Machine learning-based prediction of in-hospital death for patients with takotsubo syndrome: The InterTAK-ML model

AIMS

Takotsubo syndrome (TTS) is associated with a substantial rate of adverse events. We sought to design a machine learning (ML)-based model to predict the risk of in-hospital death and to perform a clustering of TTS patients to identify different risk profiles.

METHODS AND RESULTS

A ridge logistic regression-based ML model for predicting in-hospital death was developed on 3482 TTS patients from the International Takotsubo (InterTAK) Registry, randomly split in a train and an internal validation cohort (75% and 25% of the sample size, respectively) and evaluated in an external validation cohort (1037 patients). Thirty-one clinically relevant variables were included in the prediction model. Model performance represented the primary endpoint and was assessed according to area under the curve (AUC), sensitivity and specificity. As secondary endpoint, a K-medoids clustering algorithm was designed to stratify patients into phenotypic groups based on the 10 most relevant features emerging from the main model. The overall incidence of in-hospital death was 5.2%. The InterTAK-ML model showed an AUC of 0.89 (0.85-0.92), a sensitivity of 0.85 (0.78-0.95) and a specificity of 0.76 (0.74-0.79) in the internal validation cohort and an AUC of 0.82 (0.73-0.91), a sensitivity of 0.74 (0.61-0.87) and a specificity of 0.79 (0.77-0.81) in the external cohort for in-hospital death prediction. By exploiting the 10 variables showing the highest feature importance, TTS patients were clustered into six groups associated with different risks of in-hospital death (28.8% vs. 15.5% vs. 5.4% vs. 1.0.8% vs. 0.5%) which were consistent also in the external cohort.

CONCLUSION

A ML-based approach for the identification of TTS patients at risk of adverse short-term prognosis is feasible and effective. The InterTAK-ML model showed unprecedented discriminative capability for the prediction of in-hospital death.

Mitigation of aircraft noise-induced vascular dysfunction and oxidative stress by exercise, fasting, and pharmacological α1AMPK activation: molecular proof of a protective key role of endothelial α1AMPK against environmental noise exposure

AIMS

Environmental stressors such as traffic noise represent a global threat, accounting for 1.6 million healthy life years lost annually in Western Europe. Therefore, the noise-associated health side effects must be effectively prevented or mitigated. Non-pharmacological interventions such as physical activity or a balanced healthy diet are effective due to the activation of the adenosine monophosphate-activated protein kinase (α1AMPK). Here, we investigated for the first time in a murine model of aircraft noise-induced vascular dysfunction the potential protective role of α1AMPK activated via exercise, intermittent fasting, and pharmacological treatment.

METHODS AND RESULTS

Wild-type (B6.Cg-Tg(Cdh5-cre)7Mlia/J) mice were exposed to aircraft noise [maximum sound pressure level of 85 dB(A), average sound pressure level of 72 dB(A)] for the last 4 days. The α1AMPK was stimulated by different protocols, including 5-aminoimidazole-4-carboxamide riboside application, voluntary exercise, and intermittent fasting. Four days of aircraft noise exposure produced significant endothelial dysfunction in wild-type mice aorta, mesenteric arteries, and retinal arterioles. This was associated with increased vascular oxidative stress and asymmetric dimethylarginine formation. The α1AMPK activation with all three approaches prevented endothelial dysfunction and vascular oxidative stress development, which was supported by RNA sequencing data. Endothelium-specific α1AMPK knockout markedly aggravated noise-induced vascular damage and caused a loss of mitigation effects by exercise or intermittent fasting.

CONCLUSION

Our results demonstrate that endothelial-specific α1AMPK activation by pharmacological stimulation, exercise, and intermittent fasting effectively mitigates noise-induced cardiovascular damage. Future population-based studies need to clinically prove the concept of exercise/fasting-mediated mitigation of transportation noise-associated disease.

AB0884 Disease outcomes in patients with psoriatic arthritis completing 12 months of apremilast treatment - Real-world data from the REWARD study

Background

Patients with moderately active psoriatic arthritis (PsA) and limited joint involvement have considerable disease burden1,2. Recent data shows these patients have a high likelihood of achieving treatment goals if treated with apremilast3. This is the first report of outcomes in patients with PsA who received apremilast for 12 months in Dutch clinical practice.

Objectives

We report disease outcomes, including the PsA Impact of Disease (PsAID) 12-item questionnaire, swollen joint count (SJC), tender joint count (TJC), dactylitis and enthesitis, among patients in the prospective, multicenter, observational REWARD study who completed 12 months of apremilast treatment.

Methods

The ongoing REWARD study enrolled patients who had initiated apremilast for the treatment of PsA in the Netherlands between 13 April 2017 and 24 March 2021, and includes up to 12 months follow-up1,4. We report interim data from patients with data available as of 16 September 2021. Baseline data are summarized separately for patients who discontinued apremilast before their month 12 study visit (stoppers) and patients still receiving apremilast at their month 12 visit (completers). Post baseline data are summarized for completers. Continuous data are summarized using mean and SD, categorical data are summarized using n and percent.

Results

98 patients were included in this interim analysis; 32 had completed 12 months of apremilast treatment (completers), 54 had discontinued apremilast before month 12 (stoppers), 12 were ongoing in the study. Compared with stoppers, completers were more likely to be biologic naïve and have dactylitis, and had lower BSA. All other baseline characteristics were similar (Table 1). Among completers, all PsAID domains improved after 3 months of apremilast treatment and these improvements were maintained through month 12 (Figure 1). Mean SJC and TJC decreased between baseline and month 12 (SJC, 4.2 and 1.0 at baseline and month 12, respectively; TJC, 7.1 and 3.3, respectively). The proportion of completers with SJC, TJC, enthesitis and dactylitis scores of 0 increased from baseline to month 12 (Figure 1B). The proportion of completers reporting at least one adverse event (AE) was comparable to the overall study population (14/32 [44%] and 48/98 [49%], respectively); the reported adverse events were similar to the known safety profile of apremilast.

Table 1.

Baseline characteristics

All=all patients included in this interim analysis; Completers= patients that received apremilast for 12 months; Stoppers= patients that stopped apremilast treatment prior to 12 months.

BMI=Body Mass Index, PsO=Psoriasis, BSA PsO= Body Surface Area Psoriasis, SJC=Swollen Joint Count, TJC=Tender Joint Count, PsAID=Psoriatic Arthritis Impact of Disease, VAS=Visual Analog Scale, CRP= C-reactive protein, cDAPSA=Clinical Disease Activity in Psoriatic Arthritis, Rem=Remission, Mod=Moderate, PsA= Psoriatic Arthritis

Figure 1.

(A) PSAID scores in completers and (B) percentage of completers with no swollen joints, no tender joints, no dactylitis and no enthesitis at baseline (BSL), month 3, 6 and 12 (M3, M6, M12).

Conclusion

In this interim analysis of the REWARD study, patients completing 12 months of apremilast treatment were more likely to be biologic naïve than patients who discontinued apremilast within 12 months of initiation, and had significant decreases in TJC, SJC, dactylitis and enthesis during apremilast treatment. Completed patients also reported decreased PsAID scores during apremilast treatment, indicating improvements in their quality of life.

References

[1]Jansen TL, et al. Ann Rheum Dis. 2019; 78:913 [abstract FRI0442]

[2]Wervers et al. J Rheumatol. 2018;45:1526.

[3]Mease PJ, et al. Arthritis Care Res. 2020; 72, 6, 814–821

[4]Bos R, et al. Ann Rheum Dis. 2021; 80:805 [POS1053]

Acknowledgements

Sylvia de Jong and Claire Desborough, Amgen employees, provided medical writing and editorial assistance.

Disclosure of Interests

Reinhard Bos Consultant of: AbbVie BV, Genzyme Europe, Grant/research support from: Galapagos, Tim Jansen Speakers bureau: Grunenthal, Sobi, Consultant of: AbbVie, Celgene Corporation, Grant/research support from: ReumaNederland, Olatec, Grunenthal, Ian Bridges Shareholder of: Amgen, Employee of: Amgen, Sylvia de Jong Shareholder of: Amgen, Employee of: Amgen, Novartis, Marijn Vis Consultant of: AbbVie, Celgene Corporation, Eli Lilly, Novartis, Pfizer, Grant/research support from: Novartis, Pfizer

Scaling and Confinement in Ultrathin Chalcogenide Films as Exemplified by GeTe

Chalcogenides such as GeTe, PbTe, Sb₂ Te₃ , and Bi₂ Se₃ are characterized by an unconventional combination of properties enabling a plethora of applications ranging from thermo-electrics to phase change materials, topological insulators, and photonic switches. Chalcogenides possess pronounced optical absorption, relatively low effective masses, reasonably high electron mobilities, soft bonds, large bond polarizabilities, and low thermal conductivities. These remarkable characteristics are linked to an unconventional bonding mechanism characterized by a competition between electron delocalization and electron localization. Confinement, that is, the reduction of the sample dimension as realized in thin films should alter this competition and modify chemical bonds and the resulting properties. Here, pronounced changes of optical and vibrational properties are demonstrated for crystalline films of GeTe, while amorphous films of GeTe show no similar thickness dependence. For crystalline films, this thickness dependence persists up to remarkably large thicknesses above 15 nm. X-ray diffraction and accompanying simulations employing density functional theory relate these changes to thickness dependent structural (Peierls) distortions, due to an increased electron localization between adjacent atoms upon reducing the film thickness. A thickness dependence and hence potential to modify film properties for all chalcogenide films with a similar bonding mechanism is expected.

Doxorubicin induces wide-spread transcriptional changes in the myocardium of hearts distinguishing between mice with preserved and impaired cardiac function

AIMS

Doxorubicin (DOX) is an important drug for the treatment of various tumor entities. However, the occurrence of heart failure limits its application. This study investigated differential gene expression profiles in the left and right ventricles of DOX treated mice with either preserved or impaired myocardial function. We provide new mechanistic insights into the pathophysiology of DOX-induced heart failure and have discovered pathways that counteract DOX-induced cardiotoxicity.

MAIN METHODS

We used in total 48 male mice and applied a chronic low dose DOX administration (5 mg/kg per injection, in total 20 mg/kg over 4 weeks) to induce heart failure. Echocardiographic parameters were evaluated one week after the final dose and mice were separated according to functional parameters into doxorubicin responding and non-responding animals. Post mortem, measurements of reactive oxygen species (ROS) and gene expression profiling was performed in separated right and left hearts.

KEY FINDINGS

We detected significant ROS production in the left heart of the mice in response to DOX treatment, although interestingly, not in the right heart. We found that transcriptional changes differ between right and left heart correlating with the occurrence of myocardial dysfunction.

SIGNIFICANCE

Doxorubicin induces changes in gene expression in the entire heart of animals without necessarily impairing cardiac function. We identified a set of transcripts that are associated with DOX cardiotoxicity. These might represent promising targets to ameliorate DOX-induced heart failure. Moreover, our results emphasize that parameters of left and right heart function should be evaluated during standardized echocardiography in patients undergoing DOX therapy.

A first dedicated heart valve unit: safe and streamlined patient care for the rapidly growing field of transcatheter heart valve interventions

Background

A dedicated Heart Valve Unit was launched in 2018 to meet the demands of the growing transcatheter heart valve program by optimizing patient care in a single dedicated unit.

Purpose

To assess the performance of the heart valve unit (all steps of patient care in a single unit with intermediate care facilities) over a conventional approach (preparation on a normal ward, postprocedural intensive care unit (ICU) monitoring and transfer to an additional monitoring ward before discharge) in a high volume center.

Methods

Retrospective analysis including patients undergoing transcatheter mitral or tricuspid valve repair who were admitted to the Heart Valve Unit (02/2018–01/2020) compared to a conventional patient care approach (02/2016–01/2018). Patients who were already preprocedurally admitted to the ICU or in whom ICU monitoring postprocedurally was mandatory (direct annuloplasty, valve replacement) were excluded. The Heart Valve Unit patient care algorithm is presented in figure 1. We assessed procedural numbers, length of hospital stay, length and need for ICU monitoring, patient transfers between wards and periprocedural safety including in-hospital mortality.

Results

We observed a 164% increase in procedures (521 vs. 316 in total, 369 vs 282 with mitral valve procedures and 152 vs 34 tricuspid valve procedures) with the launch of the Heart Valve Unit over the 2-year-interval compared to the earlier time period. Length of in-hospital stay was significantly decreased compared to a conventional approach (9±7 vs. 12±11 days, p<0.001). In particular, postprocedural stay could be shortened from 7±7 to 5±6 days (p<0.001). Patients were less transferred between different wards in the Heart Valve Unit setting (p<0.001). Whereas all patients were postprocedurally transferred to the ICU in the conventional setting, only 16% of patients required an ICU bed immediately after the procedure due to complex interventions, intraprocedural events or high-risk comorbidities. The length of stay on ICU declined from 1.4±1.4 to 0.5±2.2 days. Among the patients re-transferred to the Heart Valve Unit directly after the procedure, 2% (10 patients) required an ICU bed in the further course due to hemodynamic instability (2), severe bleeding (4), seizures (1), ventricular fibrillation (1), anaesthetic overhang (1) or after urgent surgery due to a atrioventricular fistula (1). After stabilization, all patients were re-transferred to the Heart Valve Unit and discharged hereinafter. There was no intra-hospital death among these patients.

Conclusions

A dedicated Heart Valve Unit allows a safe and optimized patient care structure for transcatheter valvular interventions by combining all pre- and postprocedural steps in a single unit, thereby decreasing length of in-hospital stay to meet increasing economic demands. ICU capacity can be specifically used for complex procedures aftercare and complication monitoring.

Funding Acknowledgement

Type of funding sources: None.

POS1053 COMPARISON OF BASELINE CHARACTERISTICS BETWEEN PATIENTS CONTINUING OR DISCONTINUING APREMILAST AT TWELVE MONTHS IN THE REWARD STUDY (THE NETHERLANDS)

Background:

Previous analysis of the REWARD study reported that patients with limited joint involvement have a considerable burden of disease1. Recent data suggest that patients with moderately active psoriatic arthritis (PsA) and a limited joint involvement have a high likelihood of achieving treatment goals when treated with apremilast2. According to EULAR recommendations a PDE4 inhibitor may be considered in patients with mild disease and an inadequate response to at least one csDMARD, in whom neither a bDMARD nor a JAK inhibitor is appropriate and the value of apremilast may be found in treating patients with relatively mild disease (oligoarticular)3.

Objectives:

The objective of this prospective, multicentre, non-interventional study is to describe patient reported outcomes, effectiveness and real-life use of apremilast in patients with PsA. Patients will be followed up for a maximum of 12 months. This interim analysis compared the baseline characteristics and experience on apremilast for two subgroups of patients, those remaining on apremilast versus the ones that discontinued.

Methods:

In this interim analysis we included patients with data available at cut-off date of 03 November 2020. Patient enrollment and follow up of current subjects is ongoing. Descriptive statistics (n’s and percents for categorical data, means for continuous data) were used to summarize the baseline data by subgroup. Kaplan Meier plots are presented to show patients’ experience on apremilast by subgroup.

Results:

85 patients were included in the analysis. 30 patients have completed the study, 39 patients have discontinued and 16 are ongoing. At baseline 22 (26%) patients were biologic experienced and 62 (74%) were biologic naïve. Both groups had a comparable disease activity measured with clinical disease activity in psoriatic arthritis (cDAPSA) scores. Biologic experienced patients had a longer disease duration compared to biologic naïve patients (mean 9.7 vs 6.2 years). Inefficacy of previous medication was the main reason for starting apremilast in both subgroups. Overall, 86% (n=69) of patients were still receiving apremilast at month 3, 60% (n=46) at month 6, and 41% (n=26) at month 12 (Figure 1). Drug survival (length of time until discontinuation of apremilast) for biologic naïve patients was 93% at month 3, 73% at month 6 and 58% at month 12. Drug survival of biologic experienced patients was 67%, 20%, and 0% at months 3, 6, and 12, respectively. At baseline mean values of body mass index (BMI), swollen joint count (SJC), tender joint count (TJC), psoriatic arthritis impact of disease (PsAID) were comparable between both groups (Table 1). Reasons for discontinuation were mainly lack of efficacy (49%) and adverse events (44%). In this analysis the nature and frequency of adverse events is in line with the known profile of apremilast.

Conclusion:

In this interim analysis, patients who were biologic naïve had a better probability to remain on treatment than those who were biologic experienced. Baseline characteristics were similar between the two groups, apart from disease duration that was longer in the biologic experienced group. Best drug survival is achieved when apremilast is prescribed earlier in the PsA treatment course, before biologics and after csDMARDs, as per apremilast EU label.

References:

[1]Jansen TL, et al. Ann Rheum Dis. 2019;78:913 [abstract FRI0442]

[2]Mease PJ, et al. Arthritis Care Res 2020 72 6 814–821

[3]Gossec L, et al. Ann Rheum Dis 2020;79:700–712

Disclosure of Interests:

Reinhard Bos Consultant of: AbbVie BV, Genzyme Europe, Janssen-Cilag, Novartis, Pfizer, Grant/research support from: Galapagos, Tim Jansen Consultant of: AbbVie, Celgene Corporation – consultant, Speakers bureau: Grunenthal, Sobi – speakers bureau, Grant/research support from: ReumaNederland, Olatec, Grunenthal – grant/research support, Sylvia de Jong Shareholder of: Employee of Amgen Inc, Employee of: Employee of Amgen Inc, Antonio Castiglia Shareholder of: Employee of Amgen Inc, Employee of: Employee of Amgen Inc, Marijn Vis Consultant of: AbbVie, Celgene Corporation, Eli Lilly, Novartis, Pfizer, Grant/research support from: Novartis, Pfizer, AbbVie, Celgene Corporation, Eli Lilly, Novartis, Pfizer.

POS1124 IDENTIFYING POTENTIAL CLASSIFICATION CRITERIA FOR CALCIUM PYROPHOSPHATE DEPOSITION DISEASE (CPPD): RESULTS FROM THE INITIAL PHASES

Background:

Classification criteria for calcium pyrophosphate deposition disease (CPPD) will facilitate clinical research on this common crystalline arthritis. ACR/EULAR are jointly sponsoring development of CPPD classification criteria using a multi-phase process.

Objectives:

To report preliminary results from the first two phases of a four-phase process for developing CPPD classification criteria.

Methods:

CPPD classification criteria development is overseen by a 12-member Steering Committee. Item generation (Phase I) included a scoping literature review of five literature databases and contributions from a 35-member Combined Expert Committee and two Patient Research Partners. Item reduction and refinement (Phase II) involved a Combined Expert Committee meeting, discussions among Clinical, Imaging, and Laboratory Advisory Groups, and an item rating exercise to assess the influence of individual items toward classification. The Steering Committee reviewed the modal rating score for each item (range -3 [strongly pushes away from CPPD] to +3 [strongly pushes toward CPPD]) to determine items to retain for future phases of criteria development.

Results:

Item generation yielded 420 items (312 from the literature, 108 from experts/patients). The Advisory Groups eliminated items they agreed were unlikely to distinguish between CPPD and other forms of arthritis, yielding 127 items for the item rating exercise. Fifty-six items, most of which had a modal rating of +/- 2 or 3, were retained for future phases (see Table 1). As numerous imaging items were rated +3, the Steering Committee recommended focusing on imaging of the knee, wrist, and one additional affected joint for calcification suggestive of CPP crystal deposition.

Conclusion:

The ACR/EULAR CPPD classification criteria working group has adopted both data- and expert-driven approaches, leading to 56 candidate items broadly categorized as clinical, imaging, and laboratory features. Remaining steps for criteria development include domain establishment, item weighting through a multi-criteria decision analysis exercise, threshold score determination, and criteria validation.

Table 1.

Categories of items retained for future phases of classification criteria development

Age in decade at symptom onsetAcute inflammatory arthritis (e.g. knee, wrist, 1st MTP joint*)Recurrence and pattern of joint involvement (e.g. 1 self-limited episode, >1 self-limited episode)Physical findings (e.g. palpable subcutaneous tophus*, psoriasis*)Co-morbidities and family history (e.g. Gitelman disease, hemochromatosis, familial CPPD)Osteoarthritis location and features (e.g. 2nd or 3rd MCP joint, wrist)Synovial fluid findings (e.g. CPP crystals present, CPP crystals absent on 1 occasion* or 2 occasions*, monosodium urate crystals present*)Laboratory findings (e.g. hypomagnesemia, hyperparathyroidism, rheumatoid factor*, anti-CCP*)Plain radiograph: calcification in regions of fibro- or hyaline cartilage+Plain radiograph: calcification of the synovial membrane/capsule/tendon+Conventional CT: calcification in regions of fibro- or hyaline cartilage+Conventional CT: calcification of the synovial membrane/capsule/tendon+Ultrasound: CPP crystal deposition in fibro- or hyaline cartilage+Ultrasound: CPP crystal deposition in synovial membrane/capsule/tendons+Dual-energy CT: CPP crystal deposition in fibro- or hyaline cartilage+Dual-energy CT: CPP crystal deposition in synovial membrane/capsule/tendon+

*Potential negative predictor +Assessed in the knee, wrist, and/or 1 additional affected joint

Disclosure of Interests:

Sara Tedeschi Consultant of: NGM Biopharmaceuticals, Tristan Pascart: None declared, Augustin Latourte Consultant of: Novartis, Cattleya Godsave: None declared, Burak Kundaki: None declared, Raymond Naden: None declared, William Taylor: None declared, Nicola Dalbeth Speakers bureau: Abbvie and Janssen, Consultant of: AstraZeneca, Dyve, Selecta, Horizon, Arthrosi, and Cello Health, Tuhina Neogi: None declared, Fernando Perez-Ruiz: None declared, Ann Rosenthal: None declared, Fabio Becce Consultant of: Horizon Therapeutics, Grant/research support from: Siemens Healthineers, Eliseo Pascual: None declared, Mariano Andrés: None declared, Thomas Bardin: None declared, Michael Doherty: None declared, Hang Korng Ea: None declared, Georgios Filippou: None declared, John FitzGerald: None declared, Marwin Gutierrez: None declared, Annamaria Iagnocco: None declared, Tim Jansen Speakers bureau: Abbvie, Amgen, BMS, Grunenthal, Olatec, Sanofi Genzyme, Consultant of: Abbvie, Amgen, BMS, Grunenthal, Olatec, Sanofi Genzyme, Minna Kohler Speakers bureau: Lilly, Consultant of: Novartis, Frederic Lioté: None declared, Mark Matza: None declared, Geraldine McCarthy Consultant of: PK Med, Roberta Ramonda: None declared, Anthony Reginato: None declared, Pascal Richette: None declared, Jasvinder Singh Speakers bureau: Simply Speaking, Consultant of: Crealta/Horizon, Medisys, Fidia, UBM LLC, Trio health, Medscape, WebMD, Adept Field Solutions, Clinical Care options, Clearview healthcare partners, Putnam associates, Focus forward, Navigant consulting, Spherix, Practice Point communications, Francisca Sivera: None declared, Alexander So: None declared, Lisa Stamp: None declared, Janeth Yinh: None declared, Chio Yokose: None declared, Robert Terkeltaub Consultant of: Sobi, Horizon Therapeutics, Astra-Zeneca, Selecta, Grant/research support from: Astra-Zeneca, Hyon Choi: None declared, Abhishek Abhishek Consultant of: NGM Biopharmaceuticals.

AB0915-PARE DEVELOPMENT AND USABILITY OF A WEB-BASED PATIENT-TAILORED TOOL TO SUPPORT ADHERENCE TO URATE-LOWERING THERAPY IN GOUT PATIENTS

Background:

Adherence to prescribed urate-lowering therapy (ULT) among gout patients is considered to be among the poorest of all chronic conditions. eHealth programs can be a possible opportunity to foster ULT adherence.

Objectives:

This study describes the development and usability evaluation of a web-based tool to support ULT adherence among gout patients, specifically designed for a complement to usual care.

Methods:

The Integrated Change (I-Change) model was used as theoretical basis for the development. The model combines various socio-cognitive theories and differentiates between three phases: a pre-motivational, a motivational, and a post-motivational phase. In practices, the I-Change gout tool contains three sessions, following the three phases of the I-Change model. Patients receive tailored feedback based on their answers in the form of animated videos and text messages after each session, and are prompted to set specific goals and action plans for their ULT adherence. The content and development of the I-Change gout tool was determined along an iterative process within a steering group of clinicians and researchers, supported by patient interviews and gout specific literature related to key aspects of medication adherence behavior. A cross-sectional mixed methods design was used to test usability of the support tool consisting of a think aloud method and a usability questionnaire.

Results:

The steering group decided on the content of the three sessions of the I-Change gout tool. Depending on the intention to change ULT adherence behavior patients were navigated through the I-Change gout tool, patients with a low intention go through all 3 sessions and patients with a high intention go through the pre- and post-motivational session (figure 1). In total, the I-Change gout tool contains three sessions with 80 questions, 66 tailored textual feedback messages, and 40 tailored animated videos.

Figure 1.

Flowchart of the computer-tailored I-Change gout tool for urate-lowering therapy adherence.

Twenty gout patients and seven healthcare professionals participated in the usability tests. The program end score rating for the gout tool was on average 8.4±0.9 (range 6-10) for patients and 7.7±1.0 (range 6-9) for healthcare professionals. Furthermore, participants reported a high intention to use and/or recommend the program in the future. Yet, participants identified some issues for further improvement of the systems user-friendliness by addressing barriers (e.g. more explicitly navigation) and weaknesses (e.g. technical and health literacy). The I-Change gout tool was updated according suggestions of improvements of the participants.

Conclusion:

This study provides initial support for the usability by patients and healthcare professionals of a ULT adherence I-Change gout tool. Further studies need to be conducted to assess its efficacy and (cost-) effectiveness in daily practice.

Disclosure of Interests:

None declared

Safety of transradial and transfemoral left ventricular compared with transfemoral right ventricular endomyocardial biopsy

AIMS

With the present study, we sought to determine the safety of three different endomyocardial biopsy (EMB) access routes in 514 patients admitted for diagnostic workup of heart failure of unknown aetiology.

METHODS AND RESULTS

In this retrospective monocentric cohort study, we analysed 514 consecutive patients with heart failure without evidence of significant coronary artery disease or valvular disease undergoing EMB between November 2013 and December 2018, stratified in three access route groups: transradial arterial left ventricular (LV-)EMB (323 patients), transfemoral LV-EMB (138 patients), and transfemoral right ventricular (RV-)EMB (53 patients). Patients undergoing selective transradial LV-EMB were older compared with patients undergoing selective transfemoral LV-EMB or RV-EMB [transradial LV-EMB: 56.0 (45.0/64.0) vs. transfemoral LV-EMB: 53 (42.5/64.5), P = 0.455; transradial LV-EMB: 56 (45.0/64.0) vs. RV-EMB: 53 (42.5/64), P = 0.695] and presented more often in New York Heart Association-functional class III and IV. A total of eight major complications including permanent atrioventricular block requiring pacemaker implantation, pericardial tamponade necessitating pericardiocentesis, stroke and transient cerebral ischaemic attack as well as severe valvular damage, vascular access site complications, and ventricular fibrillation were documented with no significant differences between the groups (8/514, 1.5%). Minor complications such as transient chest pain, non-sustained electrocardiogram abnormalities, and transient atrioventricular block were rare and equally distributed between groups.

CONCLUSIONS

Transradial LV-EMB is a safe procedure for experienced radial operators and non-inferior compared with transfemoral LV-EMB and RV-EMB. An accurate peri-procedural and post-procedural monitoring and follow-up care should be recommended for all patients undergoing this procedure in order to identify potential complications.

Managing COVID-19 within and across health systems: why we need performance intelligence to coordinate a global response

Background

The COVID-19 pandemic is a complex global public health crisis presenting clinical, organisational and system-wide challenges. Different research perspectives on health are needed in order to manage and monitor this crisis. Performance intelligence is an approach that emphasises the need for different research perspectives in supporting health systems’ decision-makers to determine policies based on well-informed choices. In this paper, we present the viewpoint of the Innovative Training Network for Healthcare Performance Intelligence Professionals (HealthPros) on how performance intelligence can be used during and after the COVID-19 pandemic.

Discussion

A lack of standardised information, paired with limited discussion and alignment between countries contribute to uncertainty in decision-making in all countries. Consequently, a plethora of different non-data-driven and uncoordinated approaches to address the outbreak are noted worldwide. Comparative health system research is needed to help countries shape their response models in social care, public health, primary care, hospital care and long-term care through the different phases of the pandemic. There is a need in each phase to compare context-specific bundles of measures where the impact on health outcomes can be modelled using targeted data and advanced statistical methods. Performance intelligence can be pursued to compare data, construct indicators and identify optimal strategies. Embracing a system perspective will allow countries to take coordinated strategic decisions while mitigating the risk of system collapse.A framework for the development and implementation of performance intelligence has been outlined by the HealthPros Network and is of pertinence. Health systems need better and more timely data to govern through a pandemic-induced transition period where tensions between care needs, demand and capacity are exceptionally high worldwide. Health systems are challenged to ensure essential levels of healthcare towards all patients, including those who need routine assistance.

Conclusion

Performance intelligence plays an essential role as part of a broader public health strategy in guiding the decisions of health system actors on the implementation of contextualised measures to tackle COVID-19 or any future epidemic as well as their effect on the health system at large. This should be based on commonly agreed-upon standardised data and fit-for-purpose indicators, making optimal use of existing health information infrastructures. The HealthPros Network can make a meaningful contribution.

Attitudes of Dutch intensive care unit clinicians towards oxygen therapy

BACKGROUND

Over the last decade, there has been an increasing awareness for the potential harm of the administration of too much oxygen. We aimed to describe self-reported attitudes towards oxygen therapy by clinicians from a large representative sample of intensive care units (ICUs) in the Netherlands.

METHODS

In April 2019, 36 ICUs in the Netherlands were approached and asked to send out a questionnaire (59 questions) to their nursing and medical staff (ICU clinicians) eliciting self-reported behaviour and attitudes towards oxygen therapy in general and in specific ICU case scenarios.

RESULTS

In total, 1361 ICU clinicians (71% nurses, 24% physicians) from 28 ICUs returned the questionnaire. Of responding ICU clinicians, 64% considered oxygen-induced lung injury to be a major concern. The majority of respondents considered a partial pressure of oxygen (PaO2) of 6-10 kPa (45-75 mmHg) and an arterial saturation (SaO2) of 85-90% as acceptable for 15 minutes, and a PaO2 7-10 kPa (53-75 mmHg) and SaO2 90-95% as acceptable for 24-48 hours in an acute respiratory distress syndrome (ARDS) patient. In most case scenarios, respondents reported not to change the fraction of inspired oxygen (FiO2) if SaO2 was 90-95% or PaO2 was 12 kPa (90 mmHg).

CONCLUSION

A representative sample of ICU clinicians from the Netherlands were concerned about oxygen-induced lung injury, and reported that they preferred PaO2 and SaO2 targets in the lower physiological range and would adjust ventilation settings accordingly.

The AMP-Activated Protein Kinase Plays a Role in Antioxidant Defense and Regulation of Vascular Inflammation

Cardiovascular diseases represent the leading cause of global deaths and life years spent with a severe disability. Endothelial dysfunction and vascular oxidative stress are early precursors of atherosclerotic processes in the vascular wall, all of which are hallmarks in the development of cardiovascular diseases and predictors of future cardiovascular events. There is growing evidence that inflammatory processes represent a major trigger for endothelial dysfunction, vascular oxidative stress and atherosclerosis and clinical data identified inflammation as a cardiovascular risk factor on its own. AMP-activated protein kinase (AMPK) is a central enzyme of cellular energy balance and metabolism that has been shown to confer cardio-protection and antioxidant defense which thereby contributes to vascular health. Interestingly, AMPK is also redox-regulated itself. We have previously shown that AMPK largely contributes to a healthy endothelium, confers potent antioxidant effects and prevents arterial hypertension. Recently, we provided deep mechanistic insights into the role of AMPK in cardiovascular protection and redox homeostasis by studies on arterial hypertension in endothelial and myelomonocytic cell-specific AMPK knockout (Cadh5CrexAMPKfl/fl and LysMCrexAMPKfl/fl) mice. Using these cell-specific knockout mice, we revealed the potent anti-inflammatory properties of AMPK representing the molecular basis of the antihypertensive effects of AMPK. Here, we discuss our own findings in the context of literature data with respect to the anti-inflammatory and antioxidant effects of AMPK in the specific setting of arterial hypertension as well as cardiovascular diseases in general.

AB0784 COMPARABLE IMPACT AND BURDEN OF DISEASE OF PSORIATIC ARTHRITIS PATIENTS WITH LIMITED JOINT INVOLVEMENT VS. THOSE WITH MORE EXTENSIVE JOINT INVOLVEMENT: INTERIM RESULTS FROM THE REWARD STUDY, A PROSPECTIVE, MULTICENTER, REAL-WORLD STUDY IN PATIENTS TREATED WITH APREMILAST

Background:

Psoriatic arthritis (PsA) is associated with a high burden of disease and an increased risk of comorbidities. Recent data suggest that patients with moderate PsA benefit most from apremilast (APR) treatment.1Results from an earlier analysis of the REWARD study suggest that patients with limited joint involvement may benefit from APR treatment, with improvements in the perceived impact of disease.2Patients with limited joint involvement or comorbidities are underrepresented in randomised controlled trials; therefore, evidence from real-world patient cohorts is needed to assess and compare the impact and burden of disease on patients with limited vs. extensive joints who may also have comorbidities.

Objectives:

To compare the burden of disease and comorbidities in patients with PsA who have limited joint involvement with patients with PsA who have extensive joint involvement.

Methods:

The prospective, multicenter, observational REWARD study assessed the impact of using the Psoriatic Arthritis Impact of Disease (PsAID) questionnaire (score range: 0-10), presence of domains of PsA (enthesitis, dactylitis, skin psoriasis, nail psoriasis, axial involvement), and ongoing or history of comorbidities of interest on PsA patients considered for apremilast treatment in The Netherlands. This interim analysis compared results in patients with limited joint involvement (swollen joint count [SJC] ≤4) vs. more extensive joint involvement (SJC >4).

Results:

Currently, 77 patients have been included in the analysis (SJC ≤4: n=53; SJC >4: n=24) (Table 1). Mean baseline PsAID scores were 4.4 vs. 4.8 for the SJC ≤4 vs. SJC >4 groups (Figure 1). The proportions of patients who were not in the PsAID-defined Patient Acceptable Symptom State (PASS) were 58.7% for the SJC ≤4 group and 62.5% for the SJC >4 group. Mean pain visual analog scale (VAS) scores (0-100 mm) were 45.9 vs. 53.4 for the SJC ≤4 group vs. for the SJC >4 group. Mean scores for the individual PsAID domains for the SJC ≤4 vs. SJC >4 groups were generally comparable (Figure 2). Presence of specific manifestations of PsA for patients in the SJC ≤4 group vs. the SJC >4 group, respectively, were: moderate to severe psoriasis (psoriasis-involved body surface area [BSA] >3: 31.4% vs. 21.7%), nail psoriasis (45.3% vs. 41.7%), enthesitis (Leeds Enthesitis Index >0: 43.4% vs. 45.8%), dactylitis (18.9% vs. 33.3%), and axial involvement (3.8% vs 8.3%). Comorbidities in ≥5% of either group (SJC ≤4 vs. SJC >4) included hypertension (30.2% vs. 37.5%), hypercholesterolemia (13.2% vs. 16.7%), uveitis (1.9% vs. 8.3%), malignancy (0.0% vs. 8.3%), heart failure (5.7% vs. 8.3%), and depression (5.7 vs. 4.2%).

Table 1.

Patient Characteristics

DemographicsSJC ≤4n=53SJC >4n=24Age, mean53.154.4Female, %46.266.7Body mass index, mean, kg/m228.628.7PsA CharacteristicsSJC, mean1.210.2TJC, mean4.313.7PsAID, mean4.44.8Pain VAS, mean45.953.4Moderate to severe psoriasis (BSA >3), %31.421.7Dactylitis, %18.933.3Enthesitis, %43.445.8Nail psoriasis, %45.341.7Axial spondyloarthritis, %3.88.3ComorbiditiesHypertension, %30.237.5Hypercholesteremia, %13.216.7Uveitis, %1.98.3Malignancy, %0.08.3Heart failure, %5.78.3Depression, %5.74.2

Conclusion:

In this real-world study, no strong associations between SJC and patient-reported impact of disease or pain were observed. Similar to patients with more extensive joints involvement, patients with limited joint involvement had an associated substantial burden of disease, with more than half not achieving PsAID PASS.

References:

[1]Mease PJ, et al. Arthritis Care Res (Hoboken). 2020 Jan 7. Epub. 2. Jansen TL, et al. Ann Rheum Dis. 2019;78:913. Abstract FRI0442.

Disclosure of Interests:

Tim Jansen Grant/research support from: Olatec, Grunenthal – grant/research support, Consultant of: AbbVie, Celgene Corporation – consultant, Speakers bureau: Grunenthal, Sobi – speakers bureau, Arie Van Vliet Employee of: Amgen Inc. – employment; Celgene – employment at the time of study conduct, Marijn Vis Grant/research support from: Novartis, Pfizer – grant/research support, Consultant of: AbbVie, Celgene Corporation, Eli Lilly, Novartis, Pfizer – consultant

ARoCuS Web application promotes standardized treatment and documentation of rotator cuff tears

Purpose

To program a Web application for simplified calculation of the Advanced Rotator Cuff tear Score (ARoCuS), which is a 5-part, 18-item treatment-oriented intraoperative scoring system for intraoperative evaluation of rotator cuff tears.

Methods

ARoCuS characteristics (torn tendon, tear size, tissue quality and tear pattern) were assessed intraoperatively on 40 consecutive patients with rotator cuff tears for calculation of defect category ΔV. Video recordings were used to re-calculate the ARoCuS after surgery and to assess inter-observer reliability.

Results

The Web application “ARoCuS App” was built using Angular and transformed to a native iOS application. The intraoperative use of the app proved to be simple and intuitive. There were inter-/intra-observer differences neither in ARoCuS defect categories ΔV nor in ARoCuS characteristics (p > 0.05).

Conclusion

The ARoCuS app is a supportive tool for integration of standardized treatment procedures and documentation of rotator cuff tears in clinical routine.

α1AMPK deletion in myelomonocytic cells induces a pro-inflammatory phenotype and enhances angiotensin II-induced vascular dysfunction

Aims

Immune cell function involves energy-dependent processes including growth, proliferation, and cytokine production. Since the AMP-activated protein kinase (AMPK) is a crucial regulator of intracellular energy homeostasis, its expression and activity may also affect innate and adaptive immune cell responses. Therefore, we aimed to investigate the consequences of α1AMPK deletion in myelomonocytic cells on vascular function, inflammation, and hypertension during chronic angiotensin II (ATII) treatment.

Methods and results

We generated a mouse strain with α1AMPK deletion in lysozyme M+ myelomonocytic cells. Compared to controls, chronic ATII infusion (1 mg/kg/day for 7 days) lead to increased vascular oxidative stress and aggravated endothelial dysfunction in LysM-Cre+ x α1AMPKfl/fl mice. This was accompanied by an increased aortic infiltration of CD11b+F4/80+ macrophages and enhanced pro-inflammatory cytokine release (tumour necrosis factor-alpha, interferon-gamma, and interleukin-6). Mechanistically, we found that increased expression of C-C chemokine receptor 2 (CCR2) in α1AMPK deficient myelomonocytic cells facilitated their recruitment to the vascular wall. In addition, expression of the ATII receptor type 1a and the oxidative burst was increased in these cells, indicating an increased susceptibility towards pro-oxidant stimuli.

Conclusions

In summary, α1AMPK deletion in myelomonocytic cells aggravates vascular oxidative stress and dysfunction by enhancing their recruitment to the vascular wall and increasing their susceptibility towards pro-oxidant stimuli. Our observations suggest that metabolic control in myelomonocytic cells has profound implications for their inflammatory phenotype and may trigger the development of vascular disease.

Red-emitting K3HF2WO2F4:Mn4+ for application in warm-white phosphor-converted LEDs – optical properties and magnetic resonance characterization

A novel efficient red-emitting Mn⁴⁺ phosphor of composition K₃HF₂MO₂F₄:Mn⁴⁺ (M = Mo, W).