A noncoding regulatory variant in IKZF1 increases acute lymphoblastic leukemia risk in Hispanic/Latino children

Hispanic/Latino children have the highest risk of acute lymphoblastic leukemia (ALL) in the US compared to other racial/ethnic groups, yet the basis of this remains incompletely understood. Through genetic fine-mapping analyses, we identified a new independent childhood ALL risk signal near IKZF1 in self-reported Hispanic/Latino individuals, but not in non-Hispanic White individuals, with an effect size of ∼1.44 (95% confidence interval = 1.33-1.55) and a risk allele frequency of ∼18% in Hispanic/Latino populations and <0.5% in European populations. This risk allele was positively associated with Indigenous American ancestry, showed evidence of selection in human history, and was associated with reduced IKZF1 expression. We identified a putative causal variant in a downstream enhancer that is most active in pro-B cells and interacts with the IKZF1 promoter. This variant disrupts IKZF1 autoregulation at this enhancer and results in reduced enhancer activity in B cell progenitors. Our study reveals a genetic basis for the increased ALL risk in Hispanic/Latino children.

COVID-19 vaccines and adverse events of special interest: A multinational Global Vaccine Data Network (GVDN) cohort study of 99 million vaccinated individuals

BACKGROUND

The Global COVID Vaccine Safety (GCoVS) Project, established in 2021 under the multinational Global Vaccine Data Network™ (GVDN®), facilitates comprehensive assessment of vaccine safety. This study aimed to evaluate the risk of adverse events of special interest (AESI) following COVID-19 vaccination from 10 sites across eight countries.

METHODS

Using a common protocol, this observational cohort study compared observed with expected rates of 13 selected AESI across neurological, haematological, and cardiac outcomes. Expected rates were obtained by participating sites using pre-COVID-19 vaccination healthcare data stratified by age and sex. Observed rates were reported from the same healthcare datasets since COVID-19 vaccination program rollout. AESI occurring up to 42 days following vaccination with mRNA (BNT162b2 and mRNA-1273) and adenovirus-vector (ChAdOx1) vaccines were included in the primary analysis. Risks were assessed using observed versus expected (OE) ratios with 95 % confidence intervals. Prioritised potential safety signals were those with lower bound of the 95 % confidence interval (LBCI) greater than 1.5.

RESULTS

Participants included 99,068,901 vaccinated individuals. In total, 183,559,462 doses of BNT162b2, 36,178,442 doses of mRNA-1273, and 23,093,399 doses of ChAdOx1 were administered across participating sites in the study period. Risk periods following homologous vaccination schedules contributed 23,168,335 person-years of follow-up. OE ratios with LBCI > 1.5 were observed for Guillain-Barré syndrome (2.49, 95 % CI: 2.15, 2.87) and cerebral venous sinus thrombosis (3.23, 95 % CI: 2.51, 4.09) following the first dose of ChAdOx1 vaccine. Acute disseminated encephalomyelitis showed an OE ratio of 3.78 (95 % CI: 1.52, 7.78) following the first dose of mRNA-1273 vaccine. The OE ratios for myocarditis and pericarditis following BNT162b2, mRNA-1273, and ChAdOx1 were significantly increased with LBCIs > 1.5.

CONCLUSION

This multi-country analysis confirmed pre-established safety signals for myocarditis, pericarditis, Guillain-Barré syndrome, and cerebral venous sinus thrombosis. Other potential safety signals that require further investigation were identified.

Trauma-informed physiotherapy and the principles of safety, trustworthiness, choice, collaboration, and empowerment: a qualitative study

INTRODUCTION

Trauma is common and may lead to lasting adverse effects on health. Trauma-informed practice does not treat trauma but uses a strengths-based approach to encourage engagement in services.

OBJECTIVE

To understand how physiotherapy attends to trauma-informed principles.

METHODS

This qualitative ethnographic study was set in an Australian hospital. Three data collection methods were used, including observations of clinical practice, interactive reflexive group discussions with physiotherapists, and interviews with patients. Data analysis included an initial inductive phase followed by thematic mapping to trauma-informed principles. Critical reflexivity was used throughout to examine how the authors' perspectives and assumptions affected the analysis.

RESULTS

Twelve observations of consultations, ten interviews with people receiving physiotherapy, and five group discussions with physiotherapists were conducted. Themes produced within each of five principles of trauma-informed care included: Safety: not just a number, uncertainty beyond managing physical risks, upbeat approach as default needs balance, pragmatic environments inadequate; Trustworthiness: touch needs further consideration, assumed consent; Choice: limited options; Collaboration: let's do it together, variable consideration of the patient as expert, task focus, pushing the "right" treatment, missing insight into power imbalance; Empowerment: extending function and independence, building nonphysical skills but lack of clarity.

CONCLUSION

Physiotherapy incorporates crucial aspects of trauma-informed care, but opportunities exist to enhance physiotherapists' skills and knowledge, particularly in relation to non-physical safety considerations.

Background rates of adverse events of special interest for COVID-19 vaccines: A multinational Global Vaccine Data Network (GVDN) analysis

BACKGROUND

The Global COVID Vaccine Safety (GCoVS) project was established in 2021 under the multinational Global Vaccine Data Network (GVDN) consortium to facilitate the rapid assessment of the safety of newly introduced vaccines. This study analyzed data from GVDN member sites on the background incidence rates of conditions designated as adverse events of special interest (AESI) for COVID-19 vaccine safety monitoring.

METHODS

Eleven GVDN global sites obtained data from national or regional healthcare databases using standardized methods. Incident events of 13 pre-defined AESI were included for a pre-pandemic period (2015-19) and the first pandemic year (2020). Background incidence rates (IR) and 95% confidence intervals (CI) were calculated for inpatient and emergency department encounters, stratified by age and sex, and compared between pre-pandemic and pandemic periods using incidence rate ratios.

RESULTS

An estimated 197 million people contributed 1,189,652,926 person-years of follow-up time. Among inpatients in the pre-pandemic period (2015-19), generalized seizures were the most common neurological AESI (IR ranged from 22.15 [95% CI 19.01-25.65] to 278.82 [278.20-279.44] per 100,000 person-years); acute disseminated encephalomyelitis was the least common (<0.5 per 100,000 person-years at most sites). Pulmonary embolism was the most common thrombotic event (IR 45.34 [95% CI 44.85-45.84] to 93.77 [95% CI 93.46-94.08] per 100,000 person-years). The IR of myocarditis ranged from 1.60 [(95% CI 1.45-1.76) to 7.76 (95% CI 7.46-8.08) per 100,000 person-years. The IR of several AESI varied by site, healthcare setting, age and sex. The IR of some AESI were notably different in 2020 compared to 2015-19.

CONCLUSION

Background incidence of AESIs exhibited some variability across study sites and between pre-pandemic and pandemic periods. These findings will contribute to global vaccine safety surveillance and research.

Massively parallel base editing to map variant effects in human hematopoiesis

Systematic evaluation of the impact of genetic variants is critical for the study and treatment of human physiology and disease. While specific mutations can be introduced by genome engineering, we still lack scalable approaches that are applicable to the important setting of primary cells, such as blood and immune cells. Here, we describe the development of massively parallel base-editing screens in human hematopoietic stem and progenitor cells. Such approaches enable functional screens for variant effects across any hematopoietic differentiation state. Moreover, they allow for rich phenotyping through single-cell RNA sequencing readouts and separately for characterization of editing outcomes through pooled single-cell genotyping. We efficiently design improved leukemia immunotherapy approaches, comprehensively identify non-coding variants modulating fetal hemoglobin expression, define mechanisms regulating hematopoietic differentiation, and probe the pathogenicity of uncharacterized disease-associated variants. These strategies will advance effective and high-throughput variant-to-function mapping in human hematopoiesis to identify the causes of diverse diseases.

POS0590 SAFETY AND EFFICACY OF BIOLOGICS IN ELDERLY PATIENTS WITH RHEUMATOID ARTHRITIS IN A REAL WORLD STUDY: USE OF INTRAVENOUS GOLIMUMAB AND INFLIXIMAB IN ADULTS WITH RHEUMATOID ARTHRITIS ≥65 YEARS OF AGE

Background:

AWARE is a real-world evidence-based (RWE) study evaluating the safety and efficacy of IV golimumab (GLM) and infliximab (IFX) in adults with RA.

Objectives:

Evaluate safety and efficacy of IV GLM and IFX in elderly AWARE participants.

Methods:

AWARE, a prospective non-interventional study (88 US sites), enrolled patients (pts) initiating either IV GLM or IFX. Pt management was at the discretion of treating rheumatologists. In a post hoc analysis, pts were grouped by age (<65/≥65/≥75 yrs). Adverse events (AEs) were collected through the Week (W) 52 database lock (DBL; completed W52 or discontinued study) and at the end-of-study DBL (W104). The primary endpoint was proportion of pts with ≥1 infusion reaction through W52. Change from baseline in Clinical Disease Activity Index (CDAI) scores at Months 6 and 12 were secondary endpoints evaluated in bionaïve pts, including those with IFX dose escalation.

Results:

1270 pts were enrolled (685 IV GLM; 585 IFX). 1047 (82%) pts were female; mean age was 60 yrs (57% <65 yrs, 43% ≥65 yrs, and 7% ≥75 yrs). Mean disease durations were 9 yrs (IV GLM) and 7 yrs (IFX). Comorbidities were generally similar between IV GLM and IFX groups but more common among pts ≥65 vs <65 yrs. Through W52, 66% of IV GLM pts and 62% of IFX pts discontinued the study. Discontinuation due to lack of efficacy was generally similar across age groups within treatment groups, although somewhat higher for IV GLM (29%) vs IFX (19%). For both treatments, AEs and discontinuations due to AE through W52 were more common in pts ≥65 vs <65 yrs (Table 1). Consistent with general trends observed in elderly individuals,1 rates of serious AEs (SAEs) and serious infections increased with age for both IV GLM and IFX; however, increases were more notable in IFX- than IV GLM-treated pts ≥65 yrs. The incidence of serious infections was highest in pts ≥75 yrs for both treatments, although small sample size may limit data interpretation. No increase in opportunistic infections, including Varicella, was observed in pts ≥65 vs <65 yrs. Infusion reactions were more common in pts <65 yrs in both treatment groups, and more prevalent in IFX- than IV GLM-treated pts within each age group through W52. Generally similar safety results were seen between W52 and W104 for each treatment group (data not shown). Both IV GLM and IFX in bionaïve pts showed improvement in CDAI scores across age groups, which was maintained over time (Figure 1).

Table 1.

% of pts with ≥1 AE through W52 DBL

IV GLMIFX<65 yrs≥65 yrs≥75 yrs<65 yrs≥65 yrs≥75 yrsPatients, n3513349137021546Discontinued due to AE8.5%12.6%16.5%15.1%17.7%21.7%AE52.4%58.4%57.1%63.5%66.5%71.7%Most common AEs (≥5% of pts in either treatment group)Nausea3.7%3.3%3.3%8.4%6.0%2.2%Worsening of RA5.4%4.5%3.3%7.3%7.0%4.3%Upper respiratory tract infection5.7%5.1%4.4%6.2%5.6%2.2%Pruritis1.4%2.4%3.3%6.8%2.8%2.2%Sinusitis7.1%3.3%0%3.8%3.7%2.2%Urinary tract infection4.8%5.1%5.5%4.3%5.1%6.5%SAE7.7%16.8%20.9%9.7%18.6%26.1%Infection30.5%27.2%27.5%32.2%28.8%32.6%Serious infection3.7%6.3%7.7%3.5%7.9%15.2%Neoplasms benign, malignant and unspecified0.6%2.7%1.1%0.8%2.3%6.5%Latent tuberculosis0.3%0%00.3%0%0%Opportunistic infection1.4%1.8%4.4%1.9%1.4%4.3%Infusion reaction5.1%2.7%1.1%17.3%8.8%8.7%Death0.3%2.4%2.2%0%2.3%6.5%

Conclusion:

Elderly RA pts receiving IV GLM or IFX in this RWE study demonstrated similar safety and efficacy as reported in Phase 3 trials.2,3 The higher rates of AEs, discontinuations due to AE, and SAEs (mainly serious infections) observed in pts ≥65 yrs are in line with increased safety events seen in elderly vs younger individuals in the general population. Rates of AEs, SAEs, and infusion reactions were higher for IFX vs IV GLM. Infusion reactions were more common in pts <65 vs ≥65 yrs for both GLM and IFX, but more prevalent with IFX.

References:

[1]Castle SC. Clin Infect Dis 2000;31:578–85.

[2]Lipsky PE, et al. N Engl J Med 2000;343:1594-602.

[3]Weinblatt ME, et al. Ann Rheum Dis 2013;72:381-9.

Disclosure of Interests:

Joy Schechtman: None declared, Aaron Broadwell Speakers bureau: Amgen, AbbVie, Eli Lilly, Horizon, Janssen, Mallinckrodt, Novartis, Pfizer, Radius, Sanofi/Regeneron, and UCB, Consultant of: AbbVie, Amgen, Aurinia, Celegene, Eli Lilly, Janssen, Novartis, Pfizer, and Sandoz, Shelly Kafka Shareholder of: Johnson & Johnson, Employee of: Janssen Research & Development, LLC, Shawn Black Shareholder of: Johnson & Johnson, Employee of: Janssen Research & Development, LLC, Stephen Xu Shareholder of: Johnson & Johnson, Employee of: Janssen Research & Development, LLC, Wayne Langholff Shareholder of: Johnson & Johnson, Employee of: Janssen Research & Development, LLC, Sergio Schwartzman Shareholder of: Amgen, Boston Scientific, Gilead, Medtronic, and Pfizer, Speakers bureau: AbbVie, Janssen, Eli Lily, Novartis, Pfizer, Regeneron, Sanofi, and UCB, Consultant of: AbbVie, Gilead, Eli Lilly, Janssen, Myriad, Novartis, Regeneron, Samsung, Sanofi, and UCB

POS0607 PROMIS ASSESSMENT OF RESPONSE TO TREATMENT WITH GOLIMUMAB IV OR INFLIXIMAB IN RHEUMATOID ARTHRITIS PATIENTS: RESULTS FROM THE PHASE-4 AWARE STUDY

Background:

AWARE is a phase-4 observational study designed to provide real-world assessment of Golimumab (GLM) IV & infliximab (IFX) in patients (pts) with rheumatoid arthritis (RA).

Objectives:

To assess patient-reported aspects of social, mental, & physical health through the 8th infusion (≈1 year of treatment) using Patient Reported Outcomes Measurement Information System (PROMIS), a validated, disease-agnostic set of health assessment instruments.

Methods:

AWARE enrolled 1270 RA pts initiating treatment with GLM/IFX. The 52 week analysis set included pts with ≥1-year treatment or those discontinued and, while enrolled, completed PROMIS-29 or PROMIS short form (SF) questionnaires. PROMIS instruments were administered at baseline & prior to infusions 2, 5, & 8. The raw score was converted into a standardized T-score with a mean of 50 and SD of 10.

Results:

At baseline, treatment groups were balanced on demographics & medical characteristics. Most pts were white (87.0% GLM, 86.2% IFX) & female (83.4% GLM, 82.4% IFX). Mean ages were 58.5 ±12.96 years for GLM & 59.6 ±13.24 years for IFX. Overall, 35.3% GLM & 42.9% IFX pts were bio-naïve. The proportion of GLM & IFX pts with prior exposure to 1 or 2 biologics was similar; however, 20.1% GLM pts vs 10.8% IFX pts had exposure to ≥3 biologics. Methotrexate use was similar between GLM (76.4%) & IFX pts (75.0%). Based on mean PROMIS T-scores at baseline (Table 1), Fatigue, Pain Interference, & Physical Function domains approached or exceeded 1 SD worse than those of general US population. Through the 8th infusion, GLM- & IFX-treated pts achieved meaningful improvement based on mean changes from baseline in most PROMIS-29 domains & respective SFs with no significant difference between GLM and IFX. The percentage of GLM or IFX pts with improvements of ≥3, ≥5, or ≥10 units change in T-scores increased from infusion 2 through infusion 8.

Conclusion:

RA pts treated with GLM or IFX achieved comparable improvements across PROMIS-assessed social, mental, & physical health. PROMIS-29 was able to detect change to subsequent anti-tumor necrosis factor-α therapies.

Table 1.

Mean (SD) Change from Baseline PROMIS-29 Domain and Short Form T-Scores: 52 Week Analysis Set

GLMIFXLSM difference (95% CI)*Anxiety (4-item)N=6N=570Baseline53.4 (10.13)54.6 (10.53)Change from baseline at infusion 8N=223 -2.6 (8.10)N=286-3.7 (7.86)-0.29 (-1.54, 0.97)Depression (4-item)BaselineN=67451.9 (9.83)N=57452.5 (10.21)Change from baseline at infusion 8N=225-2.1 (7.56)N=287-2.3 (7.89)0.49 (-0.72, 1.70)Fatigue (4-item)BaselineN=67158.4 (9.91)N=57459.4 (9.99)Change from baseline at infusion 8N=225-3.4 (8.72)N=281-3.1 (7.77)0.69 (-0.64, 2.03)Short form Fatigue 7aBaselineN=68159.1 (8.51)N=57659.7 (8.25)Change from baseline at infusion 8N=228-3.2 (7.40)N=287-2.4 (6.35)1.01 (-0.11, 2.14)Pain interference (4-item)BaselineN=67963.0 (7.56)N=57463.9 (7.80)Change from baseline at infusion 8N=227-4.2 (8.23)N=284-3.1 (7.77)1.84 (0.55, 3.13)Short form Pain interference 6bBaselineN=68061.9 (7.45)N=57662.8 (7.54)Change from baseline at infusion 8N=228-3.8 (7.88)N=287-3.2 (6.67)1.31 (0.15, 2.48)Physical function (4-item)BaselineN=67838.2 (6.79)N=57138.0 (6.90)Change from baseline at infusion 8N=2242.2 (5.64)N=2831.9 (5.85)-0.76 (-1.73, 0.21)Sleep disturbance (4-item)BaselineN=67154.6 (8.72)N=569N=55.5 (8.61)Change from baseline at infusion 8N=221-1.4 (7.45)N=281-1.7 (7.61)0.23 (-0.96, 1.42)Social participation (4-item)BaselineN=67343.7 (8.40)N=57442.9 (8.77)Change from baseline at infusion 8N=2253.2 (8.15)N=2833.4 (7.48)-0.10 (-1.36, 1.16)

*Least squares mean (LSM) difference & confidence interval (CI) are based on analysis of covariance controlling for baseline PROMIS score using inverse probability of treatment weighted propensity score.

Disclosure of Interests:

Clifton Bingham Consultant of: AbbVie, BMS, Eli Lilly, Gilead, Janssen, Pfizer, Regeneron/Sanofi, Grant/research support from: Bristol-Myers Squibb, Shelly Kafka Employee of: Janssen Research & Development, LLC, Shawn Black Employee of: Janssen Research & Development, LLC, Stephen Xu Employee of: Janssen Research & Development, LLC, Wayne Langholff Employee of: Janssen Research & Development, LLC, Jeffrey Curtis Consultant of: AbbVie, Amgen, Bristol-Myers Squibb, Corrona, Janssen, Lilly, Myriad, Pfizer, Regeneron, Roche, UCB, Grant/research support from: AbbVie, Amgen, Bristol-Myers Squibb, Corrona, Janssen, Lilly, Myriad, Pfizer, Regeneron, Roche, UCB

Recruitment of Youth Living With HIV to Optimize Adherence and Virologic Suppression: Testing the Design of Technology-Based Community Health Nursing to Improve Antiretroviral Therapy (ART) Clinical Trials

Background

Despite advances in HIV diagnosis and treatment, adolescents and young adults 12-25 years old have high HIV incidence, poor engagement and retention in treatment, and low rates of adherence and virologic suppression when compared to their older counterparts. HIV has emerged as a chronic disease for which antiretroviral therapy (ART) adherence is critical for virologic suppression and long-term survival. Virologic suppression has been elusive for many youth with HIV (YHIV). Novel strategies designed to facilitate health care systems’ support for YHIV between medical visits are essential for improving ART adherence, virologic suppression, and long-term survival.

Objective

The aim of this study is to compare the effectiveness of a technology-enhanced community health nursing intervention (TECH2CHECK) to a standard of care (SOC) control group for improving ART adherence and subsequent viral suppression using a randomized trial design. The objectives are to assess the feasibility, acceptability, and cost-effectiveness of TECH2CHECK as compared to SOC for management of HIV in the outpatient setting and to examine the sustainability of self-care behavior, adherence, and virologic suppression among youth following the intervention period.

Methods

We will recruit 120 adherence-challenged YHIV being followed at clinics specializing in HIV care in the Baltimore-Washington metropolitan area and in Jacksonville. Eligible participants complete an audio, computer-assisted self-interview and are randomized to either TECH2CHECK intervention or the SOC (60 participants in each arm). The primary outcome of interest is virologic suppression (viral load <20 copies/mL) and improved treatment adherence. Participants in the intervention arm receive community health nursing visits at 2 weeks, 6 weeks, 10 weeks, 14 weeks, and 26 weeks. The intervention arm also receives SMS messaging comprising daily adherence and appointment reminders and positive reinforcement for medication adherence daily for 2 weeks, on alternate days for 2 weeks, thrice weekly for 1 month, weekly for 3 months, and every 2 weeks for the rest of the study duration. The control group receives appointment reminders and SOC per clinic protocol. Exploratory analysis will be conducted to determine differences in medication adherence and virologic suppression in the 2 arms and to assess cost-effectiveness and study feasibility and acceptability.

Results

In the first 23 months of the study (July 2018-April 2020), 56 (55%) of 102 eligible patients were enrolled and randomized. At present, participating youths are primarily African American (53/56, 95%), male (37/56, 66%), and ≥18 years old (53/56, 95%). Follow-up study visits, as required per the protocol, have been completed by 77% (43/56), 94% (45/48), 95% (37/39), 96% (24/25), and 100% (10/10) of participants at the 1-month, 3-month, 6-month, 12-month, and 18-month follow-ups, respectively.

Conclusions

Preliminary accrual and retention data suggest that TECH2CHECK is feasible and acceptable.

Trial Registration

ClinicalTrials.gov NCT03600103 https://clinicaltrials.gov/ct2/show/NCT03600103

International Registered Report Identifier (IRRID)

DERR1-10.2196/23480

Zygomaticus major muscle bony attachment site: a Thiel-embalmed cadaver study

OBJECTIVE

Thezygomaticus major is a principal muscle of facial expression which is engaged when smiling. The zygomaticus major origin of the zygomatic bone is often discussed relevant to its importance in the field of plastic surgery. In addition, the zygomaticus major attachment site is also significant for forensic craniofacial reconstruction, separating the cheek into frontal and lateral surfaces. However, there are discrepancies amongst published articles regarding the precise origin of the zygomaticus major muscle. The aim of this study is to investigate more distinctive and palpable landmarks as the bony attachment of the zygomaticus major.

METHODS

This project is the first zygomaticus major dissection study utilising Thiel embalmed cadavers. Fifty-two facial dissections were investigated in 26 Thiel embalmed bodies, bequeathed to the Centre for Anatomy and Human Identification at The University of Dundee between 2013 and 2015.

RESULTS

This study found that the origin of zygomaticus major muscle was located at the superior margin of the temporal process on the lateral surface of zygomatic bone. Moreover, the zygomaticus major muscle overlapped the anterosuperior border of the masseter muscle. One out of 52 zygomaticus major muscles presented bifurcation.

CONCLUSION

The origin site of zygomaticus major is considered important to increase resemblance in forensic craniofacial reconstruction. Furthermore, since zygomaticus major is a salient muscle involved in facial expression, the potential effects for cosmetic/surgical procedures are also relevant to the medical field and successful surgical outcomes. The current study provided easily palpable landmarks of zygomaticus major origin site which is beneficial for both surgeons and forensic craniofacial reconstruction practitioners.

FRI0567 CONSTRUCT VALIDATION OF PROMIS SHORT FORM AND PROFILE-29 T-SCORES WITH SF-36 IN RHEUMATOID ARTHRITIS PATIENTS TREATED FOR 1 YEAR: RESULTS FROM A REAL‑WORLD EVIDENCE-BASED STUDY IN THE UNITED STATES

Background:

Use of patient-reported outcomes (PROs) to assess health-related quality of life in clinical practice, research studies, and clinical trials in rheumatoid arthritis (RA) remains an ongoing area of research. SF-36 is commonly used in RA trials but is not feasible for routine use in clinical practice settings. ThePatientReportedOutcomesMeasurementInformationSystem (PROMIS) may address this gap but has not been widely assessed in RA patients starting therapy in a real-world comparative effectiveness study, nor examined in that setting in relation to the SF36 and Clinical Disease Activity Index (CDAI).

Objectives:

To assess validity of PROMIS based on Comparative and Pragmatic Study of Golimumab Intravenous (IV) Versus Infliximab in Rheumatoid Arthritis (AWARE), an ongoing Phase 4 study providing real-world assessment of IV tumor necrosis factor inhibitor (TNFi) medications in RA patients.

Methods:

AWARE is a prospective, non-interventional, 3-year study conducted at 88 US sites. RA patients were enrolled when initiating TNFi treatment. Treatment decisions were made by treating rheumatologists. We report baseline PROMIS-29 (7 domains and pain intensity), PROMIS Pain Interference (PI) Short Form (SF) 6b (PI6b) and PROMIS Fatigue (F) Short Form 7a (F7a), domain T-Scores, and SF-36 subdomain and Component Scores (CS) in AWARE patients. Here we report baseline data obtained from the final 1-year AWARE dataset. Correlations between PROMIS measures and comparable SF-36 component scores were calculated using Pearson correlations. Data is shown as mean ± standard deviation (SD).

Results:

At baseline, mean CDAI of all patients (n=1262) was 32.3±15.6, with 70.4% in high disease activity (HDA, CDAI>22), 22.8% in moderate disease activity (MDA, CDAI: >10 and ≤22), 6.1% in low disease activity (LDA, CDAI: >2.8 and ≤10), and 0.7% in remission (CDAI ≤2.8). Mean PROMIS scores were >0.5 SD worse than population means for Physical Function (PF, 38.1±6.84), PI (63.4±7.68), F (58.8±9.95), Sleep Disturbance (55.1±8.68); and Ability to Participate in Social Roles/Activities (PSRA, 43.4±8.58). Baseline Depression and Anxiety were within 0.5 SD of population T-scores. PI6b, F7a, and P29 domain T-scores correlated with the comparable SF-36 subdomain and component scores (r’s >0.58), except sleep for which no comparable SF-36 element was applicable. Examples include: P6b (r=-0.80) and P29-PI (0.81) with SF-36 Bodily Pain; F7a (-0.77) and P29-F (-0.77) with SF-36 Vitality; P29-PF with SF-36 PF (0.77), Role-Physical (0.69), and Physical CS (0.73); P29 Anxiety with SF-36 Mental Health (-0.72), Role-Emotional (-0.56), Mental CS (-0.70); and P29-PRSA with SF-36-Social Functioning (0.71). Mean PROMIS-29 T-scores (except Anxiety and Sleep Disturbance) among patients with HDA were significantly different from patients with MDA, LDA or remission (p < 0.001 for all). Further, mean PROMIS T-scores of PF, F, PSRA, PI, Pain Intensity, PI6b and P7a among patients with MDA were significantly different from patients with more or less active RA (by CDAI category).

Conclusion:

Analysis of baseline results from a large cohort of RA patients indicates high correlations between individual P29 domain T-scores and SF-36 component scores, as well as categorical CDAI, providing strong evidence of PROMIS construct validity in a real-world population of RA patients.

Disclosure of Interests:

Clifton Bingham Grant/research support from: Bristol-Myers Squibb, Consultant of: Bristol-Myers Squibb, Shelly Kafka Employee of: Janssen Scientific Affairs, LLC, Shawn Black Employee of: Janssen Research & Development, LLC, Janssen Scientific Affairs, LLC, Stephen Xu Employee of: Janssen Research & Development, LLC, Wayne Langholff Employee of: Janssen Research & Development, LLC, Jeffrey Curtis Grant/research support from: AbbVie, Amgen, Bristol-Myers Squibb, Corrona, Janssen, Lilly, Myriad, Pfizer, Regeneron, Roche, UCB, Consultant of: AbbVie, Amgen, Bristol-Myers Squibb, Corrona, Janssen, Lilly, Myriad, Pfizer, Regeneron, Roche, UCB

SAT0120 UNITED STATES RHEUMATOLOGY PRACTICE-BASED REAL-WORLD EVIDENCE OF INFUSION REACTIONS IN RHEUMATOID ARTHRITIS PATIENTS TREATED WITH INTRAVENOUS GOLIMUMAB OR INFLIXIMAB: IMPACT OF PRIOR BIOLOGIC EXPOSURE AND METHOTREXATE UTILIZATION

Background:

AWARE (Comparative and Pragmatic Study of Golimumab IV Versus Infliximab in Rheumatoid Arthritis) is an ongoing Phase 4 comparator study designed to provide a real-world assessment of intravenous golimumab (GLM) and intravenous infliximab (IFX) in patients (pts) with rheumatoid arthritis (RA). The study recently reached its primary endpoint (comparison of overall incidence of infusion reactions in GLM- vs IFX-treated pts after 52 weeks) with the last patient reaching 52 weeks of treatment or discontinuation from the study. AWARE also records prior use of biologic medications and concomitant use of methotrexate (MTX).

Objectives:

To assess the incidence of infusion reactions among GLM and IFX pts reported at baseline by examining the influence of prior biologic exposure or concurrent use of MTX.

Methods:

AWARE is a prospective, noninterventional, observational, multicenter, 3-year study conducted in the US. RA patients (1,270 adults) were enrolled at the time of initiating treatment with GLM or IFX. All treatment decisions were made at the discretion of the treating rheumatologist. An infusion reaction was any adverse event that occurred during an infusion or within 1 hour after the infusion of either GLM or IFX. Imputations were not performed on these AWARE data. Data shown are mean ± standard deviation.

Results:

Demographics are shown in Table 1 and the incidence of infusion reactions in different AWARE cohorts is shown in Table 2. GLM and IFX pts were comparable in sex and utilization of MTX at baseline. Both age and disease duration of GLM pts was greater than IFX pts by ~2 years. There was a higher proportion of bionaïve pts in IFX-treated group compared to GLM-treated group. Overall, infusion reactions occurred more frequently among IFX-treated pts compared to GLM-treated pts. The difference in infusion reaction rates between IFX- and GLM-treated pts was also evident among subgroups of bionaïve vs non-bionaïve pts, and among MTX non-users vs MTX users (characteristics reported at baseline). GLM pts did not report any serious or severe infusion reactions. These were reported rarely (3/585 pts) in IFX-treated pts. Among GLM and IFX pts with an infusion reaction, 55.6% of GLM and 77.1% of IFX pts had at least one medication for infusion reaction. Infusion reactions accounted for 9.7% and 35.1% of discontinuations due to adverse events in GLM and IFX pts, respectively.

Table 1.

Baseline Characteristics in the AWARE Study

GLM (n=685)IFX (n=585)Age (years)60.9 ± 13.4358.0 ± 12.85Sex (% female)85.0 %79.5 %Disease Duration (years)9.16 ± 9.9757.20 ± 9.716Bionaïve (%)33.0%48.6%MTX plus (%)75.4%75.1%

MTX=methotrexate

Table 2.

Infusion Reactions in AWARE in Subsets of Patients ± Prior Biologic Use or ± Concurrent MTX

GLM (n=685)IFX (n=585)GLM (n=685)IFX (n=585)BionaïveNon-BionaïveBionaïveNon-BionaïveNo MTX UseMTXUseNo MTX UseMTX UseInfusion Reactions6/242(2.5%)21/443(4.7%)36/251(14.3%)47/334(14.1%)15/265(5.7%)12/420(2.9%)44/229(19.2%)39/356(11.0%)Medication for Infusion Reactions33.3%59.1%78.9%73.6%50.%58.3%73.6%77.6%

MTX=methotrexate

Conclusion:

Whether bionaïve, non-bionaïve, MTX non-user or MTX user at baseline, the incidence of infusion reactions was notably lower among GLM- vs IFX-treated pts. Serious and/or severe infusion reactions did not occur among GLM pts and were rare among IFX pts. IFX was more commonly administered mediation for an infusion reaction compared to GLM. Infusion reactions accounted for almost four times the number of discontinuations related to adverse events in IFX pts compared to GLM pts.

Disclosure of Interests: :

Sergio Schwartzman Grant/research support from: Janssen Research & Development, LLC, Consultant of: AbbVie, Crescendo Bioscience, Dermtech, Eli Lilly and Company, Gilead Sciences, Janssen Pharmaceutica, Myriad Genetics, Novartis, Regeneron, Samsung, Sanofi, UCB, Speakers bureau: AbbVie, Eli Lilly and Company, Genentech, Janssen Pharmaceutica, Novartis, Pfizer, Regeneron, Sanofi, UCB, Aaron Broadwell Grant/research support from: Janssen Research & Development, LLC, Janssen, Eli Lilly, Consultant of: AbbVie, Amgen, AstraZeneca, Celgene, Eli Lilly, Janssen, Novartis, Pfizer, Sandoz, Speakers bureau: AbbVie, Amgen, Celgene, GSK, Horizon, Janssen, Mallinckrodt, Novartis, Pfizer, Radius, Sanofi-Regeneron, UCB, Alan Kivitz Shareholder of: AbbVie, Amgen, Gilead, GSK, Pfizer Inc, Sanofi, Consultant of: AbbVie, Boehringer Ingelheim,,Flexion, Genzyme, Gilead, Janssen, Novartis, Pfizer Inc, Regeneron, Sanofi, SUN Pharma Advanced Research, UCB, Paid instructor for: Celgene, Genzyme, Horizon, Merck, Novartis, Pfizer, Regeneron, Sanofi, Speakers bureau: AbbVie, Celgene, Flexion, Genzyme, Horizon, Merck, Novartis, Pfizer Inc, Regeneron, Sanofi, Shawn Black Employee of: Janssen Research & Development, LLC, Janssen Scientific Affairs, LLC, Stephen Xu Employee of: Janssen Research & Development, LLC, Wayne Langholff Employee of: Janssen Research & Development, LLC, Shelly Kafka Employee of: Janssen Scientific Affairs, LLC

Interaction of the Mechanosensitive Channel, MscS, with the Membrane Bilayer through Lipid Intercalation into Grooves and Pockets

All membrane proteins have dynamic and intimate relationships with the lipids of the bilayer that may determine their activity. Mechanosensitive channels sense tension through their interaction with the lipids of the membrane. We have proposed a mechanism for the bacterial channel of small conductance, MscS, that envisages variable occupancy of pockets in the channel by lipid chains. Here, we analyze protein-lipid interactions for MscS by quenching of tryptophan fluorescence with brominated lipids. By this strategy, we define the limits of the bilayer for TM1, which is the most lipid exposed helix of this protein. In addition, we show that residues deep in the pockets, created by the oligomeric assembly, interact with lipid chains. On the cytoplasmic side, lipids penetrate as far as the pore-lining helices and lipid molecules can align along TM3b perpendicular to lipids in the bilayer. Cardiolipin, free fatty acids, and branched lipids can access the pockets where the latter have a distinct effect on function. Cholesterol is excluded from the pockets. We demonstrate that introduction of hydrophilic residues into TM3b severely impairs channel function and that even "conservative" hydrophobic substitutions can modulate the stability of the open pore. The data provide important insights into the interactions between phospholipids and MscS and are discussed in the light of recent developments in the study of Piezo1 and TrpV4.

Determining discharge destination in geriatric evaluation and management units: Is progressive goal attainment a better early indicator of discharge destination than improvement in functional independence measure scores?

AIM

To determine whether progress in goal attainment is a more responsive measure of functional improvement than the Functional Independence Measure, and whether it is a more accurate predictor of discharge destination in the early phase of a Geriatric Evaluation and Management episode.

METHODS

The present study was a prospective audit of goal achievement, functional ability and discharge destination. A total of 83 patients were included in this study. Logistic regression was carried out with the outcome variable discharge destination (home vs residential care), and the predictors being goal attainment, age at admission and change in the Functional Independence Measure motor function scale from admission to 2 weeks.

RESULTS

Of the predictors, goal attainment was the only significant predictor. The overall amount of variability in the discharge destination explained by the predictors was 25% (Nagelkerke pseudo R² ).

CONCLUSIONS

Progressive goal attainment might be a better predictor of improvement in function and discharge destination than change in the Functional Independence Measure. Geriatr Gerontol Int 2018; 18: 1058-1063.

Quality Assessments of HMO Diagnosis Databases Used to Monitor Childhood Vaccine Safety

Objective: To assess the quality of automated diagnoses extracted from medical care databases by the Vaccine Safety Datalink (VSD) study.

Methods: Two methods are used to assess quality of VSD diagnosis data. The first method compares common automated and abstracted diagnostic categories (“outcomes”) in 1-2% simple random samples of study populations. The second method estimates positive predictive values of automated diagnosis codes used to identify potential cases of rare conditions (e.g., acute ataxia) for inclusion in nested case-control medical record abstraction studies.

Results: There was good agreement (64-68%) between automated and abstracted outcomes in the 1-2% simple random samples at 3 of the 4 VSD sites and poor agreement (44%) at 1 site. Overall at 3 sites, 56% of children with automated cerebella ataxia codes (ICD-9 = 334) and 22% with “lack of coordination” codes (ICD-9 = 781.3) met objective clinical criteria for acute ataxia.

Conclusions: The misclassification error rates for automated screening outcomes substantially reduce the power of screening analyses and limit usefulness of screening analyses to moderate to strong vaccine-outcome associations. Medical record verification of outcomes is needed for definitive assessments.

Anorexia nervosa: service consumption and outcome of local patients in the Leicester service

Aims and Method

A retrospective case note study provided data on the service consumption and outcome of treatment for a cohort of adult anorexia nervosa sufferers treated in a specialised secondary service.

Results

A cohort of 106 patients was studied. Only just over a quarter were ever admitted. Of a subset of 78 patients, first seen before 1994, nearly one-fifth failed to engage in treatment. Those who were admitted spent on average a total of 10 months in hospital, were in touch for four years and had over 100 therapy sessions. The majority who were treated solely as out-patients remained in touch with the service on average for over two years.

Clinical Implications

Services for anorexia nervosa sufferers need to plan for prolonged contact with their patients and high rates of service consumption.

Emergency medical service provider decision-making in out of hospital cardiac arrest: an exploratory study

BACKGROUND

There are approximately 60,000 out-of-hospital cardiac arrests (OHCA) in the United Kingdom (UK) each year. Within the UK there are well-established clinical practice guidelines that define when resuscitation should be commenced in OHCA, and when resuscitation should cease. Background literature indicates that decision-making in the commencement and cessation of resuscitation efforts in OHCA is complex, and not comprehensively understood. No relevant research from the UK has been published to date and this research study seeks to explore the influences on UK Emergency Medical Service (EMS) provider decision-making when commencing and ceasing resuscitation attempts in OHCA. The aim of this research to explore the influences on UK Emergency Medical Services provider decision-making when commencing and ceasing resuscitation attempts in OHCA.

METHODS

Four focus groups were convened with 16 clinically active EMS providers. Four case vignettes were discussed to explore decision-making within the focus groups. Thematic analysis was used to analyse transcripts.

RESULTS

This research found that there are three stages in the decision-making process when EMS providers consider whether to commence or cease resuscitation attempts in OHCA. These stages are: the call; arrival on scene; the protocol. Influential factors present at each of the three stages can lead to different decisions and variability in practice. These influences are: factual information available to the EMS provider; structural factors such as protocol, guidance and research; cultural beliefs and values; interpersonal factors; risk factors; personal values and beliefs.

CONCLUSIONS

An improved understanding of the circumstantial, individual and interpersonal factors that mediate the decision-making process in clinical practice could inform the development of more effective clinical guidelines, education and clinical decision support in OHCA. These changes have the potential to lead to greater consistency. and EMS provider confidence, with the potential for improved patient outcome from OHCA.

Home or hospital for people with dementia and one or more other multimorbidities: What is the potential to reduce avoidable emergency admissions? The HOMEWARD Project Protocol

INTRODUCTION

Older people with multimorbidities frequently access 999 ambulance services. When multimorbidities include dementia, the risk of ambulance use, accident and emergency (A&E) attendance and hospital admission are all increased, even when a condition is treatable in the community. People with dementia tend to do poorly in the acute hospital setting and hospital admission can result in adverse outcomes. This study aims to provide an evidence-based understanding of how older people living with dementia and other multimorbidities are using emergency ambulance services. It will also provide evidence of how paramedics make decisions about taking this group of patients to hospital, and what resources would allow them to make more person-focused decisions to enable optimal patient care. METHODS AND ANALYSIS: Phase 1: retrospective data analysis: quantitative analysis of ambulance service data will investigate: how often paramedics are called to older people with dementia; the amount of time paramedics spend on scene and the frequency with which these patients are transported to hospital. Phase 2: observational case studies: detailed case studies will be compiled using qualitative methods, including non-participant observation of paramedic decision-making, to understand why older people with multimorbidities including dementia are conveyed to A&E when they could be treated at home or in the community. Phase 3: needs analysis: nominal groups with paramedics will investigate and prioritise the resources that would allow emergency, urgent and out of hours care to be effectively delivered to these patients at home or in a community setting.

ETHICS AND DISSEMINATION

Approval for the study has been obtained from the Health Research Authority (HRA) with National Health Service (NHS) Research Ethics Committee approval for phase 2 (16/NW/0803). The dissemination strategy will include publishing findings in appropriate journals, at conferences and in newsletters. We will pay particular attention to dissemination to the public, dementia organisations and ambulance services.

Comprehensive clinical sitting balance measures for individuals following stroke: a systematic review on the methodological quality

PURPOSE

The aim of this systematic review was to examine the psychometric properties of published clinical sitting measurement scales containing dynamic tasks in individuals following stroke.

METHOD

Databases, including Cumulative Index of Nursing and Allied Health Literature (CINAHL), MEDLINE, EMBASE, Cochrane, PubMed and Allied and Complementary Medicine Database (AMED) were searched from inception to December 2015. The search strategy included terms relating to sitting, balance and postural control. Two reviewers independently selected and extracted data from the identified articles and assessed the methodological quality of the papers using the COnsensus-based Standards for selection of health status Measurement INstruments (COSMIN) checklist.

RESULTS

Fourteen clinical sitting measurement scales (39 papers) containing dynamic tasks met the inclusion criteria and various measurement properties were evaluated. The methodological quality of the majority of the included studies was rated as poor to fair using the COSMIN checklist, with common limitations including small sample size and inappropriate use of statistical methods.

CONCLUSIONS

This review was unable to identify measures with sufficient psychometric properties to enable recommendation as preferred tools. However, measures were identified that warrant further specific psychometric investigations to fulfil requirements for a high quality measure. Implications for Rehabilitation Fourteen clinical sitting balance scales containing dynamic tasks are available to measure sitting balance with individuals following stroke. No single scale has sufficient psychometric properties to enable recommendation as a preferred tool for measuring sitting balance with stroke survivors. Use of a balance scale or dedicated sitting balance measure containing static and dynamic sitting items should be utilised to monitor progress for individuals following stroke with more severe deficits.

Understanding the Limitations of Circulating Cell Free Fetal DNA: An Example of Two Unique Cases

Circulating cell free fetal DNA (cffDNA) is an effective screening modality for fetal aneuploidy. We report two cases of false positive results. The first case involves a female, with self-reported Down syndrome. CffDNA returned positive for trisomy 18 leading to a maternal diagnosis of mosaicism chromosome 18 with normal fetal karyotype. The second case involves a patient with an anomalous fetal ultrasound and cffDNA positive for trisomy 13. Amniocentesis demonstrated a chromosome 8p duplication/deletion. False positive cffDNA may arise in clinical scenarios where diagnostic testing is clearly indicated. Practitioners should recognize the limitations of cffDNA.

Readmissions at a public safety net hospital

Objective

We aimed to determine factors related to avoidability of 30-day readmissions at our public, safety net hospital in the United States (US).

Methods

We prospectively reviewed medical records of adult internal medicine patients with scheduled and unscheduled 30-day readmissions. We also interviewed patients if they were available. An independent panel used pre-specified, objective criteria to adjudicate potential avoidability.

Results

Of 153 readmissions evaluated, 68% were unscheduled. Among these, 67% were unavoidable, primarily due to disease progression and development of new diagnoses. Scheduled readmissions accounted for 32% of readmissions and most (69%) were clinically appropriate and unavoidable. The scheduled but avoidable readmissions (31%) were attributed largely to limited resources in our healthcare system.

Conclusions

Most readmissions at our public, safety net hospital were unavoidable, even among our unscheduled readmissions. Surprisingly, one-third of our overall readmissions were scheduled, the majority reflecting appropriate management strategies designed to reduce unnecessary hospital days. The scheduled but avoidable readmissions were due to constrained access to non-emergent, expensive procedures that are typically not reimbursed given our system’s payor mix, a problem which likely plague other safety net systems. These findings suggest that readmissions do not necessarily reflect inadequate medical care, may reflect resource constraints that are unlikely to be addressable in systems caring for a large burden of uninsured patients, and merit individualized review.

Efficacy and safety of canagliflozin in patients with type 2 diabetes mellitus inadequately controlled with metformin and sulphonylurea: a randomised trial

AIMS

Canagliflozin is a sodium glucose co-transporter 2 inhibitor developed for the treatment of type 2 diabetes mellitus (T2DM). This randomised, double-blind, placebo-controlled, Phase 3 study evaluated the efficacy and safety of canagliflozin as an add-on to metformin plus sulphonylurea in patients with T2DM.

METHODS

Patients (N = 469) received canagliflozin 100 or 300 mg or placebo once daily during a 26-week core period and a 26-week extension. Prespecified primary end-point was change in HbA1c at 26 weeks. Secondary end-points included change in HbA1c at week 52 as well as proportion of patients achieving HbA1c < 7.0%, change in fasting plasma glucose (FPG) and systolic blood pressure, and per cent change in body weight, high-density lipoprotein cholesterol, and triglycerides (weeks 26 and 52).

RESULTS

HbA1c was significantly reduced with canagliflozin 100 and 300 mg vs. placebo at week 26 (-0.85%, -1.06%, and -0.13%; p < 0.001); these reductions were maintained at week 52 (-0.74%, -0.96%, and 0.01%). Both canagliflozin doses reduced FPG and body weight vs. placebo at week 26 (p < 0.001) and week 52. Overall adverse event (AE) rates were similar across groups over 52 weeks, with higher rates of genital mycotic infections and osmotic diuresis-related AEs seen with canagliflozin vs. placebo; these led to few discontinuations. Increased incidence of documented, but not severe, hypoglycaemia episodes was seen with canagliflozin vs. placebo.

CONCLUSIONS

Canagliflozin improved glycaemic control, reduced body weight, and was generally well tolerated in T2DM patients on metformin plus sulphonylurea over 52 weeks.

Capturing the diagnosis: an internal medicine education program to improve documentation

BACKGROUND

Specific and accurate documentation of patient diagnoses and comorbidities in the medical record is critical to drive quality improvement and to ensure accuracy of publicly reported data. Unfortunately, inpatient documentation is taught to internal medicine trainees and practitioners sporadically, if at all. At Harbor-UCLA Medical Center, a public, tertiary care, academic medical center, we implemented an educational program to enhance documentation of diagnoses and comorbidities by internal medicine resident and attending physicians.

METHODS

The program consisted of a series of lectures and the creation of a pocket card. These were designed to guide providers in accurate documentation of common diagnoses that group to different levels of disease severity, achieved by capturing Centers for Medicare and Medicaid Services complication codes and major complication codes. We started the educational program in January 2010 and used a pre-post design to compare outcomes. The program's impact on complication codes and major complication codes capture rates, mortality index, and case mix index was evaluated using the University Health Consortium database.

RESULTS

The median quarterly complication codes and major complication codes capture rate for inpatients on the internal medicine service was 42% before the intervention versus 48% after (P = .003). Observed mortality did not change but expected mortality increased, resulting in a 30% decline in median quarterly mortality index (P = .001). The median quarterly case mix index increased from 1.27 to 1.36 (P = .004).

CONCLUSIONS

Thus, implementation of an internal medicine documentation curriculum improved accuracy in documenting diagnoses and comorbidities, resulting in improved capture of complication codes.

The incidence and position of melanocytic nevi for the purposes of forensic image comparison

Expert witness opinion based on the comparison of images has been accepted by UK courts as admissible evidence in relation to issues of identity. Within images of the hand are a multiplicity of anatomical features of different aetiology, incidence and distribution patterns and this includes melanocytic nevi, referred to more colloquially as moles and/or birthmarks. The hand is not a common place for these isolated features to develop and so their presence in this anatomical region has the potential to be useful for issues of identity. The results of this study show that approximately 9 % of individuals in a sample of 476 hands, displayed at least one nevus on the back of their hand and, contrary to the literature, the incidence was found to be greater in females (15 % of female cohort) than males (7 % of male cohort). Almost a third of all nevi identified on the dorsum of the hand were abnormal or dysplastic. The most frequent location for these aggregations of melanocytes was in the central region of the dorsum of the hand or at the base of the index finger. The relevance of nevi identified in the image of a perpetrator’s hand and also on that of a suspect/accused is discussed in relation to the issue of whether the images have originated from the same individual.