A pharmacist-led penicillin allergy de-labelling project within a preoperative assessment clinic: the low-hanging fruit is within reach

BACKGROUND

Having a false penicillin-allergy label is linked to longer hospital stays and to an increased risk of Clostridioides difficile and meticillin-resistant Staphylococcus aureus infection.

AIM

To assess a penicillin-allergy de-labelling tool designed for use by the non-allergist.

METHODS

Patients attending the surgical preoperative assessment clinic (POAC) at a large UK teaching hospital, who reported a penicillin allergy, were directly de-labelled by nursing or pharmacy staff, where appropriate. A penicillin-allergy de-labelling tool designed for use by the non-allergist was adapted and applied; nursing staff were provided with supporting information and education to enable removal of spurious labels. Antimicrobial pharmacists (AMPs) provided follow-up, cross-checked prophylactic antibiotics administered, interrogated clinical notes, and telephoned patients following their surgery, for details of any adverse reactions suffered.

FINDINGS

A total of 163 patients reporting a penicillin allergy were identified for intervention. Twenty-nine (17.8%) patients reported a penicillin-allergy history appropriate for direct de-labelling, of whom eight (27.6%) declined to consent. The remaining 21 patients (12.8%) were directly de-labelled, with 12 (7.4%) patients consenting during their POAC appointment; the remaining nine (5.5%) patients were consented and de-labelled after their surgery by an AMP.

CONCLUSION

The POAC was identified as an appropriate location and time-point in the patient pathway to enable the direct removal of spurious penicillin-allergy labels prior to surgery. Results suggest that this could be undertaken by nursing staff, although support from AMPs enabled a greater number of patients to be de-labelled.

Bayesian cluster analysis

Bayesian cluster analysis offers substantial benefits over algorithmic approaches by providing not only point estimates but also uncertainty in the clustering structure and patterns within each cluster. An overview of Bayesian cluster analysis is provided, including both model-based and loss-based approaches, along with a discussion on the importance of the kernel or loss selected and prior specification. Advantages are demonstrated in an application to cluster cells and discover latent cell types in single-cell RNA sequencing data to study embryonic cellular development. Lastly, we focus on the ongoing debate between finite and infinite mixtures in a model-based approach and robustness to model misspecification. While much of the debate and asymptotic theory focuses on the marginal posterior of the number of clusters, we empirically show that quite a different behaviour is obtained when estimating the full clustering structure. This article is part of the theme issue 'Bayesian inference: challenges, perspectives, and prospects'.

OP0068 DISTINCT STROMAL AND IMMUNE CELL INTERACTIONS SHAPE THE PATHOGENESIS OF RHEUMATOID AND PSORIATIC ARTHRITIS

Background

Rheumatoid (RA) and psoriatic arthritis (PsA) are common autoimmune and autoinflammatory diseases of unknown aetiology characterised by complex synovial pathology with a detrimental effect on the patient’s quality of life. Significant differences in pathophysiology may explain distinct clinical manifestations and account for differential responses to specific therapeutics. Recent implementation of single cell transcriptomic analysis of sorted synovial cells has revealed the diverse cellular landscape of the RA synovial stromal and immune cell compartments, however, a complete analysis of immune and stromal cells in tandem, for RA and PsA patient synovial tissue has not been performed.

Objectives

To combine novel scRNA transcriptomic approaches and ex vivo assays in order to: identify differences in the cellular landscape of RA and PsA synovial tissue inflammation and immune – stromal cell interactions that drive pathology in RA and PsA.

Methods

Single cell transcriptomic profiling of 178,000 synovial tissue cells from 5 PsA and 4 RA patients, importantly, without prior sorting of immune and stromal cells. This approach enabled the generation of a unique cell atlas of intact synovial tissue identifying immune and stromal cell interactions. State of the art data integration and annotation techniques identified and characterised 18 stromal and 14 immune cell clusters. Bioinformatic examination of cell-cell communication via construction of receptor-ligand interaction networks with further in vitro validation of stromal and immune cell crosstalk through flow cytometric analysis, multiplex ELISA and mitochondrial and single cell metabolic profiling by multiphoton and florescent lifetime imaging microscopy, seahorse.

Results

Following quality control and data integration the PsA and RA cellular landscape was generated and nine mega clusters indicative of fibroblasts, endothelial cells, pericytes, macrophages, dendritic cells (DC), B cells, plasma cells, T cells and NKT consisting of several sub clusters were identified. Distinct points of transcriptomic deviation and convergence between RA and PsA were identified for each of the major cell types of the joint. Specifically, cell cycle and trajectory analysis revealed that only a fraction of synovial T cells are actively proliferating. Additionally, the differential usage of immunoglobulin light chains by memory and plasma cells indicates that plasma cells are potentially not derived from the local memory B cell pool of the synovial tissue. Importantly, we report distinct fibroblast and endothelial cell transcriptomes indicating differentially abundant subpopulations in RA and PsA characterised by distinct transcription factor usage and signalling pathway enrichment. Specifically transcriptomic imputation analysis revealed abundance of invasive FAPα+THY1+ regulated by transcription factor TEAD1 in RA compared to PsA synovial tissue. In order to identify potential cell-cell communication driving inflammation in RA and PsA, novel receptor–ligand interaction networks were generated and downstream of the receptor, target characterisation was performed. Herein we identify RA-specific synovial T cell-derived TGF-β and macrophage IL-1β synergy in driving the transcriptional profile of FAPα+THY1+ invasive synovial-fibroblasts, expanded in RA compared to PsA synovial tissue biopsies (Figure 1). Ex vivo treatment of RA patient synovial fibroblasts identified TGF-b and IL-1b synergy are a major driver of IL-6 production, fibroblast activation and adhesion molecule expression. Interestingly, the aforementioned proinflammatory changes of RA patient synovial fibroblasts were coupled with significant alterations in mitochondrial eccentricity and size and a marked metabolic adaptation towards a strongly glycolytic profile (Figure 1).

Figure 1.

Conclusion

Disrupting specific immune and stromal cell interactions offers novel opportunities for targeted therapeutic intervention in RA and PsA.

Disclosure of Interests

Achilleas Floudas: None declared, Conor Smith: None declared, Orla Tynan: None declared, Nuno Neto: None declared, Vinod Krishna Employee of: Janssen Pharmaceuticals, Sarah Wade: None declared, Megan Hanlon: None declared, Clare Cunningham: None declared, Viviana Marzaioli: None declared, Mary Canavan: None declared, Jean Fletcher: None declared, Suzanne Cole Employee of: Janssen Pharmaceuticals, Ling-Yang Hao Employee of: Janssen Pharmaceuticals, Sunil Nagpal Employee of: Janssen Pharmaceuticals, GSK, Michael Monaghan: None declared, Douglas Veale Consultant of: Janssen, Eli Lilly, Pfizer, Ursula Fearon Consultant of: Janssen, Eli Lilly, Pfizer.

POS0495 CYTOKINE SYNERGY ENHANCES SYNOVIAL FIBROBLAST ACTIVATION IN CHILDREN WITH DOWN’S SYNDROME-ASSOCIATED ARTHRITIS

Background

We have previously shown that children with Down’s syndrome-associated arthritis (DA) display a more aggressive form of inflammatory arthritis compared to that of Juvenile Idiopathic Arthritis (Shih et al., 2019). DA is associated with an increase in polyfunctional T-cells coexpressing TNF-α DA is associated with an increase in polyfunctional T-cells coexpressing TNF-fibroblasts (FLS) (Foley et al., 2019).

Objectives

In this study we examine the effect of cytokine synergy on primary DA FLS function.

Methods

Primary DA FLS were cultured and stimulated with TNF-α (0.1 and 1ng/ml), IL-17A (20 and 50ng/ml), IFN-ɣ (10 and 50ng/ml) and GM-CSF (20 and 100ng/ml) or a combination of these cytokines and the following functional experiments performed. Chemokine and adhesion molecule cell surface expression were quantified by flow cytometry, in addition to quantification of leukocyte-DA-FLS adhesion assays. Gene and protein expression of proinflammatory and metabolic mediators were quantified by ELISA and RT-PCR. Furthermore, real-time metabolic activity in response to cytokine stimulation was assessed by measuring the two major energy pathways: glycolysis (ECAR) and oxidative phosphorylation (OCR), by the Seahorse XFe96 Analyser.

Results

We examined the effects of T cell derived cytokines, TNF-α, IL-17A, IFN-γ and GM-CSF, alone and in combination on DA FLS function. TNF-α, IL-17A and IFN-γ induced IL-6, RANTES and MCP-1 production, with no effect observed for GM-CSF. Furthermore, TNF-α, IFN-ɣ and IL-17A increased leukocyte adhesion to DA FLS. TNF-α and IFN-ɣ induced cell surface expression of CXCR3, CXCR4, ICAM-1 and VCAM-1 on DA FLS. Next, we investigated the potential synergistic relationship that these cytokines could have on proinflammatory mediators. IL-17A and IFN-ɣ potentiated the effects TNF-α on IL-6 and MCP-1 secretion compared to stimulation alone. Furthermore, cytokine synergy significantly induced IL-6, IL-8, RANTES and LDHA mRNA expression compared to basal. IL-17A and IFN-αL-17A and IFN- eeased ts TNF-α on IL-6 and MCP-1 secretion compared to stimulation alone. Additionally, IFN the ECAR:OCR ratio demonstrating a shift in the metabolic profile of DA FLS to glycolysis. Overall DA FLS are transformed from a quiescent metabolic state to an energetic phenotype.

Conclusion

TNF-αNF-lusion:OCR ratio demonstrating a shift in the metabolhe aggressive phenotype of DA FLS through increased cytokine, adhesion molecule and chemokine expression, which is pathways for the treatment of DA.

References

[1]Foley, C. et al. (2019) ‘Increased T cell plasticity with dysregulation of T follicular helper, T peripheral helper and T regulatory cell responses in children with JIA and Down syndrome-associated arthritis’, Arthritis & Rheumatology, pp. 0–1. doi: 10.1002/art.41150.

[2]Shih, Y. J. et al. (2019) ‘Enthesitis-related arthritis is the most common category of juvenile idiopathic arthritis in Taiwan and presents persistent active disease’, Pediatric Rheumatology. Pediatric Rheumatology. doi: 10.1186/s12969-019-0363-0.

Disclosure of Interests

None declared.

AB0074 RAPAMYCIN INHIBITS IL-1β INDUCED RA SYNOVIAL FIBROBLAST ACTIVATION, AN EFFECT ASSOCIATED WITH ALTERATION IN THEIR METABOLIC PROFILE

Background

Rheumatoid Arthritis (RA) is a common autoimmune disease characterized by systemic polyarthritis affecting the joints, most notably of the hands and feet. A fundamental feature of RA is inflammation within the synovial joint due to neo-angiogenesis which facilitates an influx of immune cells and release of pro-inflammatory mediators.

Objectives

In this study we investigate the effect of metabolic reprogramming on IL-1β regulation of stromal cell activation and invasiveness in RA.

Methods

Primary RA synovial fibroblasts (RAFLS) and human umbilical vein endothelial cells (HUVEC) were cultured with IL-1 β (2 ng/mL) alone or in combination with the metabolic inhibitor rapamycin (100nM). Pro-inflammatory cytokines IL-6, MCP-1 and Rantes were quantified by real-time PCR and ELISA. Cellular adhesion and network formation were quantified by adhesion binding assays and Matrigel invasion assays. pS6 (a surrogate marker of the mTOR pathway) was quantified by flow cytometry. Cellular bioenergetics was assessed using the Seahorse-XFe-technology and key glycolytic genes (HK2, PKM2, G6DP) were quantified by real-time PCR. YAP was measured by Western-Blot.

Results

IL-1β significantly induced secretion of IL-6 (p<0.05), MCP-1 (p<0.01) and Rantes (p<0.01) from RAFLS. IL-1β induced leukocyte adhesion to RAFLS (p=0.062) and HUVEC (p=0.051), in addition to an increase RAFLS and HUVEC network formation. This was accompanied by a change in the cellular bioenergetic profile of cells, where IL-1β increased the ECAR/OCR ratio in favour of glycolysis for RAFLS (p<0.05) and HUVEC, and induced the % frequency in the cell surface expression of pS6 on RAFLS. Rapamycin inhibited IL-1β -induced leukocyte adhesion and network formation in RAFLS (p<0.05; p<0.05 respectively) and HUVEC (p<0.05). Rapamycin inhibited IL-1β -induced Rantes secretion (p<0.05), no effect observed for IL-6 and MCP-1. Rapamycin also inhibited IL-1b-induce YAP protein expression which is involved in FLS invasive capacity through cytoskeletal rearrangement. This was accompanied by a shift in the metabolic profile from a glycolytic/energetic state back towards a more quiescent state.

Conclusion

Rapamycin inhibits IL-1β -induced pro-inflammatory mechanisms in key stromal cells involved in the pathogenesis of RA. Targeting metabolism may lead to new potential therapeutic or adjuvant strategies, particularly for those patients who have sub-optimal responses to current treatments.

References

[1]Kim EK, Min HK, Lee SY, Kim DS, Ryu JG, Na HS, Jung KA, Choi JW, Park SH, Cho ML. Metformin rescues rapamycin-induced mitochondrial dysfunction and attenuates rheumatoid arthritis with metabolic syndrome. Arthritis Res Ther. 2020 Apr 10;22(1):77. doi: 10.1186/s13075-020-02174-3. PMID: 32276645; PMCID: PMC7149912.

Disclosure of Interests

None declared

AB0916-PARE KNOWLEDGE OF DISEASE, DIAGNOSIS, ADHERENCE AND IMPACT OF RESEARCH IN PATIENTS WITH INFLAMMATORY ARTHRITIS

Background:

The diagnosis and treatment of inflammatory arthritis has been transformed largely by the development of drugs that target specific molecules of the immune system. However, these changes have increased the complexity of the mechanisms of disease, its treatment and patients understanding. Patient education is needed in this area to facilitate decision making and to facilitate strong patient-partnerships in research.

Objectives:

The aim of this study was to examine the level of understanding of inflammatory arthritis patients and the need for strong patient-partnership in research.

Methods:

An online anonymous survey addressed questions about diagnosis, routine tests, medications and how they work, medication adherence, disease flare, heredity, pregnancy, and patient involvement in research.

Results:

There were 1,873 respondents, 1416 of which had inflammatory arthritis (IA)-RA (65.8%) and PsA (34.2%). They were predominantly female (RA 86%, PsA 85 %), aged 55±13 and 50±12. Less than 35% of patients had an understanding of diagnostic tests, what was measured and the implication for disease, with 75.5% also concerned about heredity. There was a high level of understanding of how specific medications treat inflammatory arthritis (72.9%). Adherence was also very high (>87%), with the main reasons for stopping medication without the advice of their clinician, ‘feeling better’ and ‘side effects’ however a significant proportion of patients (69.9%) reported a disease-flare following cessation of medication. Patients of childbearing age (69%) were also concerned that inflammatory arthritis reduced their chances of getting pregnant, with only 8% believing arthritis medications were safe to take during pregnancy. Finally, only 9% of patients had ever been asked to participate in a research study.

Conclusion:

This study demonstrates a need for the development of stronger patient-partnerships with clinicians and researchers in relation to patient education and engagement with research, to create a platform where patients can have meaningful input and involvement in future research studies.

Acknowledgements:

We wish to thank all the patients who contributed to this study

Disclosure of Interests:

Mary Canavan: None declared, Viviana Marzaioli: None declared, Alex Donnelly: None declared, Siobhan Wade: None declared, Alexander Fraser: None declared, Tim O’Sullivan: None declared, Sinead Harney: None declared, Arthritis Ireland: None declared, Douglas Veale Speakers bureau: Abbvie, Janssen, Novartis, MSD, Pfizer, UCB, Consultant of: Abbvie, Janssen, Novartis, MSD, Pfizer, UCB, Grant/research support from: Janssen, Abbvie, Pfizer, UCB, Ursula Fearon Speakers bureau: Abbvie, Grant/research support from: Janssen, Abbvie, Pfizer, UCB

POS0411 TARGETING JAK-STAT SIGNALLING ALTERS THE PHENOTYPIC CHARACTERISTICS OF PsA SYNOVIAL FIBROBLASTS IN RESPONSE TO THE JAK/STAT ACTIVATOR ONCOSTATIN M

Background:

Psoriatic arthritis (PsA) is a chronic inflammatory arthritis associated with psoriasis. The JAK/STAT pathway has been linked to the pathogenesis of PsA. Recently, JAK/STAT inhibitors (JAKi) have emerged as an encouraging class of drugs for the treatment of PsA. Only a few of these inhibitors have been approved for use in PsA patients with others currently in clinical trials.

Objectives:

The aim of this study was to examine the effect of JAKi on primary PsA synovial fibroblasts (FLS) function.

Methods:

Primary PsA FLS were isolated and cultured with JAKi (Peficitinib, Filgotinib, Baricitinib and Upadacitinib) in the presence of the pro-inflammatory JAK/STAT activator - Oncostatin M (OSM). The effect of JAKi on these cells was determined by Migration and Invasion Assays, ELISA and rtPCR. PsA FLS bioenergetics was assessed using an XF24 analyser, which simultaneously quantifies two energetic pathways- glycolysis (ECAR) and Oxidative phosphorylation (OCR).

Results:

OSM-induced Migration and Invasion was supressed by all JAKi with Peficitinib, Filgotinib and Baracitinib showing the greatest effect. Analysis by ELISA and rtPCR showed reduction in MCP-1 and IL-6 expression in response to JAKi, in contrast, an increase in IL-8 was observed. These functional effects were accompanied by a change in the cellular bioenergetic profile of PsA FLS, where OSM significantly increased the ECAR:OCR ratio in favour of glycolysis where PsA FLS displayed a hypermetabolic phenotype. This effect was reversed in the presence of JAKi, which specifically targeted the glycolytic pathway with PsA FLS returning to a more quiescent phenotype.

Conclusion:

This study demonstrates that JAK/STAT signalling mediates the complex interplay between inflammation and cellular metabolism in PsA pathogenesis, inhibition of which shows effective suppression of the pathogenic phenotype of PsA FLS that drives joint destruction.

References:

[1]Chen M, Dai SM. A novel treatment for psoriatic arthritis: Janus kinase inhibitors. Chin Med J (Engl). 2020;133(8):959-967.

Disclosure of Interests:

Aisling O’ Brien: None declared, Megan Hanlon: None declared, Viviana Marzaioli: None declared, Keelin Flynn: None declared, Siobhan Wade: None declared, Douglas Veale Speakers bureau: Abbvie, Janssen, Novartis, MSD, Pfizer, UCB, Consultant of: Abbvie, Janssen, Novartis, MSD, Pfizer, UCB, Grant/research support from: Janssen, Abbvie, Pfizer, UCB, Ursula Fearon Speakers bureau: Abbvie, Grant/research support from: Janssen, Abbvie, Pfizer, UCB

OP0025 CD209+/CD14+ DENDRITIC CELLS ARE ENRICHED AND ACTIVATED AT THE SITE OF INFLAMMATION AND ARE MODULATED BY JAK/STAT SIGNALLING

Background:

Dendritic cells (DCs) are a heterogeneous population of professional antigen-presenting cells which are at the interface between innate and adaptive immunity. A specific subset of DCs is known to derive from monocyte and has a key role in inflammation and infection.

Objectives:

This study aimed to characterize the phenotype and function of a distinct CD209+/CD14+ DC subset in the periphery and at the site of inflammation in patients with rheumatoid (RA) and psoriatic arthritic (PsA), in addition to examining the effect Tofacitinib and TNF inhibitor on their development.

Methods:

Peripheral blood and synovial fluid mononuclear cells (PBMC and SFMC) were isolated by Ficoll density gradient from healthy subject (HC), and patients with RA and PsA. Single cell synovial tissue suspension (ST) from RA and PsA patients were also established using enzymatic/mechanical digestion. PBMC, SFMC and ST were analysed by flow cytometry to identify the CD209+/CD14+ DC subset, its frequency and the cell surface expression of chemokines receptors (CCR6, CCR7, CXCR3, CXCR4 and CXCR5) and activation markers (CD40 and CD80). In addition, PBMC were stimulated with different TLR (LPS, CPG, R848, Poly I:C) and intracellular staining for IL12, TNFα, IL1β and IL6 was performed by flow cytometry. Lineage negative cells (CD3/CD19/CD56-) were stimulate with GMCSF/IL4 in the presence or absence of the JAK/STAT inhibitor Tofacitinib or the TNF inhibitor Humira, and the CD209+/CD14+ DC development was evaluated by flow cytometry.

Results:

We identified, for the first time, a distinct CD209+/CD14+ DC population in PBMC of patients with RA and PsA, with similar frequency across the groups. However, when PBMC were stimulated with TLRs, an increase of IL12 and TNFα was observed in RA and PsA PBMC when compared to HC. Interestingly, this distinct DC population was significantly enriched at the site of inflammation, in both SFMC and ST, displaying a more mature phenotype, evident by the observed significant increase in CD40 and CD80 expression. SPICE analysis further identified differential expression and co-expression of chemokine receptors at the periphery of RA and PsA patients, when compared to the HC. Furthermore synovial tissue single cell analysis from RA/PsA demonstrated a unique chemokines receptors profile demonstrating increased single expression and co-expression of CXCR3 and CXCR5 compared to periphery. Finally, we have previously observed that JAK/STAT is involved in monocyte-derived dendritic cells population development (1,2), therefore we performed CD3, CD19 and CD56 depletion of RA/PsA PBMC followed by stimulation with GMCSF/IL4, to spike the Mo-DC population, in the presence of Tofacitinib or Humira. Interestingly, we observed that JAK/STAT inhibition, but not TNF inhibitor, reduced the generation and development of CD209+/CD14+ DC.

Conclusion:

We identify for the first time a distinct monocyte-derived DC population characterized as CD209+/CD14+ in the periphery of RA and PsA patients. This population was enriched at the site of inflammation and displayed a unique chemokine receptor profile and activation markers, suggesting that these cells are already activated in the periphery of IA patients, and are recruited and further activated in the inflamed joint. In addition, we showed that the CD209+/CD14+ DC development is regulated by JAK/STAT signalling, but not TNF inhibition.

References:

[1]Marzaioli V, Canavan M, Floudas A, et al. Monocyte-Derived Dendritic Cell Differentiation in Inflammatory Arthritis Is Regulated by the JAK/STAT Axis via NADPH Oxidase Regulation. Front. Immunol. 2020;11:1406.

[2]Marzaioli V, Hurtado-Nedelec M, Pintard C, et al. NOX5 and p22phox are 2 novel regulators of human monocytic differentiation into dendritic cells. Blood. 2017;130(15):1734–1745.

Acknowledgements:

The authors also wish to thank all the patients who volunteered to participate into this study and the funding

Disclosure of Interests:

Viviana Marzaioli: None declared, Achilleas Floudas: None declared, Mary Canavan: None declared, Siobhan Wade: None declared, Kieran Murray: None declared, Ronan Mullan: None declared, Douglas Veale Speakers bureau: Abbvie, Janssen, Novartis, MSD, Pfizer, UCB, Consultant of: Abbvie, Janssen, Novartis, MSD, Pfizer, UCB, Grant/research support from: Janssen, Abbvie, Pfizer, UCB, Ursula Fearon Speakers bureau: Abbvie, Grant/research support from: Janssen, Abbvie, Pfizer, UCB

POS0069 INCREASED T CELL RESPONSES, METABOLIC ACTIVITY AND FIBROBLAST INVASIVE CAPACITY IN CHILDREN WITH DOWN’S SYNDROME-ASSOCIATED ARTHRITIS COMPARED TO JUVENILE IDIOPATHIC ARTHRITIS

Background:

Juvenile idiopathic arthritis (JIA) was thought to be the most common inflammatory arthritis in children (Shih et al., 2019). However an aggressive, erosive arthritis of little-known immunologic mechanism occurs 20 times more frequently in children with Down’s syndrome (Foley et al., 2019).

Objectives:

This study was undertaken to characterize immune cell responses and synovial fibroblast invasiveness in children with Down’s syndrome-associated arthritis (DA).

Methods:

Multiparametric flow cytometric analysis was used to examine peripheral blood T cell, B cell and monocyte populations. In addition, T cell cytokine responses and their metabolic profile in children with DA, JIA, Down’s Syndrome (trisomy 21 [T21]), and in healthy controls were assessed. The function of DA primary synovial fibroblasts (FLS) was assessed in response to stimulation with pro-inflammatory mediators alone and in combination (TNF-α, IL-17a, IFN-γ, GM-CSF). The two major energy pathways glycolysis (ECAR) and oxidative phosphorylation (OCR) were quantified by the Seahorse XFe96 Analyser. Migration, adhesion, invasion and cytokine/chemokine secretion were quantified by wound repair scratch assays, Transwell collagen invasion chambers, adhesion binding assays, and ELISAs.

Results:

T cell frequencies were higher in DA compared to JIA and T21 in contrast to B cell frequencies which were decreased. T cell responses in DA were characterized by increased frequencies of CD4+ and CD8+ TNF- α, IFN- γ and GM-CSF producing T cells. The frequency of T peripheral helper (Tph) cells were elevated in children with DA compared to all other groups. In parallel, an increase in their metabolic profile evident by higher phosphorylation of mTOR pathway components AKT, mTOR and S6. Comparison of DA and JIA FLS demonstrated that DA FLS display a more invasive/migratory capacity and are more metabolically active. Based on the increased cytokine responses in DA T cells, we next examined the effect T cell derived cytokines TNF-α, IL-17A, IFN-γ and GM-CSF alone and in combination on DA FLS function. TNF-α, IL-17a and IFN-γ induced IL-6, RANTES and MCP-1 secretion, with no effect observed for GM-CSF. Furthermore, TNF-α and IL-17A induced DA FLS migration and PBMC adhesion to DA FLS. Finally IL17A and IFN-γ potentiated the effect of TNF-α on IL-6 and MCP-1 secretion compared to stimulations alone.

Conclusion:

DA is a more common and aggressive form of arthritis compared to JIA. It is characterized by increased T cell responses and a more invasive FLS phenotype compared to that of JIA, with T cell derived cytokine alone and in combination further inducing DA FLS pathogenic mechanisms. These effects mirror the increased erosive disease observed clinically.

References:

[1]Foley, C. et al. (2019) ‘Increased T cell plasticity with dysregulation of T follicular helper, T peripheral helper and T regulatory cell responses in children with JIA and Down syndrome-associated arthritis’, Arthritis & Rheumatology, pp. 0–1. doi: 10.1002/art.41150.

[2]Shih, Y. J. et al. (2019) ‘Enthesitis-related arthritis is the most common category of juvenile idiopathic arthritis in Taiwan and presents persistent active disease’, Pediatric Rheumatology. Pediatric Rheumatology. doi: 10.1186/s12969-019-0363-0.

Disclosure of Interests:

None declared.

ROBUST: A Phase III Study of Lenalidomide Plus R-CHOP Versus Placebo Plus R-CHOP in Previously Untreated Patients With ABC-Type Diffuse Large B-Cell Lymphoma

Patients with the activated B-cell-like (ABC) subtype of diffuse large B-cell lymphoma (DLBCL) historically showed inferior survival with standard rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP). Phase II studies demonstrated that adding the immunomodulatory agent lenalidomide to R-CHOP improved outcomes in ABC-type DLBCL. The goal of the global, phase III ROBUST study was to compare lenalidomide plus R-CHOP (R2-CHOP) with placebo/R-CHOP in previously untreated, ABC-type DLBCL.

Awake tracheal intubation in a suspected COVID-19 patient with critical airway obstruction

We report the airway management of a patient with suspected COVID-19 with impending airway obstruction requiring urgent surgical tracheostomy. To our knowledge, this is the first reported case of an awake tracheal intubation in a suspected COVID-19-positive patient. Various modifications were put in place during the awake tracheal intubation and surgical tracheostomy procedures to minimise aerosol generation from the patient, such as avoiding high-flow nasal oxygen, establishing conscious sedation with remifentanil before commencing airway topicalisation and avoiding transtracheal local anaesthetic infiltration. A multidisciplinary team discussion before performing the case highlighted aspects of both the airway management and the surgical procedure where particular care and modifications are required. There is a lack of national and international guidance for awake tracheal intubation and tracheostomy in COVID-19 cases. This report nevertheless addresses the key procedural modifications required.

A simple guide to regional anaesthesia

Regional anaesthesia is widely used in modern anaesthetic practice for perioperative and postoperative analgesia. In the operating theatre, regional anaesthesia is used both on its own and in combination with other techniques (general anaesthesia and sedation). Regional anaesthesia is now a core skill set in anaesthetic training. This article provides a basic outline of regional anaesthesia for surgeons and other non-anaesthetic staff working with anaesthetists, reviewing preparation, consent, basic and specialist equipment, central neuraxial blocks (spinal, epidural and caudal), trunk blocks, upper limb blocks (interscalene, supraclavicular, infraclavicular and axillary) and lower limb blocks (femoral, fascia iliaca, sciatic, popliteal and ankle). It also discusses the pharmacology of the agents used and common complications.

Dental student self-assessment of a medical history competency developed by Oral and Maxillofacial Surgery Faculty

PURPOSE

To develop a standardized competency exam to evaluate dental student knowledge of patients with complex medical histories. Analysis was performed to determine if there is a difference between dental student self-assessment of the exam compared to oral surgery faculty. The overall goal is to enhance student comprehension of advanced medical patients in the pre-doctoral oral and maxillofacial surgery clinic and make changes based on student responses.

METHODS

The exam took place in a simulation laboratory containing two-way mirrors where the student could not see the evaluator. Three standardized patients (trained actors) were given different medical history scenarios to learn prior to the exam. Students were randomly assigned to interview one patient. The graders consisted of senior and junior level faculty. In real time (live) randomized manner, faculty assessed each student using a standardized rubric to assign a score of 1 to 4. Immediately afterwards, students assessed their own performance using the same scale.

RESULTS

Students gave themselves significantly higher grades (P < 0.001) on the exam (10.7 ± 0.12) compared to the faculty (9.2 ± 0.17). There was no significant difference in student (P = 0.16) or faculty assessment (P = 0.29) between the three different medical scenarios. There was no significant difference between faculty in assessment of student performances (P = 0.16).

CONCLUSION

These results suggested that students overestimated their performance compared to the faculty assessment. This could be due to that students assessed their performance based on memory and self-confidence; that exceeds their expectations. Internal calibration of student performances and faculty grading using standardized criteria may produce more accurate and reliable outcomes in student scoring.

Fear of falling, fracture history, and comorbidities are associated with health-related quality of life among European and US women with osteoporosis in a large international study

We studied 7,897 women with postmenopausal osteoporosis to assess factors that influence health-related quality of life (HRQoL). An increased number of comorbidities, fear of falling, and previous vertebral fracture were associated with significant reductions in HRQoL. Understanding the factors that affect HRQoL may improve management of these patients.

INTRODUCTION

HRQoL is impaired in women treated for postmenopausal osteoporosis (PMO). The objective of this study was to examine the relationship between clinical characteristics, comorbidities, medical history, patient demographics, and HRQoL in women with PMO.

METHODS

Baseline data were obtained and combined from two large and similar multinational observational studies: Prospective Observational Scientific Study Investigating Bone Loss Experience in Europe (POSSIBLE EU®) and in the US (POSSIBLE US™) including postmenopausal women in primary care settings initiating or switching bone loss treatment, or who had been on bone loss treatment for some time. HRQoL measured by health utility scores (EQ-5D™) were available for 7,897 women (94 % of study participants). The relationship between HRQoL and baseline clinical characteristics, medical history and patient demographics was assessed using parsimonious, multivariable, mixed-model analyses.

RESULTS

Median health utility score was 0.80 (interquartile range 0.69-1.00). In multivariable analyses, young age, low body mass index, previous vertebral fracture, increased number of comorbidities, high fear of falling, and depression were associated with reduced HRQoL. Regression-based model estimates showed that previous vertebral fracture was associated with lower health utility scores by 0.08 (10.3 %) and demonstrated the impact of multiple comorbidities and of fear of falling on HRQoL.

CONCLUSIONS

In this large observational study of women with PMO, there was substantial interindividual variability in HRQoL. An increased number of comorbidities, fear of falling, and previous vertebral fracture were associated with significant reductions in HRQoL.

[Seasonal variations in the nutritional status of nomad and sedentary children less than 5 years of age living in the Sahel in Chad]

Malnutrition is widespread among rural and nomad populations in the Sahel. It is linked to socio-economic factors and exhibits significant seasonal variations. The aim of this study was to assess the prevalence of malnutrition and associated risk factors among children less than 5 years of age. A repeated cross-sectional study design based on interviews and anthropometric measurements was used. A total of 653 nomad children and 579 sedentary children ranging in age from 0 to 59 months were randomly selected in households/camps on the south-eastern shore of Lake Chad. Data were collected from the same number of children at the end of the dry season (May/June, 2007) and at the end of rainy season (October 2007). Findings showed significant interseasonal variation in the prevalence of global acute malnutrition (GAM) between the end of the dry season and end of the rainy season. The respective variations were 17.9% to 13.7% (p = 0.03) in nomad children and 16.5% to 10.6% (p = 0.004) in sedentary children. Backward stepwise multivariate analysis by logistic regression showed that GAM among children under 5 years of age was significantly correlated with the following risk factors: seasonal variation, child's age, mother's nutritional status, ethnic group, and place of residence (LRT=172 and p < 0.001 for the logistic regression model). These findings demonstrate the critical state of the nutritional situation in the Sahel and rural areas.

Design of the POSSIBLE UStrade mark Study: postmenopausal women's compliance and persistence with osteoporosis medications

Failure to take prescribed medication is common. The POSSIBLE US study is evaluating the impact of physician and patient characteristics on patient-reported compliance and persistence with osteoporosis medications. We report our study design and the baseline characteristics of 4,994 postmenopausal women recruited from primary care physician offices in 33 states.

INTRODUCTION

The Prospective Observational Scientific Study Investigating Bone Loss Experience (POSSIBLE US) is a longitudinal cohort study of osteoporosis therapy in primary care.

METHODS

Between 2004 and 2007, 134 physicians (in 33 states) enrolled postmenopausal women initiating, changing, or continuing osteoporosis medications. After completing a baseline questionnaire, participants will provide data semi-annually for up to 3 years through 2008. Physicians provide patient data at baseline and routine follow-up visits. Participants from 23 sites also signed a release regarding administrative claims data for economic analyses and validation of self-reported data.

BASELINE RESULTS

Four thousand nine hundred and ninety-four evaluable women were recruited from internal medicine (n = 1,784), family practice (n = 1,556), obstetrics/gynecology (n = 1,556), and from one rheumatology practice (n = 98). Mean participant age was 64.3 years (SD = 9.97); 89% were Caucasian; 59% had some college education. Sixty-three percent used a single osteoporosis agent, usually a bisphosphonate. For monotherapy patients, concordance between clinic- and patient-reported medication use was lowest for patients prescribed estrogen therapy (70%) or calcium/vitamin D (72%). Obstetrician/gynecologists enrolled younger women, who were more likely to use estrogen therapy than patients enrolled by other physicians. The 934 women (19%) prescribed only calcium/vitamin D were younger than women prescribed pharmacologic therapy.

CONCLUSIONS

POSSIBLE US provides a unique foundation for evaluating longitudinal use of osteoporosis medications and related outcomes.

The rheology of collapsing zeolites amorphized by temperature and pressure

Low-density zeolites collapse to the rigid amorphous state at temperatures that are well below the melting points of crystals of the same composition but of conventional density. Here we show, by using a range of experimental techniques, how the phenomenon of amorphization is time dependent, and how the dynamics of order-disorder transitions in zeolites under temperature and pressure are equivalent. As a result, thermobaric regions of instability can be charted, which are indicative of polyamorphism. Moreover, the boundaries of these zones depend on the rate at which temperature or pressure is ramped. By directly comparing the rheology of collapse with structural relaxation in equivalent melts, we conclude that zeolites amorphize like very strong liquids and, if compression occurs slowly, this is likely to lead to the synthesis of perfect glasses.

The importance of high-level training for nutrition scientists in Sub-Saharan Africa

Can the African people investigate and critically analyse nutrition needs in their context, identify national or community nutrition problems, plan and evaluate nutrition programs, educate, and communicate scientific knowledge in nutrition without high-level trained staffs with a strong scientific base in human nutrition? Will they be able to tackle their nutrition problems without a sustainable organisation for long-term training and research? In this paper, an attempt is made to analyse factors that will contribute to improving human nutrition in Sub-Saharan Africa. The paper also highlights an experience of institutional capacity building in Senegal, West Africa.

Novel aspects to the structure of rabbit articular cartilage

Applying cryo and modified chemical preparation techniques, mainly for scanning electron microscopy, revealed entirely new aspects to the structure of the radial zone of rabbit tibial plateau articular cartilage. The aggrecan component of the extracellular matrix was contained radially in columns, each with a diameter of 1-3 mm, by a tightly packed matrix of collagen fibrils. The collagen fibrils were arranged radially, some straight and others in an opposed spiral arrangement, with regularly repeating patterns. This organization existed in the regions surrounding the columns of chondrocytes, known as chondrons. The load bearing property of the tissue was explained by the directed flow and containment of the interstitial fluid, modulated by the protein-carbohydrate complexes, along these collagen bounded tubular structures. The reason why such a structure has not been described previously may be that it is not retained by aldehyde fixation followed by dehydration, the method commonly used for tissue preparation for electron microscopy.

Neurobehavioral symptoms in childhood closed-head injuries: changes in prevalence and correlates during the first year postinjury

OBJECTIVE

To examine changes in the prevalence and correlates of neurobehavioral symptoms during the first year following childhood closed-head injuries (CHIs).

METHODS

Participants included 31 children with severe CHIs, 38 with moderate CHIs, and 53 with orthopedic injuries (OIs). Children and their families were assessed shortly after injury and at 6- and 12-month follow-ups. Parents rated 15 symptoms classified as either cognitive/somatic (C/S) or emotional/behavioral (E/B).

RESULTS

Both kinds of symptoms were more common in the CHI groups than in the OI group. C/S symptoms declined in the CHI groups over time, whereas E/B symptoms became relatively more common. Measures of injury severity, children's premorbid behavioral adjustment, and concurrent cognitive functioning predicted C/S symptoms. E/B symptoms were predicted by injury severity, concurrent cognitive functioning soon after the injury, and concurrent parent and family functioning later in time. Both types of symptoms contributed to the prediction of perceived family burden, with the relationships strengthening over time.

CONCLUSIONS

The findings indicate that the prevalence and correlates of neurobehavioral symptoms in childhood CHIs vary as a function of symptom type and time since injury.

Explaining drug spending trends: does perception match reality?

Several recent studies have made clear that drug expenditures are rising more rapidly than other health care spending. What has not been clear, however, is how much drug spending is driven by price rather than volume and whether volume increases are appropriate. This DataWatch takes a closer look at the components and drivers of drug spending using large claims databases from managed care and employer-sponsored health benefit plans. In both environments this study found volume, not price, to be the largest driver of drug spending for seven diseases studied. For four of the diseases, we review the clinical issues that may have influenced volume growth.

Freeze-substitution of rabbit tibial articular cartilage reveals that radial zone collagen fibres are tubules

Investigations of the micromorphology of rabbit tibial articular cartilage using scanning and transmission electron microscopy revealed that the collagenous elements in the tissue form fluid-containing tubular structures. The commonly described radial or deep zone longitudinal fibres were found to be tubular structures with internal diameters of 1-2 microm. The walls of the tubules were composed of tightly packed fibrils of collagen. The tangential zone, close to the tibial plateau, was composed mainly of a spongy arrangement of collagen fibrils, containing bunches of tangentially lying small (< 1 microm) diameter tubules. The application of conventional chemical fixation techniques resulted in the fine detail of this tissue being obscured. When the tissue was frozen, followed by cryo-scanning electron microscopy or freeze-drying, prior to observation in the scanning electron microscope the tubule structures were not obviously present. It was only by applying freeze-substitution techniques, followed by critical point drying or resin embedding, that the structure was revealed clearly. Segregation of water into ice crystals did occur during the freezing process, but the formation of those crystals played no part in creating the tubular morphology observed. A similar structure was still revealed following pre-treatment with glycerol, methanol or Triton X-100, provided that concentration of these additives was not too high. The walls of the tubules in the radial region were composed of straight, longitudinally arranged as well as helically arranged, 30 nm diameter fibrils. The lumen of the tubules appears to be lined by a circumferentially arranged array of approximately 10 nm diameter fibres, spaced at regular intervals of 50-70 nm.

Efficient discovery of inhibitory ligands for diverse targets from a small combinatorial chemical library of chimeric molecules

Living systems are mainly composed and regulated by compounds in four biochemical classes and their polymers-nucleotides, carbohydrates, lipids, and amino acids. Early combinatorial chemistry libraries consisted of peptides. The present report describes the general bioactivity and biophysical properties of a combinatorial chemical library that used glyco, nucleotidyl, and lipid building blocks. The resulting chimeric combinatorial library of 361 compounds had a confirmed cumulative hit rate of 0.16%, which is 8-fold higher than a commonly claimed industrial benchmark of 0. 02%. It produced 7 structurally confirmed hits for a third of 12 proprietary drug discovery projects, and these comprised a variety of molecular targets. Diversity analyses demonstrated that despite the small number of compounds, a wider range of diversity space was covered by this library of biochemical chimeras than by a branched tripeptide library of the same size and similar generic formula.

HIV testing practices of Zimbabwean physicians and their perspectives on the future use of rapid on-site tests

To improve HIV testing procedures, rapid on-site HIV tests have been introduced in Zimbabwe. At present, little is known about physicians' perspectives on the potential use of rapid tests in their clinics or about their current laboratory-based testing practices. In a sample of 63 general practitioners in Harare, this study found physicians were generally testing individuals, not couples, and an important reason for suggesting a patient be tested was medical symptoms; frequent reasons for patients requesting the test were insurance purposes, being about to get married or having suspicions about a partner. A primary deterrent to physicians testing patients, even when patients requested it, was fear of traumatizing them. Fifty-six per cent of the physicians believed rapid tests would increase the number of HIV tests they performed; significant associations were found between this belief and whether physicians ever chose not to test patients they suspected were HIV-positive (a positive association) and whether they chose not to test specifically out of fear that patients would commit suicide (a negative association). Prior to any expansion of testing with rapid tests, training in counselling and confidentiality measures is essential, given that over half the medical personnel providing counselling to these physicians' patients had received no training in pre- and post-test HIV counselling.

Promoting quality of care for older people: developing positive attitudes to working with older people

AIMS

Managers and administrators have a key strategic role and responsibility for the way the care of older people is delivered within health and social care services, since the decisions made and directions taken at this level have a direct influence on services delivered. This article provides an outline of the context in which the services provided for older people have emerged, especially within health care, and offers strategies for the way forward.

BACKGROUND

The standard of care received by older people is high on the agenda in contemporary health care. Frequent reports have questioned this quality over the years, yet concerns still remain. A key factor influencing quality of care received by older people, can be attributed to the persistence and perpetuation of ageist attitudes held by society and those working within health and social care settings at all levels.

METHODS

Drawing upon a range of literature, an overview of those factors that seem to be attributable to the development of contemporary attitudes and perceptions about older people and their care are reviewed, focusing particularly upon health and social care workers, especially nurses.

FINDINGS

The role of education in particular is explored as this has a key role in influencing attitudes towards caring for older people and will impact directly on the way in which all care and services develop.

CONCLUSION

A number of areas are outlined for future development and research that aim to address and serve the needs of older people, and which could be supported at a managerial and administrative level to promote positive attitudes.

The family burden of injury interview: reliability and validity studies

OBJECTIVE

To assess the reliability and validity of a new instrument, the Family Burden of Injury Interview (FBII) was designed to assess the impact of childhood traumatic head injuries (THI) on the family.

PARTICIPANTS

99 Mothers of school-age children who experienced THI.

RESULTS

The FBII Total Score revealed group differences between families of children with severe THI and families of children with moderate THI. The measure also showed concurrent and predictive relationships to measures of the general impact of injury on families and maternal and child functioning.

CONCLUSION

The FBII is a promising tool for measuring the impact of injury-related stressors on the family.

The sleep of older people in hospital and nursing homes

Disturbed sleep can affect personal wellbeing and impede the rehabilitation and recovery of older people from illness. This paper reports the findings of a pilot study which included examination of sleep quality and sleep patterns of older people in community hospital and nursing home settings. A marked proportion of older people reported sleeping well in nursing care settings, and those in nursing homes slept better than those in the community hospital. The main causes of sleep disturbance in both settings were: needing to go to the toilet, noise, pain, and discomfort; a similar pattern was seen across the different settings. No discernible difference was found in quality of sleep and whether patients felt rested or not between those patients on hypnotic medication and those who were not. The implications of the findings for practice and future research are discussed.

Evaluation of gross and fine motor functions in children with hemidecortication: predictors of outcomes and timing of surgery

The purpose of this study is three-fold: First, to determine the levels of gross and fine motor functions in children before and after hemidecortication, using standardized measurement tools; second, to investigate if predictors of these outcomes can be characterized; and third, to explore if both clinical measures and functional magnetic resonance imaging (MRI) potentially can identify optimal timing of surgery. The Gross Motor Function Measure and the Quality of Upper Extremity Skills Test are shown to be comprehensive, standardized outcome measures of movement performance in affected children. Age at surgery and interval between age at seizure onset and age at surgery could be the most reliable predictors of clinical outcomes. Functional MRI studies are valuable in exploring the potential of the cortical reorganization that sustains residual sensorimotor function. The combination of clinical measures with functional MRI is a promising method of inquiry into developmental and plasticity processes.

Acute psychosocial impact of pediatric orthopedic trauma with and without accompanying brain injuries

BACKGROUND

The acute psychosocial effects of orthopedic injuries on children and their families are poorly understood. Previous studies have relied on retrospective reports or failed to take into account accompanying brain injuries. The purpose of the present study was to examine prospectively the psychosocial impact of pediatric orthopedic traumatic fractures with and without accompanying brain injuries.

METHODS

Participants were 108 children 6 to 12 years old with orthopedic injuries requiring hospitalization: group 1 (n=80) had fractures only, group 2 (n=28) also had moderate or severe brain injuries. Using standardized measures and parent interviews, we obtained preinjury estimates of family functioning and child behavior problems and postinjury measures of parental distress, family stresses, and child behavior.

RESULTS

Parents reported significant clinical distress (35% in group 1, 57% in group 2), family burdens (group 2 > group 1), and child behavioral changes (41% in group 1, 89% in group 2). Multiple regression analyses indicated that preinjury family status and brain injuries predicted postinjury parental and family distress.

CONCLUSION

Pediatric orthopedic injuries have greater social effects on children with accompanying brain injuries and poorer preinjury family functioning.

Effect of food processing on iron availability of African pearl millet weaning foods

The effects of different cereal precooking process (roasting and extrusion cooking) on iron availability and protein digestibility of four African weaning foods were investigated using in vitro methods. In two weaning foods based on pearl millet, cowpea and peanut, the cereal was extruded (A) or roasted (B). In two other weaning foods having a similar composition, a low proportion of milk powder was added and the cereal extruded (C) or roasted (D). The mean +/- SD iron values (mg/100 g) were: A, 5.56 +/- 0.18; B, 9.12 +/- 0.93; C, 5.89 +/- 0.23; D, 9.04 +/- 0.85. When the pearl millet was roasted, the iron content was higher than in the extruded weaning foods (P < 0.01). However, the percent of available iron of the roasted weaning foods was very low (B, 1.64 +/- 0.01; D, 0.91 +/- 0.02). The iron availability of the extruded weaning foods, A and C, was 3.5 times and 6.5 times higher than the corresponding roasted weaning foods, B and D, respectively. This represented 332.4 +/- 4.4 and 375.1 +/- 5.8 micrograms of available iron/100 g for A and C, respectively versus 149.5 +/- 0.9 and 82.2 +/- 1.8 micrograms of available iron/100 g for B and D, respectively. No significant differences in polyphenol contents were found according to the precooking process of the cereal. The extruded weaning foods showed a higher protein digestibility of approximately 10% than the roasted ones (P < 0.05). A positive correlation was found between in vitro iron availability and protein digestibility (r = 0.976, P < 0.02). Despite a high content of iron, the iron availability of roasted pearl millet weaning foods was quite low. Extrusion cooking of the cereal improved the protein digestibility and iron availability of pearl millet weaning foods; however, the amount of available iron remained insufficient to meet the iron requirements of infants whatever the cereal processing.