCNA = 0.027, Padj.interaction/AiCNA = 0.125 and Pinteraction/PGA = 0.053, Padj.interaction/PGA = 0.176], whilst no difference was observed in the docetaxel arm.

CONCLUSIONS

Patients with tumours lacking HLAMP and demonstrating intermediate CIN-measurements formed a subgroup benefitting from carboplatin relative to docetaxel treatment within the TNT trial. This suggests a complex and paradoxical relationship between the extent of genomic instability in primary tumours and treatment response in the metastatic setting.

Translating evidence-based treatment for digital health delivery: a protocol for family-based treatment for anorexia nervosa using telemedicine

BACKGROUND

Family-based treatment (FBT) is an efficacious outpatient intervention for young people diagnosed with Anorexia Nervosa (AN). To date, treatment to protocol has relied on standard face-to-face delivery. Face-to-face therapy is subject to geographic, temporal and human factors, rendering it particularly susceptible to inequities and disruption. This has resulted in poorer service provision for rural and regional families, and recently a significant challenge to providing face-to-face services during the COVID-19 global pandemic. The present study examines whether FBT for AN can be successfully translated to a digital delivery platform to address these access issues.

METHOD

Forty young people aged 12 to 18 years who meet DSM-5 diagnostic criteria for AN, and live in a rural or regional setting, will along with their family be recruited to the study. Trained therapists will provide 18 sessions of FBT over 9 months via telemedicine to the home of the young person and their family. The analysis will examine treatment effectiveness, feasibility, acceptability, and cost-effectiveness.

DISCUSSION

The study addresses the treatment needs of families not able to attend face-to-face clinical services for evidence-based treatment for eating disorders. This might be due to several barriers, including a lack of local services or long travel distances to services. There has been a recent and unprecedented demand for telemedicine to facilitate the continuity of care during COVID-19 despite geographical circumstances. If delivering treatment in this modality is clinically and economically effective and feasible, it will facilitate access to potentially lifesaving, evidence-based treatments for families formerly unable to access such care and provide evidence for the continuity of services when and where face-to-face treatment is not feasible.

SAT0382 THE SAME BUT DIFFERENT? ANALYSIS OF A COHORT OF PATIENTS WITH LATE ONSET ANKYLOSING SPONDYLITIS

Background:

Ankylosing spondylitis(AS) has long been described as presenting in the third decade of life with the onset rarely occurring over the age of 45 years old. Previous research has shown there are small numbers of patients being diagnosed with AS later in life. These studies have been limited to small numbers limiting the ability to detect patterns in disease. The Ankylosing Spondylitis Registry of Ireland (ASRI) is an epidemiological data source on patients with AS in Ireland. Large registries, such as this, are an opportunity to further study this subtype in large numbers with greater power to detect differences between late and typical onset.

Objectives:

The purpose of this study was to examine late onset AS in a large, well characterized cohort.

Methods:

Patient registered in ASRI were analysed on the basis of their age of symptom onset using IBM SPSS version 26. Patients were divided into two groups with an age over 45 years old at symptoms onset categorized at late onset. Mean BASMI, BASFI, BASDAI, HAQ, and ASQoL scores were compared between the two groups and tested for statistical significance using an independent two tailed t-test. Further analysis looking at differences in gender, HLA B27 status, sacroiliitis on MRI, medication use and extra-articular manifestations(EAMs) was also performed using a chi-squared test for independence.

Results:

A total of 851 patients with AS were included in the analysis. Of these patients 659(77.4%) were males, with 192(22.6%) females, mean age of 45.8 years and mean disease duration of 19.4 years (means: ASQoL 6.52, HAQ 0.54, BASDAI 4.03, BASFI 3.7, BASMI 4.03). Patient population was made up of 797 patients(93.7%) categorized as typical onset, 54 patients(6.3%) categorized as late onset(table 1). Males had a higher rate of late onset AS than females, but this did not reach significance (6.8% vs 4.7%, p=0.19). Patients with late onset AS were noted to have higher BASFI (5.53 vs 3.58, p<0.01), HAQ (0.75 vs 0.53, p<0.01) and ASQoL scores (7.68 vs 6.44, p<0.01). Late onset patients also had lower rates of HLA-B27 positivity (76.5% vs 91.2%, p<0.01). No significant difference was detected in BASDAI or BASMI scores. No difference was detected between groups regarding rates EAMs. The late onset AS patients were noted to have lower rates of biologic therapy use (50% vs 72%, p<0.01). No significant difference was detected in rates of NSAID use.

Table 1.Onset < 45 years (n=797)Late Onset (n=54)pvalueMales (n=659)93.2% (614)6.8% (83.3)0.19Females (n=192)23% (183)16.6% (9)HLA B27+ (n=580)90.5% (554)76.5% (26)<0.01Enthesitis (n=146)16.9% (135)20.4% (11)0.45Dactylitis (n=54)6% (48)11.1% (6)0.21Arthritis (n=256)29.7% (237)35.2% (19)0.4MRI Sacroiliitis (n=384)45.3% (361)42.6% (23)0.69Bilateral sacroiliits (n=668)79% (628)74% (40)0.07BASDAI4.024.190.6BASFI3.585.53<0.01BASMI3.964.970.12HAQ0.530.75<0.01ASQoL6.447.68<0.01Uveitis28.5% (227)24.1% (13)0.07IBD9.9% (79)14.8% (8)0.32Psoriasis16.4% (131)18.5% (10)0.54Smokers (ever)57.3% (457)64.8% (35)0.01Alcohol consumption (ever)82% (654)75.9% (41)0.53Biologic tx69.1% (551)48.1% (26)<0.01NSAID tx54.2% (432)61.1% (33)0.2Figure 1.

Conclusion:

This analysis shows that late onset AS does occur in up to 6.3% of patients with AS. Patients with late onset disease were noted to have similar patterns of disease, EAMs and radiological findings consistent with current classification criteria for AS. Less patients with late onset disease were HLA-B27 positive, the reason for this is unknow. These patients had worse functional outcomes, which could reflect the older age of symptom onset. It is notable that patients with late onset AS are being treated with less biologic agents, and have a slightly higher rate of NSAID usage. Additional registry studies into this subgroup would help to understand these variations in medication usage and prescribing practices.

Disclosure of Interests:

Sinead Maguire Grant/research support from: ASRI is supported by funding from Pfizer, AbbVie and UCB, Phil Gallagher: None declared, Finbar Barry O’Shea Grant/research support from: ASRI is supported by funding from Pfizer, AbbVie and UCB

SAT0381 UNDERSTANDING JOINT REPLACEMENT SURGERY IN AXIAL SPONDYLOARTHROPATHY

Background:

Axial spondyloarthropathy(axSpA) is a form of inflammatory arthritis that primarily affects the axial skeleton and sacroiliac joint, but can be associated with a peripheral arthritis. Rapid advances in the field of axSpA has led to faster detection, diagnosis and treatment of this disease. This improved management has led to improved level of function and quality of life for patients, despite this a proportion of patients are still requiring joint replacement surgery. The Ankylosing Spondylitis Registry of Ireland (ASRI) is a source of epidemiological data on patients with axSpA in Ireland. Given the large size of the ASRI to date, this is a prime opportunity to analyze patients with axSpA requiring joint replacement surgery.

Objectives:

Detailed analysis of a large cohort of patients with axSpA with a focus on those who underwent joint replacement to determine trends in disease and baseline demographics.

Methods:

The patient population registered in the ASRI was analysed using IBM SPSS version 26. Analysis was performed by comparing patients who underwent joint replacement surgery to the rest of the ASRI cohort. Mean age, disease duration, delay to diagnosis and scores of disease activity (BASDAI, BASFI, HAQ, ASQoL and BASMI) were compared between these two groups. Differences between the groups was tested for significance using an independent two tailed t-test. Further analysis on gender, HLA-B27 status, co-morbidities and medication exposure was done using a chi-squared test for independence. A p value of less than 0.05 was deemed significant.

Results:

At present 860 patients are currently enrolled in the ASRI with 76.6% (659) males and 23.4% (201) females. Average age of patients is 45.8 years, mean disease duration of 19.4 years with 95.5% (821) of patients listed as Caucasian. Mean scores were BASDAI 4.02, BASFI 3.7, BASMI4.02, HAQ 0.55, and ASQoL of 6.51. In total 33 (3.8%) of patients underwent joint replacement surgery. These patients were noted to be significantly older than the rest of the rest of the cohort (55.3 years old vs 45.1, p<0.01), with a longer disease duration (31.6 years vs 18.3, p<0.01) and higher rates of HLA-B27 positivity (94.7% vs 80.2%, p<0.01). No significant differences were noted between gender(table 1). No significant difference was found between medication exposure rates, although the joint replacement population did have higher rates of NSAID, sDMARD and biologic therapy usage than the rest of the population although this did not reach significance. These patients also scored worse in all measures of disease activity, although this only reached significance in the BASFI (5.67 vs 3.64, p<0.01), HAQ (0.9 vs 0.54, p<0.01) and the BASMI (6.07 vs 3.94, p<0.01).

Table 1.Joint replacement (n=33)No Joint Replacement (n=827)p valueAge55.345.1<0.01Disease duration31.618.31<0.01Delay to dx6.977.970.51HLA-B27+94.7% (18)71.9% (491)<0.01Males78.8% (26)64.7% (535)0.76Females21.2% (7)19.3% (160)0.76Mean ScoresBASDAI4.914.060.06BASFI5.673.64<0.01HAQ0.90.54<0.01ASQoL7.426.670.45BASMI6.073.94<0.01MedicationsNSAIDs51.5% (17)47% (389)0.21Bio tx72.7% (24)57.2% (473)0.9DMARDs33.3% (11)15.7% (130)0.1

Conclusion:

Patients requiring joint replacement surgery, although few in number, represent a cohort with significantly impaired function and quality of life. This is likely due to the fact that these patients were older with more established disease. It is therefore not surprising that this cohort had significantly worse spinal mobility. As registries continues to develop, it will be interesting to see if rates of joint replacement surgery will decline with increased use of biologic therapy at an earlier stage of disease. This will help to differentiate patients requiring joint replacement surgery due to underlying inflammatory arthritis and those with osteoarthritis.

Disclosure of Interests:

Sinead Maguire Grant/research support from: ASRI is supported by funding from Pfizer, AbbVie and UCB, Phil Gallagher: None declared, Finbar Barry O’Shea Grant/research support from: ASRI is supported by funding from Pfizer, AbbVie and UCB

AB0704 PRESCRIBING PRACTICES IN AXIAL SPONDYLOARTHROPATHY

Background:

Axial spondyloarthropathy(axSpA) treatment has undergone a number of significant developments over the past number of decades. Previously limited to non-steroidal anti-inflammatories (NSAIDs) and corticosteroids, treatment options now include synthetic disease modifying anti-rheumatic drugs(sDMARDs) and biologic agents. The development of national registries for inflammatory arthritis provides an opportunity to study medication usage in a large cohort of patients with axSpA. The Ankylosing Spondylitis Registry of Ireland (ASRI) is a source of epidemiological data on patients with axSpA in Ireland. The aim of this study was to examine medication exposure and outcomes.

Objectives:

To characterize a large cohort of patients with axSpA in terms of medications usage, burden of disease and patient reported outcomes.

Methods:

The patient population registered in the ASRI was analysed using IBM SPSS version 26. Patients were analyzed on the basis of medication exposure. The four treatment groups were classified as no treatment, NSAIDs only, biologics only, or biologics and NSAIDs. Mean age, duration of disease and delay to diagnosis was compared between groups. Burden of disease was assessed via mean BASDAI, BASFI, BASMI, HAQ and ASQoL between the four groups. Differences between groups was tested for statistical significance a one-way analysis of variance (ANOVA). A chi-squared test for independence was used to compare differences in rates of HLA-B27 positivity rates and gender. Results were deemed significant where p < 0.05.

Results:

At present 860 patients are currently enrolled in the ASRI with 76.6% (659) males and 23.4% (201) females. Average age of patients is 45.8 years, mean disease duration of 19.4 years with 95.5% (821) of patients listed as Caucasian. Mean scores were BASDAI 4.02, BASFI 3.7, BASMI 4.02, HAQ 0.55, and ASQoL of 6.51. Treatment groups were made up of 9.9%(85) on no treatment, 22.2%(191) NSAIDs treatment only, 34.8%(299) biologics treatment only and 32.1%(276) treated with both NSAIDs and biologics. Patients only on NSAIDs were noted to be older than patients on biologics, and those on both biologics and NSAIDs (p=0.02). Patients on NSAIDs were older at symptom onset than those on both biologic and NSAID treatment (p=0.02), however the effect size is small(0.012). No significant difference was noted between groups regarding disease duration, delay to diagnosis or distribution between genders (table 1). Difference in BASDAI scores between groups was significant between all groups, with patients on both biologics and NSAIDs having the highest scores and those on no treatment with the lowest scores(4.74 vs 3.37) possibly a reflection of disease severity(table 2).

Table 1.ASRINo txNSAIDs txBiologic txBiologic & NSAIDsp valueNumber8609.9% (85)22.2% (191)37.8% (299)32.1% (276)Age45.849.746.245.345.10.02Symptom onset26.427.528.226.125.20.02Disease duration19.422.21819.119.80.06Delay to dx89.88.17.480.13Table 2.ASRINo txNSAIDs txBiologic txBiologic & NSAIDsp valueEffect SizeBASDAI4.023.374.213.44.740.063.374.210.043.374.74<0.014.213.4<0.013.44.74<0.01

Conclusion:

A large proportion of patients in the ASRI were treated with either biologics only or both biologics and NSAIDs. No treatment was the least common treatment within this cohort. Patients not on treatment tended to be older than those on any type of treatment. Overall patients on biologics alone tended to have better patient reported outcomes as compared to all other treatment groups. The development of longitudinal data for the ASRI will help to further understand the reason behind these differences.

Disclosure of Interests:

Sinead Maguire Grant/research support from: ASRI is supported by funding from Pfizer, AbbVie and UCB, Phil Gallagher: None declared, Finbar Barry O’Shea Grant/research support from: ASRI is supported by funding from Pfizer, AbbVie and UCB

The relationship between sarcopenia and survival at 1 year in patients having elective colorectal cancer surgery

Background

Colorectal cancer remains a common cause of cancer death in the UK, with surgery being the mainstay of treatment. An objective measurement of the suitability of each patient for surgery, and their risk–benefit calculation, would be of great utility. We postulate that sarcopenia (low muscle mass) could fulfil this role as a prognostic indicator. The aim of this study was to determine the relationship between sarcopenia and long-term outcomes in patients undergoing elective bowel resection for colorectal cancer.

Methods

One hundred and sixty-three consecutive patients who had elective curative colorectal resection for cancer were eligible for inclusion in the study. Psoas muscle mass was assessed on preoperative computed tomography scan at the level of the L3 vertebra and standardised for patient height (total psoas index, TPI). Sarcopenia (low muscle mass) was defined as < 524 mm²/m² in males and 385 mm²/m² in females. In addition to clinical–pathological parameters, postoperative complications were recorded and patients were followed up for mortality for 1 year after surgery.

Results

Sarcopenia was present in 19.6% of the study participants and was significantly related to body mass index (p = 0.007), 30-day mortality (p = 0.042) and 1-year mortality (p = 0.046). In univariate analysis, American Society of Anesthesiologists grade (p = 0.016), tumour stage (p = 0.018) and sarcopenia (p = 0.043) were found to be significant independent predictors of 1-year mortality.

Conclusions

This study has found sarcopenia to be prevalent in patients with colorectal cancer having elective surgery. Independent of age, sarcopenia was associated with poorer 30-day mortality and survival at 1 year. Measurement of muscle mass preoperatively could be used to stratify a patient’s risk, allowing targeted strategies such as prehabilitation, to be implemented to modify sarcopenia and improve long-term outcomes for patients.

A comparison of four different imaging modalities - Conventional, cross polarized, infra-red and ultra-violet in the assessment of childhood bruising

Background

It is standard practice to image concerning bruises in children. We aim to compare the clarity and measurements of bruises using cross polarized, infra-red (IR) and ultra-violet (UV) images to conventional images.

Methods

Children aged <11 years with incidental bruising were recruited. Demographics, skin and bruise details were recorded. Bruises were imaged by standard protocols in conventional, cross-polarized, IR and UV lights. Bruises were assessed in vivo for contrast, uniformity and diffuseness, and these characteristics were then compared across image modalities. Color images (conventional, cross polarized) were segmented and measured by ImageJ. Bruises of grey scale images (IR, UV) were measured by a ‘plug in’ of ImageJ. The maximum and minimum Feret's diameter, area and aspect ratio, were determined. Comparison of measurements across imaging modalities was conducted using Wilcoxon rank sum tests and modified Bland-Altman graphs. Significance was set at p < 0.05.

Results

Twenty five children had 39 bruises. Bruises that were of low contrast, i.e. difficult to distinguish from surrounding skin, were also more diffuse, and less uniformity in vivo. Low contrast bruises were best seen on conventional and cross-polarized images and less distinctive on IR and UV images. Of the 19 bruises visible in all modalities, the only significant difference was maximum and minimum Feret's diameters and area were smaller on IR compared to conventional images. Aspect ratios were not affected by the modality.

Conclusions

Conventional and cross-polarized imaging provides the most consistent bruise measurement, particularly in bruises that are not easily distinguished from surrounding skin visually.

•

Diffuse bruises may be measured on conventional & cross polarized imaging.

•

Infrared or ultraviolet imaging may not show bruises which are difficult to see in vivo.

•

Measurements of bruises using infrared imaging may be smaller than other modalities.

Optimising the measurement of bruises in children across conventional and cross polarized images using segmentation analysis techniques in Image J, Photoshop and circle diameter measurements

BACKGROUND

Bruising is a common abusive injury in children, and it is standard practice to image and measure them, yet there is no current standard for measuring bruise size consistently. We aim to identify the optimal method of measuring photographic images of bruises, including computerised measurement techniques.

METHODS

24 children aged <11 years (mean age of 6.9, range 2.5-10 years) with a bruise were recruited from the community. Demographics and bruise details were recorded. Each bruise was measured in vivo using a paper measuring tape. Standardised conventional and cross polarized digital images were obtained. The diameter of bruise images were measured by three computer aided measurement techniques: Image J (segmentation with Simple Interactive Object Extraction (maximum Feret diameter), 'Circular Selection Tool' (Circle diameter), & the Photoshop 'ruler' software (Photoshop diameter)). Inter and intra-observer effects were determined by two individuals repeating 11 electronic measurements, and relevant Intraclass Correlation Coefficient's (ICC's) were used to establish reliability. Spearman's rank correlation was used to compare in vivo with computerised measurements; a comparison of measurement techniques across imaging modalities was conducted using Kolmogorov-Smirnov tests. Significance was set at p < 0.05 for all tests.

RESULTS

Images were available for 38 bruises in vivo, with 48 bruises visible on cross polarized imaging and 46 on conventional imaging (some bruises interpreted as being single in vivo appeared to be multiple in digital images). Correlation coefficients were >0.5 for all techniques, with maximum Feret diameter and maximum Photoshop diameter on conventional images having the strongest correlation with in vivo measurements. There were significant differences between in vivo and computer-aided measurements, but none between different computer-aided measurement techniques. Overall, computer aided measurements appeared larger than in vivo. Inter- and intra-observer agreement was high for all maximum diameter measurements (ICC's > 0.7).

CONCLUSIONS

Whilst there are minimal differences between measurements of images obtained, the most consistent results were obtained when conventional images, segmented by Image J Software, were measured with a Feret diameter. This is therefore proposed as a standard for future research, and forensic practice, with the proviso that all computer aided measurements appear larger than in vivo.

Donegal Going against the Flow: National Differences in Long-Term Urinary Catheterisation Rates in Men (> 65 Years) With Benign Prostatic Hypertrophy

An analysis of Primary Care Reimbursement Service (PCRS, 2013) data demonstrated high rates of urinary catheter changes in Donegal compared to other regions of Ireland. There is a catheter change rate of 10.2% in Donegal men over 65 with medical cards (GMS) compared to rates of 2.7% and 0.17% in Waterford and South Dublin, respectively1. This 60-fold difference between an area with perceived good access to services (South Dublin) and Donegal an area that does not, prompted a survey of general practitioners in each of these areas to assess whether true male catheterisation rates were similarly disproportionate in Donegal. Based on this, data was collected from a population of 23,794 GMS patients in GP training practices in Donegal (Rural), Leinster (Urban) and Waterford (Suburban). The data sampled for Donegal demonstrated 19 long-term catheters (LTCs per 8603 GMS) compared to four LTCs (per 5,800 GMS) in Leinster and 3 LTCs (per 9,391 GMS) in Waterford (Table 1). This anomaly in LTC rates may be a proxy for lack of access to basic Urology services.

Characteristics of non-vitreoretinal ocular injury in child maltreatment: a systematic review

PurposeTo identify the spectrum of non-vitreoretinal ocular injury due to child maltreatment.MethodsAll language search of MEDLINE, PsychINFO, EMBASE, AMED, Web of Science, and CINAHL databases, 1950-2015, was conducted.

INCLUSION CRITERIA

explicit confirmation of injury aetiology, age <18 years, examination conducted by an ophthalmologist. Exclusion: post-mortem data, organic diseases, review articles. Standardised critical appraisal and narrative synthesis was conducted of included publications by two independent reviewers.ResultsOf 1492 studies identified, 153 full texts were assessed, 49 underwent full review, resulting in five included studies: three case series and two case reports. The 26 included cases describe a wide variety of ocular, facial and skeletal injuries occurring as a consequence of child maltreatment. Ocular signs included periorbital oedema, chemosis, injection, abrasion, hyphaema, and cataract. Of interest all children that had suffered physical abuse with ocular injury had subconjunctival haemorrhages. Children presenting with abusive ocular injuries had a mean age of 13.9 months (range 1-68), while those who suffered violent corporal punishment were considerably older (mean 96 months). All cases, apart from severe corporal punishment, underwent screening for occult fractures, but neuroimaging only apparent in 2/5 eligible cases.ConclusionAlthough, the face is the most common site of abusive injury, there is a paucity of high-quality data on non-vitreoretinal ocular abusive injury. Thus, while subconjunctival haemorrhages are a potential sentinel injury of maltreatment, and may warrant further evaluation, the lack of large-scale published data limits our ability to highlight further specific characteristics of non-vitreoretinal ocular injury indicative of child abuse.

Abstract P1-05-14: Copy number aberration-induced gene breakage analysis identifies recurrent FOXP1 fusions in breast cancer

Background: Genomic instability is a critical feature of breast cancers, which manifests in genome-wide copy number aberrations (CNA), often causing “gene breakage” and the generation of fusion genes. We aimed to identify aborted transcripts with underlying CNAs and to investigate the molecular landscape of breast cancers harbouring such events.

Methods: A walking student's t-test algorithm was applied to Affymetrix Exon 1.0ST array data of 123 breast cancers to identify regions of aborted transcription and overlaid with DNA breakpoints derived from matched Affymetrix SNP6 ASCAT-segmented copy number. Aborted transcripts were investigated as potential fusion gene partners through RNA-seq analysis of 151 breast cancer samples (TCGA) and 51 breast cancer cell lines (BCCL) using ChimeraScan. Clinical correlates were established for clinicopathological features, genomic instability measures, and gene expression-based molecular classifiers including PAM50, TNBCtype, IntClust subtypes and immune signatures.

Results: One hundred and six genes with recurrent CNA-induced aborted transcription were identified. Aborted transcription showed hormone receptor subtype-specificity for 7 genes (nTNBC=1, nNon-TNBC=6) and was less prevalent in samples of IntClust 2 and IntClust 4 subtypes (p: 0.0043, 0.0011). Aborted transcripts were more frequently observed in samples with greater copy-neutral loss of heterozygosity (p=0.012), while aborted transcription of 54/106 genes significantly affected enrichment of 27 tumor-infiltrating lymphocyte subpopulations.14 aborted transcripts were found as a fusion gene with one partner in RNA-seq of TCGA and BCCL, while 19 were involved in multiple fusion events (range=1-6, median=2). Nine of 106 genes displayed gene breakage and fusion events exclusively in samples with an enriched tandem duplication phenotype. Notably, FOXP1, localised to a tumour suppressor locus at 3p14.1, reported the highest number of fusion configurations (n=6) with concurrent aborted transcription across all RNA-seq datasets (nPRADA=9, nTCGA=38, nBCCL=6).

Conclusion: CNA-induced gene breakage affects the molecular landscape of breast cancers and is linked with many genomic configurations of interest including copy-neutral loss of heterozygosity and tandem duplications. In particular, the role of recurrent gene fusions of the tumour suppressor, FOXP1, in tumourigenesis warrants further investigation.

Citation Format: Mohd Noor A, Maguire S, Watkins J, Quist J, Mirza H, Tutt A, Gillett C, Natrajan R, Grigoriadis A. Copy number aberration-induced gene breakage analysis identifies recurrent FOXP1 fusions in breast cancer [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P1-05-14.

Robust anti-obesity and metabolic effects of a dual GLP-1/glucagon receptor peptide agonist in rodents and non-human primates

AIMS

To characterize the pharmacology of MEDI0382, a peptide dual agonist of glucagon-like peptide-1 (GLP-1) and glucagon receptors.

MATERIALS AND METHODS

MEDI0382 was evaluated in vitro for its ability to stimulate cAMP accumulation in cell lines expressing transfected recombinant or endogenous GLP-1 or glucagon receptors, to potentiate glucose-stimulated insulin secretion (GSIS) in pancreatic β-cell lines and stimulate hepatic glucose output (HGO) by primary hepatocytes. The ability of MEDI0382 to reduce body weight and improve energy balance (i.e. food intake and energy expenditure), as well as control blood glucose, was evaluated in mouse models of obesity and healthy cynomolgus monkeys following single and repeated daily subcutaneous administration for up to 2 months.

RESULTS

MEDI0382 potently activated rodent, cynomolgus and human GLP-1 and glucagon receptors and exhibited a fivefold bias for activation of GLP-1 receptor versus the glucagon receptor. MEDI0382 produced superior weight loss and comparable glucose lowering to the GLP-1 peptide analogue liraglutide when administered daily at comparable doses in DIO mice. The additional fat mass reduction elicited by MEDI0382 probably results from a glucagon receptor-mediated increase in energy expenditure, whereas food intake suppression results from activation of the GLP-1 receptor. Notably, the significant weight loss elicited by MEDI0382 in DIO mice was recapitulated in cynomolgus monkeys.

CONCLUSIONS

Repeated administration of MEDI0382 elicits profound weight loss in DIO mice and non-human primates, produces robust glucose control and reduces hepatic fat content and fasting insulin and glucose levels. The balance of activities at the GLP-1 and glucagon receptors is considered to be optimal for achieving weight and glucose control in overweight or obese Type 2 diabetic patients.

Electroconvulsive Therapy - What Do Patients Think Of Their Treatment?

BACKGROUND

The Regulation and Quality Improvement Authority (RQIA) monitors the administration of electroconvulsive therapy (ECT) in Northern Ireland (NI). As part of their inspection methodology RQIA wished to include feedback from ECT patients. The aim of this report is to summarise the opinions of ECT patients over a 1-year period and to compare their feedback about treatment with the standards of best practice, as defined by the Electroconvulsive Therapy Accreditation Service (ECTAS).

METHOD

RQIA was granted permission to use the ECTAS patient questionnaire. The questionnaire was distributed to all the ECT clinics in NI and staff were requested to give them to patients who had received a course of ECT.

RESULTS

A total of 42 individuals returned questionnaires, 24 females (57.1%) and 18 (42.9%) males. The response rate was 26%. Almost half of respondents were detained under the Mental Health (Northern Ireland) Order 1986 (n=19, 45.2%), with one third receiving ECT as a day patient (n=14, 33.3%). Respondents reported having detailed information about ECT, with ECTAS standards 4.2 and 4.3 being affirmed in over 80% of cases. Eighty percent of respondents (n=34) believed they benefited from ECT.

CONCLUSION

The results are mainly favourable towards ECT. The majority felt they benefited from treatment.

Child abuse and fabricated or induced illness in the ENT setting: a systematic review

BACKGROUND

Child maltreatment is persistently under-recognised. Given that a third of maltreated children may return with serious or fatal injuries, it is imperative that otolaryngologists who are in frequent contact with children are able to detect maltreatment at first presentation.

OBJECTIVE OF REVIEW

This review aims to identify ENT injuries, signs or symptoms that are indicative of physical abuse or fabricated or induced illness (child maltreatment).

TYPE OF REVIEW

Systematic review.

SEARCH STRATEGY

An all-language search, developed in Medline Ovid and consisting of 76 key words, was conducted of published and grey literature across 10 databases from inception to July 2015, for primary observational studies involving children aged <18 years.

EVALUATION METHOD

Each relevant article underwent two independent reviews with full critical appraisal, applying strict quality standards.

RESULTS

Of the 2448 studies identified and screened, 371 underwent full review, resulting in 38 included studies that detailed 122 maltreated children. Pharyngeal perforations (n = 20) were the most frequent abusive ENT injury, predominantly affecting neonates and infants, presenting with dysphagia, drooling, haemoptysis and surgical emphysema. At least 52% of children with abusive pharyngeal injuries had additional co-existent injuries. The majority of ear injuries were inflicted to the external ear (n = 11) and included auricular deformity, abrasions, petechiae, lacerations and burns. Fabricated or induced illness cases presented most commonly with recurrent, unexplained otorrhoea or ENT lesions that failed to heal despite appropriate therapy.

CONCLUSIONS

All clinicians should be familiar with the signs of child maltreatment. Pharyngeal injuries, or injuries to the external ear, presenting in young children without an explicit history of witnessed injury should prompt a child protection referral for full evaluation. Likewise, children who present with recurrent, or apparently intractable symptoms and signs despite appropriate treatment, should raise the possibility of fabricated or induced illness, and discussion with a child protection specialist is advised. Early recognition of possible child maltreatment and instigation of appropriate safeguarding measures are essential to prevent repetition and escalation of injury. This is of paramount importance to otolaryngologists, who have the potential to identify these children in their practice.

Isolated anterior mediastinal tuberculosis in an immunocompetent patient

Background

The differential diagnosis of a mediastinal mass is a common challenge in clinical practice, with a wide range of differential diagnosis to be considered. One of the rarer causes is tuberculosis. Atypical presentations of tuberculosis are well documented in immunocompromised patients, but should also be considered in the immunocompetent.

Case presentation

This case outlines a previously healthy 22 year-old immunocompetent male presenting with worsening chest pain, positional dyspnea, dry cough and dysphagia. Chest x-ray showed evidence of an isolated anterior mediastinal mass, which was confirmed on computed tomography. A mediastinoscopy was diagnostic as histology revealed necrotizing granulomatous inflammation and the presence of acid-fast bacilli, indicating mediastinal tuberculosis.

Conclusion

Typically the underlying presentation of mediastinal tuberculosis is mediastinal lymphadenitis. This case was unusual in that we detected an isolated large anterior mediastinal mass accompanied by a relatively small burden of mediastinal lymphadenitis. Cases similar to this have been documented in immunosuppressed patients however in our case no evidence of immunosuppression was found. This case report emphasizes the importance that a detailed and logical pathway of investigation is pursued when encountering a mediastinal mass.

Electronic supplementary material

The online version of this article (doi:10.1186/s12890-016-0175-7) contains supplementary material, which is available to authorized users.

Patient journey to a specialist amyotrophic lateral sclerosis multidisciplinary clinic: an exploratory study

Background

The multidisciplinary approach in the management of Amyotrophic Lateral Sclerosis (ALS) has been shown to provide superior care to devolved care, with better survival, improved quality of care, and quality of life. Access to expert multidisciplinary management should be a standard for patients with ALS. This analysis explores the patient journey from symptom onset and first engagement with health services, to the initial visit to a specialist ALS Multidisciplinary Clinic (MDC) in Dublin, Ireland.

Methods

A retrospective exploratory multi-method study details the patient journey to the MDC. Data from medical interviews and systematic chart review identifies interactions with the health services and key timelines for thirty five new patients presenting with a diagnosis of ALS during a 6 month period in 2013.

Results

The time from first symptom to diagnosis was a mean of 16 months (median 13 months), with a mean interval of 19 months (median 14.6) from first symptoms to arrival at the MDC. The majority of patients were seen by a general practitioner, and subsequently by neurology services. There was an average of four contacts with health services and 4.8 investigations/tests, prior to their first Clinic visit. On the first visit to the MDC patients are linked into an integrated ‘system’ that can provide specialist care and link with voluntary, palliative and community services as required.

Conclusions

Engagement with a multidisciplinary team has implications for service utilization and quality of life of patients and their families. We have demonstrated that barriers exist that delay referral to specialist services. Comprehensive data recording and collection, using multiple data sources can reconstruct the timelines of the patient journey, which can in turn be used to identify pathways that can expedite early referral to specialist services.

Treating severe and enduring anorexia nervosa: a randomized controlled trial

BACKGROUND

There are no evidence-based treatments for severe and enduring anorexia nervosa (SE-AN). This study evaluated the relative efficacy of cognitive behavioral therapy (CBT-AN) and specialist supportive clinical management (SSCM) for adults with SE-AN.

METHOD

Sixty-three participants with a diagnosis of AN, who had at least a 7-year illness history, were treated in a multi-site randomized controlled trial (RCT). During 30 out-patient visits spread over 8 months, they received either CBT-AN or SSCM, both modified for SE-AN. Participants were assessed at baseline, end of treatment (EOT), and at 6- and 12-month post-treatment follow-ups. The main outcome measures were quality of life, mood disorder symptoms and social adjustment. Weight, eating disorder (ED) psychopathology, motivation for change and health-care burden were secondary outcomes.

RESULTS

Thirty-one participants were randomized to CBT-AN and 32 to SSCM with a retention rate of 85% achieved at the end of the study. At EOT and follow-up, both groups showed significant improvement. There were no differences between treatment groups at EOT. At the 6-month follow-up, CBT-AN participants had higher scores on the Weissman Social Adjustment Scale (WSAS; p = 0.038) and at 12 months they had lower Eating Disorder Examination (EDE) global scores (p = 0.004) and higher readiness for recovery (p = 0.013) compared to SSCM.

CONCLUSIONS

Patients with SE-AN can make meaningful improvements with both therapies. Both treatments were acceptable and high retention rates at follow-up were achieved. Between-group differences at follow-up were consistent with the nature of the treatments given.

In search of Pinkel's children: unravelling the biological heterogeneity of childhood acute lymphoblastic leukaemia by genotype and treatment molecular response

BACKGROUND

Acute lymphoblastic leukaemia (ALL), the commonest childhood malignancy has seen remarkable progress since the 1960s with cure rates now approaching 85%. To achieve this patients undergo intensive treatment that usually takes 2.5-3.5 years involving on average 15 different chemotherapeutic drugs. In 1971, Donald Pinkel reported Total Therapy-Protocol V that used 5 drugs and cranial radiation therapy over a similar time period. Today, one half of these patients (Pinkel's children) remain alive and free of leukaemia.

AIM

The aim of this study was to evaluate the impact post-induction minimal residual disease (MRD) levels had on survival and its relationship with the more established clinical and biological prognostic predictors of outcome in the hope of identifying a subgroup of patients that are at very low risk of failure.

METHODS

A retrospective review of 250 Irish children with ALL was carried out. MRD status after 28 days of induction chemotherapy and other known predictors of outcome were correlated with 5 year event-free survival (EFS).

RESULTS

MRD status was the strongest predictor of outcome with 5 year EFS rates greater that 90% seen in those patients with low-risk MRD and this was associated with TEL/AML1 rearrangement, high hyperdiploidy (HH) karyotype and female gender.

CONCLUSION

Both MRD and karyotype are powerful determinants of outcome in childhood ALL. Therefore, it is reasonable to conclude that the majority of children cured by Pinkel et al. in the late 1960s were most likely composed of low-risk MRD, TEL/AML1 and HH patients.

Which injuries may indicate child abuse?

Making the decision as to whether an injury is a result of child abuse or not is stressful for both the family involved and the clinical team. It is not a decision that is taken lightly, and with an increasing expectation by the investigating agencies, lawyers and the public in general, to ensure that it is based on explicit 'evidence', clinicians need to be up to date with the latest scientific publications in the field. This article aims to summarise the current evidence in relation to all physical injuries except those pertaining to the central nervous system, which will form a separate article. It will examine the pattern of accidental and abusive bruises, fractures, burns, abdominal injuries and oral injuries focusing on discriminating features and necessary investigations.

What are the clinical and radiological characteristics of spinal injuries from physical abuse: a systematic review

AIM

Systematic review of 'What are the clinical and radiological characteristics of inflicted spinal injury?'

METHODS

Literature search of 20 electronic databases, websites, references and bibliographies (1950-2009) using selected keywords. Critical appraisal: by two trained reviewers, (a third review, if discrepant).

INCLUSION CRITERIA

primary studies of inflicted spinal injury in children <18 years, alive at presentation, with a high surety of diagnosis of abuse and sufficient detail to analyse.

RESULTS

19 studies of 25 children were included. Twelve children (median age 5 months) had cervical injury. In seven cases, the clinical signs of spinal injury were masked by respiratory symptoms and impaired levels of consciousness; six of these children had coexistent inflicted head trauma. Twelve children had thoraco-lumbar injury (median age 13.5 months), 10/12 had lesions at T11-L2, and 9/12 had fracture dislocations. All children had focal signs: 10/12 had lumbar kyphosis or thoraco-lumbar swelling, and two had focal neurology. One child had cervical, thoracic and sacral injuries.

CONCLUSIONS

Spinal injury is a potentially devastating inflicted injury in infants and young children. The published evidence base is limited. However, this case series leads us to recommend that any clinical or radiological indication of spinal injury warrants an MRI. In children undergoing brain MRI for abusive head trauma, consideration should be given to including an MRI of the spine. All skeletal surveys in children with suspected abuse should include lateral views of the cervical and thoraco-lumbar spine. Further prospective comparative studies would define the discriminating features of inflicted spinal injuries.

Intra-aortic mural thrombosis and splenic infarction in association with ulcerative colitis

BACKGROUND

Arterial thrombosis is a very rare, but recognised complication of inflammatory bowel disease that can result in significant morbidity and mortality.

CASE PRESENTATION

We present the case of a 48-year-old female with previously well-controlled ulcerative colitis who presented with severe left upper quadrant abdominal pain. Imaging investigations subsequently revealed a large intra-aortic mural thrombus extending into the coeliac axis complicated by splenic infarction. This occurred in the absence of other prothrombotic states such as thrombophilias or vasculitis.

CONCLUSION

This case highlights the frequently overlooked association between inflammatory bowel disease and arterial thrombosis.

Which clinical features distinguish inflicted from non-inflicted brain injury? A systematic review

AIM

A systematic review of the scientific literature to define clinical indicators distinguishing inflicted (iBI) from non-inflicted brain injury (niBI).

METHODS

An all language literature search of 20 electronic databases, websites, references and bibliographies from 1970-2008 was carried out. Relevant studies were independently reviewed by two trained reviewers, with a third review where required. Inclusion criteria included primary comparative studies of iBI and niBI in children aged <18 years, with high surety of diagnosis describing key clinical features. Multilevel logistic regression analysis was conducted, determining the positive predictive value (PPV) and odds ratios (OR) with p values for retinal haemorrhage, rib/long bone/skull fractures, apnoea, seizures and bruising to head/neck.

RESULTS

8151 studies were identified, 320 were reviewed and 14 included, representing 1655 children, 779 with iBI. Gender was not a discriminatory feature. In a child with intracranial injury, apnoea (PPV 93%, OR 17.06, p<0.001) and retinal haemorrhage (PPV 71%, OR 3.504, p = 0.03) were the features most predictive of iBI. Rib fractures (PPV 73%, OR 3.03, p = 0.13) had a similar PPV to retinal haemorrhages, but there were less data for analysis. Seizures and long bone fractures were not discriminatory, and skull fracture and head/neck bruising were more associated with niBI, although not significantly so.

CONCLUSIONS

This systematic review shows that apnoea and retinal haemorrhage have a high odds ratio for association with iBI. This review identifies key features that should be recorded in the assessment of children where iBI is suspected and may help clinicians to define the likelihood of iBI.

What neuroimaging should be performed in children in whom inflicted brain injury (iBI) is suspected? A systematic review

AIMS

To investigate the optimal neuroradiological investigation strategy to identify inflicted brain injury (iBI).

MATERIALS AND METHODS

A systematic review of studies published between 1970-2008 in any language was conducted, searching 20 databases and four websites, using over 100 keywords/phrases, supplemented by hand-searching of references. All studies underwent two independent reviews (with disagreements adjudicated by a third reviewer) by trained reviewers from paediatrics, paediatric neuroradiology and related disciplines, using standardized critical appraisal tools, and strict inclusion/exclusion criteria. We included primary studies that evaluated the diagnostic yield of magnetic resonance imaging (MRI), in addition to initial computed tomography (CT), or follow-up CT or ultrasound in children with suspected iBI.

RESULTS

Of the 320 studies reviewed, 18 met the inclusion criteria, reflecting data on 367 children with iBI and 12 were published since 1998. When an MRI was conducted in addition to an abnormal early CT examination, additional information was found in 25% (95% CI: 18.3-33.16%) of children. The additional findings included further subdural haematoma, subarachnoid haemorrhage, shearing injury, ischaemia, and infarction; it also contributed to dating of injuries. Diffusion-weighted imaging (DWI) further enhanced the delineation of ischaemic changes, and assisted in prognosis. Repeat CT studies varied in timing and quality, and none were compared to the addition of an early MRI/DWI.

CONCLUSIONS

In an acutely ill child, the optimal imaging strategy involves initial CT, followed by early MRI and DWI if early CT examination is abnormal, or there are ongoing clinical concerns. The role of repeat CT imaging, if early MRI is performed, is unclear, as is the place for MRI/DWI if initial CT examination is normal in an otherwise well child.