Diagnosis and management of placentitis with severe funisitis in a multiparous Warmblood mare

Placentitis is an important cause of reproductive losses in the equine industry. Many cases of clinical placentitis are not diagnosed until late in the course of the disease, and for this reason there is variability in the timing of intervention, diagnostic measurements, and treatment protocols. An 8-year-old multiparous Dutch Warmblood mare that was recently exposed to EHV-1 in the herd of origin presented for routine foaling management. Placentitis was diagnosed upon intake, and medical treatment was initiated. The mare delivered a term foal, and diagnostics for infectious etiology were unrewarding. While there were obvious clinical signs supporting a diagnosis of placentitis, histopathologic examination did not reveal active inflammatory lesions in the chorioallantois; however, severe funisitis was present. This report reviews early diagnosis and management of placentitis, demonstrates an array of classic and subtle pathologic lesions seen on microscopic examination, and discusses pathophysiology of placentitis.

Federated Learning Survival Model and Potential Radiotherapy Decision Support Impact Assessment for Non-small Cell Lung Cancer Using Real-World Data

AIMS

The objective of this study was to develop a two-year overall survival model for inoperable stage I-III non-small cell lung cancer (NSCLC) patients using routine radiation oncology data over a federated (distributed) learning network and evaluate the potential of decision support for curative versus palliative radiotherapy.

METHODS

A federated infrastructure of data extraction, de-identification, standardisation, image analysis, and modelling was installed for seven clinics to obtain clinical and imaging features and survival information for patients treated in 2011-2019. A logistic regression model was trained for the 2011-2016 curative patient cohort and validated for the 2017-2019 cohort. Features were selected with univariate and model-based analysis and optimised using bootstrapping. System performance was assessed by the receiver operating characteristic (ROC) and corresponding area under curve (AUC), C-index, calibration metrics and Kaplan-Meier survival curves, with risk groups defined by model probability quartiles. Decision support was evaluated using a case-control analysis using propensity matching between treatment groups.

RESULTS

1655 patient datasets were included. The overall model AUC was 0.68. Fifty-eight percent of patients treated with palliative radiotherapy had a low-to-moderate risk prediction according to the model, with survival times not significantly different (p = 0.87 and 0.061) from patients treated with curative radiotherapy classified as high-risk by the model. When survival was simulated by risk group and model-indicated treatment, there was an estimated 11% increase in survival rate at two years (p < 0.01).

CONCLUSION

Federated learning over multiple institution data can be used to develop and validate decision support systems for lung cancer while quantifying the potential impact of their use in practice. This paves the way for personalised medicine, where decisions can be based more closely on individual patient details from routine care.

When not hitting your sales target is 'the end of the world': Examining the effects of rational emotive behaviour therapy on the irrational beliefs and emotional reactivity of UK-based sales professionals

Against the backdrop of the COVID-19 pandemic, workplace wellbeing is a key priority for employers. Severe market and health conditions continue to bring inevitable problems that could be reduced with the application of psychological interventions to prevent mental and physical health issues, making this study a highly pertinent and valuable contribution to the field. This paper reports the effects of a rational emotive behaviour therapy (REBT) programme on the irrational beliefs and emotional reactivity of 56 office-based sales professionals located in the northwest region of the UK. A pre-test, post-test experimental design was utilised, and a mixed model ANOVA (repeated measures) was adopted to assess changes in mean differences concerning irrational beliefs and emotional reactivity at pre and post-test stages for the intervention group, in comparison to a control group. Results indicate that those in the REBT group reported significant reductions in irrational beliefs and emotional reactivity, whilst those in the control group reported no such changes. It is recommended that future research studies consider utilizing a mixed methods design and focus on a strategic collaboration of organisational and individual level interventions for improving the psychological wellbeing and performance of sales personnel.

Frequency-Dependent Squeezed Vacuum Source for the Advanced Virgo Gravitational-Wave Detector

In this Letter, we present the design and performance of the frequency-dependent squeezed vacuum source that will be used for the broadband quantum noise reduction of the Advanced Virgo Plus gravitational-wave detector in the upcoming observation run. The frequency-dependent squeezed field is generated by a phase rotation of a frequency-independent squeezed state through a 285 m long, high-finesse, near-detuned optical resonator. With about 8.5 dB of generated squeezing, up to 5.6 dB of quantum noise suppression has been measured at high frequency while close to the filter cavity resonance frequency, the intracavity losses limit this value to about 2 dB. Frequency-dependent squeezing is produced with a rotation frequency stability of about 6 Hz rms, which is maintained over the long term. The achieved results fulfill the frequency dependent squeezed vacuum source requirements for Advanced Virgo Plus. With the current squeezing source, considering also the estimated squeezing degradation induced by the interferometer, we expect a reduction of the quantum shot noise and radiation pressure noise of up to 4.5 dB and 2 dB, respectively.

Updated Results of the COVID-19 in MS Global Data Sharing Initiative

Background and Objectives

Certain demographic and clinical characteristics, including the use of some disease-modifying therapies (DMTs), are associated with severe acute respiratory syndrome coronavirus 2 infection severity in people with multiple sclerosis (MS). Comprehensive exploration of these relationships in large international samples is needed.

Methods

Clinician-reported demographic/clinical data from 27 countries were aggregated into a data set of 5,648 patients with suspected/confirmed coronavirus disease 2019 (COVID-19). COVID-19 severity outcomes (hospitalization, admission to intensive care unit [ICU], requiring artificial ventilation, and death) were assessed using multilevel mixed-effects ordered probit and logistic regression, adjusted for age, sex, disability, and MS phenotype. DMTs were individually compared with glatiramer acetate, and anti-CD20 DMTs with pooled other DMTs and with natalizumab.

Results

Of 5,648 patients, 922 (16.6%) with suspected and 4,646 (83.4%) with confirmed COVID-19 were included. Male sex, older age, progressive MS, and higher disability were associated with more severe COVID-19. Compared with glatiramer acetate, ocrelizumab and rituximab were associated with higher probabilities of hospitalization (4% [95% CI 1–7] and 7% [95% CI 4–11]), ICU/artificial ventilation (2% [95% CI 0–4] and 4% [95% CI 2–6]), and death (1% [95% CI 0–2] and 2% [95% CI 1–4]) (predicted marginal effects). Untreated patients had 5% (95% CI 2–8), 3% (95% CI 1–5), and 1% (95% CI 0–3) higher probabilities of the 3 respective levels of COVID-19 severity than glatiramer acetate. Compared with pooled other DMTs and with natalizumab, the associations of ocrelizumab and rituximab with COVID-19 severity were also more pronounced. All associations persisted/enhanced on restriction to confirmed COVID-19.

Discussion

Analyzing the largest international real-world data set of people with MS with suspected/confirmed COVID-19 confirms that the use of anti-CD20 medication (both ocrelizumab and rituximab), as well as male sex, older age, progressive MS, and higher disability are associated with more severe course of COVID-19.

Evaluating the feasibility of a real world pharmacovigilance study (OPTIMISE:MS)

Background

Clinical trial populations do not fully reflect routine practice. The power of routinely collected data is increasingly recognised.

Methods

The OPTIMISE:MS pharmacovigilance study is a prospective, pragmatic observational study, conducted across 13 UK MS centres. Data were collected at the time of routine clinical visits. The first participant was recruited on 24th May 2019; data were extracted on 11th November 2021.

Results

2112 participants were included (median age 44.0 years; 1570 (72%) female; 1981 (94%) relapsing- remitting MS). 639 (30%) were untreated at study entry, 205 (10%) taking interferon beta/copaxone, 1004 (47%) were taking second/third generation DMT first line (including dimethyl fumarate, oral cladribine, natalizumab, ocrelizumab), and 264 (13%) had escalated from either interferon beta or copaxone. 342 clinical events were reported, of which 108 were infections. There was an increased risk of adverse events in people taking second/third generation DMT (RR 3.45, 95%CI 1.57-7.60, p<0.01 vs no DMT). Unadjusted Poisson regression demonstrated increased incident adverse events in people taking natalizumab (IRR 5.28, 95%CI 1.41-19.74, p<0.05), ocrelizumab (IRR 3.24, 95%CI 1.22-8.62, p<0.05), and GA biosimilar (Brabio) (IRR 4.89, 95%CI 1.31-18.21, p<0.05) vs no DMT.

Conclusions

Routinely collected healthcare data can be used to evaluate DMT safety in people with MS. These data highlight the potential of pragmatic studies to guide understanding of risks and benefits associated with DMT.

Search for Subsolar-Mass Binaries in the First Half of Advanced LIGO's and Advanced Virgo's Third Observing Run

We report on a search for compact binary coalescences where at least one binary component has a mass between 0.2  M_{⊙} and 1.0  M_{⊙} in Advanced LIGO and Advanced Virgo data collected between 1 April 2019 1500 UTC and 1 October 2019 1500 UTC. We extend our previous analyses in two main ways: we include data from the Virgo detector and we allow for more unequal mass systems, with mass ratio q≥0.1. We do not report any gravitational-wave candidates. The most significant trigger has a false alarm rate of 0.14  yr^{-1}. This implies an upper limit on the merger rate of subsolar binaries in the range [220-24200]  Gpc^{-3} yr^{-1}, depending on the chirp mass of the binary. We use this upper limit to derive astrophysical constraints on two phenomenological models that could produce subsolar-mass compact objects. One is an isotropic distribution of equal-mass primordial black holes. Using this model, we find that the fraction of dark matter in primordial black holes in the mass range 0.2  M_{⊙}<m_{PBH}<1.0  M_{⊙} is f_{PBH}≡Ω_{PBH}/Ω_{DM}≲6%. This improves existing constraints on primordial black hole abundance by a factor of ∼3. The other is a dissipative dark matter model, in which fermionic dark matter can collapse and form black holes. The upper limit on the fraction of dark matter black holes depends on the minimum mass of the black holes that can be formed: the most constraining result is obtained at M_{min}=1  M_{⊙}, where f_{DBH}≡Ω_{DBH}/Ω_{DM}≲0.003%. These are the first constraints placed on dissipative dark models by subsolar-mass analyses.

Severity of COVID19 infection among patients with multiple sclerosis treated with interferon-β

BACKGROUND

Interferon-β, a disease-modifying therapy (DMT) for MS, may be associated with less severe COVID-19 in people with MS.

RESULTS

Among 5,568 patients (83.4% confirmed COVID-19), interferon-treated patients had lower risk of severe COVID-19 compared to untreated, but not to glatiramer-acetate, dimethyl-fumarate, or pooled other DMTs.

CONCLUSIONS

In comparison to other DMTs, we did not find evidence of protective effects of interferon-β on the severity of COVID-19, though compared to the untreated, the course of COVID19 was milder among those on interferon-β. This study does not support the use of interferon-β as a treatment to reduce COVID-19 severity in MS.

P-728 Prevalence of Infertility among women with Multiple Sclerosis compared to the general population of women matched for age

Study question

Is the prevalence of infertility among multiple sclerosis female patients higher compared to the general population?

Summary answer

The prevalence of infertility among women with multiple sclerosis is similar to the matched general population

What is known already

Multiple sclerosis (MS) is an autoimmune disease predominant in women (1:3 ratio) during childbearing years. Studies addressing the question of infertility among multiple sclerosis patients are inconclusive and whether fertility is impaired in this population is debatable.

Study design, size, duration

Data regarding multiple sclerosis diagnosis and treatment and data about infertility and ART treatments was collected for patients during childbearing years (18-45) between the years 2005 to 2020 from the health service computerized database.

Participants/materials, setting, methods

The prevalence of infertility among women with MS was analyzed and compared to healthy controls (1:5) matched for age. Association between multiple sclerosis and the different ART treatments: in vitro fertilization (IVF) versus controlled ovarian hyperstimulation (COH) were analyzed.

Main results and the role of chance

1,570 women with multiple sclerosis were compared to 7,851 healthy women matched for age. Mean age of both groups was 32 years old. The prevalence of infertility was 34.1% (534) in the MS population compared to 33.3% (2,601) in the matched general population (p = 0.4). 299 of the 536 MS patients were diagnosed with infertility after they were diagnosed with multiple sclerosis. The prevalence of the different ART treatments was similar between MS patients and healthy women matched for age: (IVF: 7.1% vs 7% p = 0.813 and COH: 5.7% vs 6% p = 0.6; respectively).

Limitations, reasons for caution

The major limitation of our study is its retrospective nature. Furthermore, we were not able to evaluate for confounding factors possibly contributing to postponed family planning.

Wider implications of the findings

To date this is the largest study evaluating the prevalence of infertility and ART treatment among MS patients during childbearing years. Our findings may reassure patients with MS that their risk for infertility and need for ART treatments is comparable to the health general population.

Trial registration number

not applicable

AB0209 PHYSICIAN TRUST RATHER THAN RHEUMATOID ARTHRITIS KNOWLEDGE RELEVANT IN DISEASE OUTCOMES IN ETHNIC MINORITY PATIENTS WITH RHEUMATOID ARTHRITIS

Background

Ethnic minority (EM) patients with Rheumatoid Arthritis (RA) have more severe disease, more disability, and less use of biologic disease modifying anti-rheumatic drugs (bDMARDs). A Treat to target (T2T) strategy has been recommended to improve clinical outcomes but barriers include patient preference, access to specialty care and increased administrative effort. Additionally, EM patients in the US often have low health literacy, express greater reluctance to accept physician recommendations, in part due to sociocultural preference and mistrust of a historically biased healthcare system. It is unknown whether improving knowledge of RA would improve T2T outcomes in EM active RA patients.

Objectives

To assess the proportion of EM RA patients who achieve low disease activity or remission following implementation of a coordinator-based education program highlighting T2T RA strategy.

Methods

Adult participants with active RA (RAPID3>6 or CDAI > 10) were invited to participate in a series of five one-on-one 20-minute educational sessions, co-occurring with scheduled routine clinic visits (6 -12-week intervals). Sessions were facilitated by a rheumatology care coordinator, a non-healthcare professional with intensive training over 4 weeks to conduct RA patient education. Sociodemographic data was collected, and disease activity measures (TJC, SJC, RAPID3, CDAI) and validated patient questionnaires on RA Knowledge (ACREU), compliance (CQR5), and physician trust (Trust in Physician Scale) were recorded at baseline and after the final educational session. Descriptive statistics were applied and medians and ranges for instrument scores are reported. Paired T-test was used to test for significant differences in scores after the education sessions. Correlations between the ACREU scores and clinical-demographic variables were measured using Pearson’s correlation coefficient.

Results

20 EM patients (75% Female, mean age, 58.8 years (12.2) seen by EM physicians were enrolled, with mean RA disease duration of 7 years and poor prognosticators (75% double seropositivity). ACREU scores were low at baseline (mean 0.45 (0.16)), with no significant improvement on completion of educational sessions, and no correlation with years of education or duration of RA. There was a positive correlation between ACREU and compliance scores at baseline (r=0.3). Average duration of the education period was 9.72 months, with a 33% decrease in average RAPID3 over time, and 42% of patients achieving a target of remission or LDA. Trust in Physician scores were high at baseline and persisted with >50% of patients completing at least one medication change during study period.

Conclusion

RA knowledge did not impact RA patient outcomes in this cohort of EM patients. However, patients had high trust in their providers and achieved clinical remission or LDA despite risk for poor outcomes highlighting the importance of the provider- patient relationship in achieving targeted goals of therapy. Limitations include the small sample size from a single institution, and the lengthy time between initial and final assessment of RA knowledge.

References

[1]Lineker SC, Badley EM, Hughes EA, Bell MJ. Development of an instrument to measure knowledge in individuals with rheumatoid arthritis: the ACREU rheumatoid arthritis knowledge questionnaire. The Journal of rheumatology. 1997/04// 1997;24(4):647-653.

[2]Hughes LD, Done J, Young A. A 5 item version of the Compliance Questionnaire for Rheumatology (CQR5) successfully identifies low adherence to DMARDs. BMC Musculoskeletal Disorders. 2013-12-01 2013;14(1):286. doi:10.1186/1471-2474-14-286

[3]Anderson LA, Dedrick RF. Development of the Trust in Physician Scale: A Measure to Assess Interpersonal Trust in Patient-Physician Relationships. Psychological Reports. 1990-12-01 1990;67(3_suppl):1091-1100. doi:10.2466/pr0.1990.67.3f.1091

Acknowledgements

Sincere gratitude to our patients for their participation, and to the team at Bristol Myers Squibb for supporting this research initiative.

Disclosure of Interests

Sharon Dowell Speakers bureau: Horizon Pharma, Aurinia Pharmaceuticals Inc, Abbvie, Grant/research support from: Pfizer, Bristol Myers Squibb, Mercedes Quinones Speakers bureau: Abbvie, Sanofi Genzyme, Grant/research support from: Bristol Myers Squibb, Pfizer, Alani Miller: None declared, Oshoze Kadiri: None declared, Tahereh Jamshidi: None declared, Gail Kerr Speakers bureau: Aurinia Pharmaceuticals Inc, Consultant of: CSL Behring, Janssen, Pfizer, Samumed, UCB, Viela Bio/Horizon, Grant/research support from: Novartis

025 Baseline data from OPTIMISE: MS – a prospective, real word pharmacovigilance study in MS

Background

Therapeutic options in MS have increased rapidly, but real-world safety data is limited. Safety signals have emerged from clinical trials and early clinical experience with newer MS therapies, however the rates at which these occur in a real-world, UK MS population is unknown.

Methods

OPTIMISE: MS is a longitudinal observational study that will recruit at least 4000 people with MS eligible for DMT from centres across the UK. It will follow them up for at least 5 years in the first instance using electronic case records. Serious adverse events (SAEs), DMT use and disease outcomes will be captured. The study design has been informed by rheumatological biologic registries and is anticipated to expand in scope, as participants consent to be re-contacted regarding sub-studies.

Results

Since its initiation in June 2019, 906 people with MS have enrolled. 72% are female (mean age

44.5 (SD 11.1); mean disease duration 8.9 years (SD 7.3)) 95% study population have RRMS and 35% were receiving DMT prior to consent. Data from a larger cohort will be presented.

Conclusions

This study has the potential to deliver clinically meaningful data on the association of MS DMT with serious adverse events in a real-world population. The association of SAEs with lymphopaenia, and prior DMT/DMT switching will be studied. Rates of malignancies will be examined with particular reference to immunosuppressive therapies.

ruth.dobson@qmul.ac.uk

Challenges and Opportunities of Real-World Data: Statistical Analysis Plan for the Optimise:MS Multicenter Prospective Cohort Pharmacovigilance Study

Introduction

Optimise:MS is an observational pharmacovigilance study aimed at characterizing the safety profile of disease-modifying therapies (DMTs) for multiple sclerosis (MS) in a real world population. The study will categorize and quantify the occurrence of serious adverse events (SAEs) in a cohort of MS patients recruited from clinical sites around the UK. The study was motivated particularly by a need to establish the safety profile of newer DMTs, but will also gather data on outcomes among treatment-eligible but untreated patients and those receiving established DMTs (interferons and glatiramer acetate). It will also explore the impact of treatment switching.

Methods

Causal pathway confounding between treatment selection and outcomes, together with the variety and complexity of treatment and disease patterns observed among MS patients in the real world, present statistical challenges to be addressed in the analysis plan. We developed an approach for analysis of the Optimise:MS data that will include disproportionality-based signal detection methods adapted to the longitudinal structure of the data and a longitudinal time-series analysis of a cohort of participants receiving second-generation DMT for the first time. The time-series analyses will use a number of exposure definitions in order to identify temporal patterns, carryover effects and interactions with prior treatments. Time-dependent confounding will be allowed for via inverse-probability-of-treatment weighting (IPTW). Additional analyses will examine rates and outcomes of pregnancies and explore interactions of these with treatment type and duration.

Results

To date 14 hospitals have joined the study and over 2,000 participants have been recruited. A statistical analysis plan has been developed and is described here.

Conclusion

Optimise:MS is expected to be a rich source of data on the outcomes of DMTs in real-world conditions over several years of follow-up in an inclusive sample of UK MS patients. Analysis is complicated by the influence of confounding factors including complex treatment histories and a highly variable disease course, but the statistical analysis plan includes measures to mitigate the biases such factors can introduce. It will enable us to address key questions that are beyond the reach of randomized controlled trials.

OPTIMISE: MS study protocol: a pragmatic, prospective observational study to address the need for, and challenges with, real world pharmacovigilance in multiple sclerosis

INTRODUCTION

The power of 'real world' data to improve our understanding of the clinical aspects of multiple sclerosis (MS) is starting to be realised. Disease modifying therapy (DMT) use across the UK is driven by national prescribing guidelines. As such, the UK provides an ideal country in which to gather MS outcomes data. A rigorously conducted observational study with a focus on pharmacovigilance has the potential to provide important data to inform clinicians and patients while testing the reliability of estimates from pivotal trials when applied to patients in the UK.

METHODS AND ANALYSIS

The primary aim of this study is to characterise the incidence and compare the risk of serious adverse events in people with MS treated with DMTs. The OPTIMISE:MS database enables electronic data capture and secure data transfer. Selected clinical data, clinical histories and patient-reported outcomes are collected in a harmonised fashion across sites at the time of routine clinical visits. The first patient was recruited to the study on 24 May 2019. As of January 2021, 1615 individuals have baseline data recorded; follow-up data are being captured and will be reported in due course.

ETHICS AND DISSEMINATION

This study has ethical permission (London City and East; Ref 19/LO/0064). Potential concerns around data storage and sharing are mitigated by the separation of identifiable data from all other clinical data, and limiting access to any identifiable data. The results of this study will be disseminated via publication. Participants provide consent for anonymised data to be shared for further research use, further enhancing the value of the study.

1411 Amoebic Colitis: Inaccurate Diagnosis; Inappropriate Surgery

Global prevalence of symptomatic Amoebiasis (pathogen Entamoeba histolytica) is approximately 50 million cases per year, with an annual mortality of up to 100,000. Despite this, a diagnosis of amoebiasis is rarely considered in the UK. Transmission is via the faeco-oral route, person-to-person contact or oral-anal sexual contact. The majority of cases diagnosed in the UK are in international travellers or immigrants.

Symptoms of amoebiasis can closely mirror those of Inflammatory Bowel Disease (IBD) resulting in diagnostic uncertainty. A misdiagnosis could result in treatment with corticosteroids, immunosuppressant or biological agents when standard treatment for amoebiasis is actually Metronidazole. In exceptional circumstances, a misdiagnosis of IBD may lead to a patient requiring colectomy and formation of end ileostomy due to an apparent failure of medical management. Emergency colonic surgery is associated with a risk of complications such as wound infections and collections, together with the psychological consequences of major illness and surgery.

We report on two patients who have undergone emergency subtotal colectomy and end ileostomy in whom a diagnosis of amoebic colitis was made on histology. Both British Asian patients were under 55 years of age, had a travel history to India and presented with diarrhoea.

The diagnosis of amoebiasis must be considered in the differential diagnosis for all returning travellers and immigrants who present with GI symptoms, consistent with IBD. A correct diagnosis allows appropriate, simple, curative treatment and avoids unnecessary surgery with its attendant morbidity. Polymerase chain reaction is the gold standard diagnostic test and is currently significantly under-utilised.

Simultaneous orthogonal bipole mapping compared to conventional electrode configurations and impact on ablation strategies: results from a real world observational study

Funding Acknowledgements

Type of funding sources: Private company. Main funding source(s): Abbott

Background

3D mapping systems are pivotal to identify low voltage areas and to define ablation strategies. In this context, high-density multipolar mapping catheters with varying electrode configurations are used for accurate myocardial substrate definition. High density mapping using a grid shaped catheter allows for use of simultaneous analysis of adjacent orthogonal bipolar signals that may assist in more accurate substrate characterization and ablation strategy decisions.

Purpose

This was a prospective, multicenter observational study to characterize the utility of electroanatomical mapping with a high density grid-style mapping catheter (HD Grid) in subjects undergoing catheter ablation for persistent atrial fibrillation (PersAF) or ventricular tachycardia (VT) in real-world clinical settings.

Methods

Mapping was performed with the HD Grid catheter to generate high-density maps of cardiac chambers in order to assess the potential influence of the simultaneous orthogonal bipole configuration on PersAF and VT ablation strategies. Differences in substrate identification between simultaneous orthogonal bipole configuration and standard along-the-spline electrode configuration, and potential effects on ablation strategies were investigated.

Results

During the study period (January 2019 through April 2020), 367 subjects underwent catheter ablation for PersAF (N = 333, average age 64.1yr, 75% male) or VT (N = 34, average age = 64.3yr, 85.3% male).

In total, 494 maps were generated to treat patients undergoing PersAF ablation and 57 to treat patients undergoing VT ablation. Compared to standard along-the-spline configuration, mapping with the simultaneous orthogonal bipole configuration showed differences in 57.8% (178/308) of maps generated, with the greatest difference noticed in surface area of low voltage (62.9%) and location of low voltage (55.6%).

In comparisons performed live during the procedure (n = 50), simultaneous orthogonal bipole configuration assisted in identification of ablation targets in 70.0% of cases, changing the ablation strategy compared to that identified with along-the-spline configuration in 34.3%.

In comparisons performed retrospectively after the procedure (n = 258), the ablation strategy identified with simultaneous orthogonal bipole configuration differed from along-the-spline configuration in 21.7% of maps. Even compared to a higher-density electrode configuration using all-bipoles rather than along-the-spline bipoles, simultaneous orthogonal bipole configuration identified differences in 57.1% of maps.

Conclusion

The HD grid catheter combined with simultaneous orthogonal bipole configuration can define myocardial substrate more accurately compared to standard along-the-spline configuration. The difference in substrate identification has potential impact on ablation strategy. Further clinical trials are needed to elucidate the role of orthogonal bipole configuration mapping and improved ablation success rates.

Impact of high density mapping using a grid shaped catheter with orthogonal signal analysis on ventricular tachycardia ablation strategy

Funding Acknowledgements

Type of funding sources: Private company. Main funding source(s): Abbott

Background

Ventricular tachycardia (VT) in patients with structural heart disease (SHD) is related to scar and slow conduction areas. Substrate-based ablation has become the gold standard treatment in patients with SHD-related refractory VT. A new high-density grid shaped catheter that allows simultaneous analysis of adjacent orthogonal bipolar signals can allow better understanding of these slow conduction areas with the potential to improve ablation results.

Purpose

This was a prospective, multicenter observational study to characterize the utility of electroanatomical mapping with a high density grid-style mapping catheter (HD Grid) in subjects undergoing catheter ablation for ventricular tachycardia (VT) in real-world clinical settings.

Methods

During the study period, patients who underwent VT ablation using the HD Grid catheter as the primary mapping catheter were included. Comparisons both during the procedure and retrospectively were performed between conventional electrode configuration maps and simultaneous orthogonal bipole electrode configuration maps. The influence of these different configurations on ablation strategy was analyzed.

Results

  During study period (January 2019 – April 2020) 57 maps were performed in 34 VT subjects (average age: 64.3yr, male: 85.3%, ischemic cardiomyopathy: 70.6%). The left ventricle was mapped in 94.1% of subjects, including left ventricular outflow tract and papillary muscles in 20.6% and 8.8% respectively, reporting minimal or no ectopic beats in 97.1% of the subjects. The total number of mapping points collected was 14172.0 ± 15174.8 in 24.3 ± 17.9 min per map.

Simultaneous orthogonal bipole mapping identified differences in 67.6% of maps compared to linear along-the-spline electrode configurations. The differences consisted mainly in the surface area (92%) and location of low voltage (40%). When compared during the procedure, simultaneous orthogonal bipole mapping was used to identify ablation strategy in 100% of cases. When compared to a standard along-the-spline configuration retrospectively, the ablation strategy identified with simultaneous orthogonal bipoles was different in 30.1% of cases.  The ablation strategy used in these subjects was mainly substrate ablation (late potentials and low voltage areas in scar regions) with an acute success rate of 97.1%.

Conclusions

The use of the HD Grid catheter with the ability to analyze orthogonal signals is feasible and has the potential to change the ablation strategy in one third of VT patients with a high acute success rate.

Development of an artificial intelligence-based assessment model for prediction of embryo viability using static images captured by optical light microscopy during IVF

STUDY QUESTION

Can an artificial intelligence (AI)-based model predict human embryo viability using images captured by optical light microscopy?

SUMMARY ANSWER

We have combined computer vision image processing methods and deep learning techniques to create the non-invasive Life Whisperer AI model for robust prediction of embryo viability, as measured by clinical pregnancy outcome, using single static images of Day 5 blastocysts obtained from standard optical light microscope systems.

WHAT IS KNOWN ALREADY

Embryo selection following IVF is a critical factor in determining the success of ensuing pregnancy. Traditional morphokinetic grading by trained embryologists can be subjective and variable, and other complementary techniques, such as time-lapse imaging, require costly equipment and have not reliably demonstrated predictive ability for the endpoint of clinical pregnancy. AI methods are being investigated as a promising means for improving embryo selection and predicting implantation and pregnancy outcomes.

STUDY DESIGN, SIZE, DURATION

These studies involved analysis of retrospectively collected data including standard optical light microscope images and clinical outcomes of 8886 embryos from 11 different IVF clinics, across three different countries, between 2011 and 2018.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The AI-based model was trained using static two-dimensional optical light microscope images with known clinical pregnancy outcome as measured by fetal heartbeat to provide a confidence score for prediction of pregnancy. Predictive accuracy was determined by evaluating sensitivity, specificity and overall weighted accuracy, and was visualized using histograms of the distributions of predictions. Comparison to embryologists’ predictive accuracy was performed using a binary classification approach and a 5-band ranking comparison.

MAIN RESULTS AND THE ROLE OF CHANCE

The Life Whisperer AI model showed a sensitivity of 70.1% for viable embryos while maintaining a specificity of 60.5% for non-viable embryos across three independent blind test sets from different clinics. The weighted overall accuracy in each blind test set was >63%, with a combined accuracy of 64.3% across both viable and non-viable embryos, demonstrating model robustness and generalizability beyond the result expected from chance. Distributions of predictions showed clear separation of correctly and incorrectly classified embryos. Binary comparison of viable/non-viable embryo classification demonstrated an improvement of 24.7% over embryologists’ accuracy (P = 0.047, n = 2, Student’s t test), and 5-band ranking comparison demonstrated an improvement of 42.0% over embryologists (P = 0.028, n = 2, Student’s t test).

LIMITATIONS, REASONS FOR CAUTION

The AI model developed here is limited to analysis of Day 5 embryos; therefore, further evaluation or modification of the model is needed to incorporate information from different time points. The endpoint described is clinical pregnancy as measured by fetal heartbeat, and this does not indicate the probability of live birth. The current investigation was performed with retrospectively collected data, and hence it will be of importance to collect data prospectively to assess real-world use of the AI model.

WIDER IMPLICATIONS OF THE FINDINGS

These studies demonstrated an improved predictive ability for evaluation of embryo viability when compared with embryologists’ traditional morphokinetic grading methods. The superior accuracy of the Life Whisperer AI model could lead to improved pregnancy success rates in IVF when used in a clinical setting. It could also potentially assist in standardization of embryo selection methods across multiple clinical environments, while eliminating the need for complex time-lapse imaging equipment. Finally, the cloud-based software application used to apply the Life Whisperer AI model in clinical practice makes it broadly applicable and globally scalable to IVF clinics worldwide.

STUDY FUNDING/COMPETING INTEREST(S)

Life Whisperer Diagnostics, Pty Ltd is a wholly owned subsidiary of the parent company, Presagen Pty Ltd. Funding for the study was provided by Presagen with grant funding received from the South Australian Government: Research, Commercialisation and Startup Fund (RCSF). ‘In kind’ support and embryology expertise to guide algorithm development were provided by Ovation Fertility. J.M.M.H., D.P. and M.P. are co-owners of Life Whisperer and Presagen. Presagen has filed a provisional patent for the technology described in this manuscript (52985P pending). A.P.M. owns stock in Life Whisperer, and S.M.D., A.J., T.N. and A.P.M. are employees of Life Whisperer.

Quantum Backaction on kg-Scale Mirrors: Observation of Radiation Pressure Noise in the Advanced Virgo Detector

The quantum radiation pressure and the quantum shot noise in laser-interferometric gravitational wave detectors constitute a macroscopic manifestation of the Heisenberg inequality. If quantum shot noise can be easily observed, the observation of quantum radiation pressure noise has been elusive, so far, due to the technical noise competing with quantum effects. Here, we discuss the evidence of quantum radiation pressure noise in the Advanced Virgo gravitational wave detector. In our experiment, we inject squeezed vacuum states of light into the interferometer in order to manipulate the quantum backaction on the 42 kg mirrors and observe the corresponding quantum noise driven displacement at frequencies between 30 and 70 Hz. The experimental data, obtained in various interferometer configurations, is tested against the Advanced Virgo detector quantum noise model which confirmed the measured magnitude of quantum radiation pressure noise.

Applying Gamification to the Library Orientation

By providing an overview of library services as well as the building layout, the library orientation can help newcomers make optimal use of the library. The benefits of this outreach can be curtailed, however, by the significant staffing required to offer in-person tours. One academic library overcame this issue by turning to user experience research and gamification to provide an individualized online library orientation for four specific user groups: undergraduate students, graduate students, faculty, and community members. The library surveyed 167 users to investigate preferences regarding orientation format, as well as likelihood of future library use as a result of the gamified orientation format. Results demonstrated a preference for the gamified experience among undergraduate students as compared to other surveyed groups.

Exploring the views of undocumented migrant women on access to maternity services in the UK

Background

Migrant women face inequalities in access to health-care services and are known to experience poorer maternal and child outcomes than women born in the UK. The development of more restrictive health policies in the UK and Europe, including being denied or charged for healthcare at maternity services, may be exacerbating these outcomes, particularly among undocumented migrant women without permission to reside. We investigated undocumented migrant women's experiences of accessing maternity services in the UK and their impact on health outcomes.

Methods

We did semi-structured in-depth qualitative interviews with a purposive sample of migrant women (born outside the UK) who were aged 18 and over, and had experiences of pregnancy in the UK whilst undocumented. Participants were recruited through the Doctors of the World UK clinic. Interviews were transcribed and analysed using thematic analysis.

Results

We did interviews with 20 undocumented women (age range 31-40 years; mainly from Africa and Asia). Among participants, of whom 13 were pregnant at the time of interview, 10 (50%) first accessed antenatal care late (after the national target of 13 weeks). Women described an ongoing cycle of precariousness, defined by their legal status, social isolation, and poor economic status. Women reported receiving bills of up to £11,500 for maternity services (range £3,072 to £11.500). The impact of their experiences meant that they were deterred from seeking timely health care and were reluctant to present to health services, with women reporting fear and loss of trust in the health system.

Conclusions

These women's narratives illustrated the potential deterrent and detrimental impact of increasingly restrictive health policies on women's access to care and their health. UK and European health policies must be equitable, non-discriminatory, and better align with our commitments to promote universal health coverage among all individual residing in the region.

Key messages

Increasingly restrictive health policies may have a deterrent and detrimental impact on migrant women’s access to health care. Undocumented migrant women in the UK reported fear and loss of trust in the health system.

Left behind: the state of universal health coverage in Europe

Background

Barriers to access healthcare and lack of data undermine Universal Health Coverage (UHC) in Europe, despite the region's clear commitment to the Sustainable Development Goals and UHC. Current indicators measuring unmet healthcare needs in the European Union (EU) often exclude more marginalised groups, further rendering their health needs invisible and the data to inform policy flawed. For effective evaluation of UHC, comprehensive data on the health of these groups is needed.

Methods

We conducted an evaluation of humanitarian healthcare provision of people attending Médecins du Monde (MdM) programmes in seven countries in Europe (Belgium, France, Germany, Luxembourg, Sweden, Switzerland, and the United Kingdom). MdM is a humanitarian organisation, providing care to those excluded from mainstream healthcare services. We describe the characteristics of MdM service users, their determinants of health and healthcare access.

Results

A total of 29,359 people were seen between January 2017 and December 2018. Nearly all were migrants (97.2%, 21,591/22,136), with 66.3% (11,690/17,629) of people reported not having a right or permission to reside in the country they presented in. A majority were living below the poverty line (92.6%, 7,660/8,268), residing in insecure housing (44.3%, 8,895/20,097) or living as street homeless or in emergency shelters (20.4%, 4,107/20,097). Most people reported having no healthcare coverage (81.7%, 14,848/18,164). When asked about barriers to accessing healthcare, 20.8% of responses reported economic barriers (3,960/19,020) and 14.3% reported a lack of knowledge of health system/entitlements (2,718/19,020).

Conclusions

This humanitarian service evaluation highlights the intersecting vulnerabilities and barriers to access healthcare for people excluded from mainstream healthcare systems across Europe. Our findings provide a unique insight into the extent of unmet healthcare needs of migrants and other marginalised populations.

Key messages

UHC requires comprehensive data on the population groups who are many times left without access to health services and who are often excluded from national data collection and research. A majority of MdM service users do not have healthcare coverage and experience multiple and intersecting barriers to access healthcare across Europe.

FRI0403 CLINICAL FEATURES OF PROSTHETIC JOINT INFECTIONS DIFFER IN PATIENTS WITH INFLAMMATORY ARTHRITIS AND OSTEOARTHRITIS

Background:

Inflammatory arthritis (IA) patients are at increased risk for prosthetic joint infections (PJI). However, because active IA patients without infections can have elevated inflammatory markers that mimic joint infection, PJI diagnosis is challenging in this population.

Objectives:

We used an institutional PJI registry to identify and compare the clinical, microbiologic, and histopathologic features of culture positive (CP) and culture negative (CN) total hip and knee PJI in IA and OA patients. We also evaluated the relationship between culture positivity, IA, and clinical outcomes.

Methods:

A retrospective cohort of THA/TKA PJIs, from 2009 to 2016, were identified by ICD codes, and confirmed by chart review. IA diagnosis was also confirmed by use of IA-specific medications. CN cases were defined as PJIs with no evidence of microbial growth in intraoperative cultures and CP PJI cases were defined by positive microbial growth in intraoperative cultures. Treatment failure was defined as subsequent surgical treatment for infection after the initial infection surgery. H&E slides of OA and IA PJI cases matched by age (+/-5) sex, and culture status were reviewed by a pathologist for evidence of the histopathologic features listed in Table 2. Fisher’s exact test, chi-square test, and Kaplan-Meier estimates were used.

TABLE 1.

Patient characteristics in IA and OA PJIs

IAOAN%/SDN%/SDp-valueTotal36771Age58.511.466.812<.001BMI30.26.7306.70.861Female2877.833243.1<.001CCI2.81.71.72.10.002Smoking411.18611.20.792Glucorticoids1027.8395.1<.001Culture Negative1027.810914.10.024Treatment Success at 2 years1952.8509660.146

IA- inflammatory arthritis; OA – osteoarthritis; PJI -prosthetic joint infection; CCI – Charlson Comorbidity Index

TABLE 2.

Histopathology and clinical presentation in IA and OA PJIs

OA (N=57)IA (N= 31)CP-IA (N=23)CN-IA (N=8)N (%)p-valueN (%)p-valuePathology Review>10 PMN per HPF42 (74)22 (71)0.80620 (87)2 (25)0.003Chronic Inflammation13 (23)23 (74)0.00118 (78)5 (63)0.393Necrosis17 (30)9 (29)18 (35)1 (13)0.38Clinical PresentationMSIS50 (88)26 (84)0.74722 (96)4 (50)0.009Sinus Tract7 (12)7 (23)0.2335 (22)2 (25)1Elevated ESR or CRP41 (72)24 (77)0.62217 (74)7 (88)1Elevated Synovial WBC33 (58)19 (61)0.82313 (57)6 (75)1Elevated Synovial %PMN31 (54)20 (65)0.37714 (61)6 (75)0.333

OA – osteoarthritis; IA – inflammatory arthritis; CP – culture positive; CN – culture negative; MSIS – meets Musculoskeletal Infection Society diagnostic criteria

Results:

807 PJI cases were identified including 36 IA (33 RA and 3 SLE) and 771 OA. A higher proportion of IA PJI were CN (N=10, 27%) vs. OA PJI (N=109, 14%, p=0.02). IA-PJI were younger, female, on glucocorticoids, and with more comorbidities. Type of surgical treatment did not differ significantly between IA and OA groups. Comparing CN-IA vs. CP-IA, no difference was observed in age, smoking, diabetes, surgical treatment, IA-specific meds or Charlson comorbidities. One-year survivorship of CN-IA and CN-OA were 66% and 87% (p>0.05). Across all CP cases, 57% were staphylococcal, with no differences between groups. Treatment failure was more frequent for CP-IA (42%) compared to CP-OA (30%), (p=0.2).

Histopathology of 88 PJIs (31 IA and 57 OA) was reviewed. The IA cohort presented with more chronic inflammation (p=0.001) than the OA cohort. Within the IA cohort, a higher proportion of CP-IA had >10PMN per HPF (p= 0.003) and met MSIS criteria (p=0.009). Comparing CP-OA and CN-OA, there were no significant differences in histopathology findings or number of patients meeting MSIS criteria.

Conclusion:

IA PJIs are more likely to be culture negative than OA PJIs. Although our analysis was limited by our cohort size, our findings including differences in histopathology, and better clinical outcomes suggest the presence of biologic differences between CN and CP PJI that require further study.

Disclosure of Interests:

Milan Kapadia: None declared, Tania Pannellini: None declared, Carine Moezinia: None declared, Andy Miller: None declared, Mark Figgie: None declared, Peter Sculco: None declared, Michael Cross: None declared, Michael Henry: None declared, Linda Russell: None declared, Laura Donlin Consultant of: Consultant – Genentech/Roche, Allina Nocon: None declared, Susan Goodman Shareholder of: Reginosine- Investment, Grant/research support from: Novartis, Horizon, Consultant of: Novartis, Celgene, UCB

0276 Does Losing Sleep Unleash Anger?

Introduction

Sleeping is understood as essential to affective function, yet little is known about how sleep shapes more specific and contextualized emotional responses besides anxiety and depression, such as anger. Anger itself involves arousal and can disrupt sleep. To examine the causal role of sleep in anger, a daily-diary study and an experimental study tested whether shortened sleep amplifies angry feelings, while exploring mediating mechanisms of this influence.

Methods

The daily-diary study (N = 202) collected daily reports of last-night’s sleep, daily stressors, and state anger across one month from college students, examining sleep and anger within everyday life. The experimental laboratory study (N = 147 community residents) examined changes in anger experienced during aversive noise following random assignment to either at-home sleep restriction (by about 5 hours across 2 nights), or to individuals’ regular schedule.

Results

In the daily-diary study, individuals experienced more anger on days following less sleep than their usual, with half of this effect attributed to the increased frequency of stressors experienced on such days, and somewhat independently from the effect of sleep duration on negative affect more generally. In the experimental study, well-slept individuals adapted to noise and reported less anger and negative affect after 2 days. In contrast, sleep-restricted individuals exhibited higher and increased anger responses. The impact of sleep restriction on anger held even after accounting for negative emotions more generally. Subjective sleepiness accounted for most of the experimental effect of sleep loss on anger.

Conclusion

Together, these results provide compelling evidence that lost sleep amplifies anger in both the laboratory and everyday life, while also pointing to short-term (subjective sleepiness) and mid-term (stress) mediators of these influences. The findings also point to the value of examining specific emotional reactions (and their regulation) in the context of sleep disruption, alongside affect more broadly.

Support

N/A

0230 Sleep and Interrogation: Does Losing Sleep Impact Criminal History Disclosure?

Introduction

Despite centuries of using sleep deprivation during interrogation, there is virtually no scientific evidence on how sleep shapes behavior in interrogation settings. Moreover, investigative interviews are often conducted at night, or with fatigued subjects. To evaluate the impact of sleeplessness on subjects’ behavior during investigative interviews, an experimental study examined the impact of moderate sleep restriction on information disclosure and behavioral reactions during interviews about past illegal acts.

Methods

Healthy participants (N=120) were recruited from the university community and randomly assigned to either maintain or curb their sleep (up to 4 hours a night) across two days. Back in the laboratory individuals privately indicated whether they committed various illegal acts. Participants were interviewed while video-recorded about the most severe act they acknowledged. After the initial disclosure, participants listened to a ‘model’ statement, an unrelated example of a person’s detailed event account designed to encourage additional disclosure, after which they again provided information about their offense. Key variables were the severity of the illegal behavior reported and the amount of information provided before and after the model statement (blindly coded from transcripts for quantity and quality).

Results

Sleep-restricted participants slept on average 4.5 hours less (confirmed via actigraphy), reported no differences in perceived treatment by the interviewer, and tended to report less severe offenses. Critically, sleep-restricted participants provided almost 20% less information during their initial disclosure (d = .53, p =.01). After the model statement, however, disclosure was generally higher and similar across conditions (d = .15, p = .35). Sleep-restricted individuals also reported less overall motivation to recall information (d=.27, p = .01).

Conclusion

Results suggest that even moderate sleep loss can inhibit criminal disclosure during interviews, and that reduced motivation could play a role. Also, the use of the model statement could compensate for this effect.

Support

N/A

Reducing medical error during a pandemic

On 30 January 2020, the WHO declared the coronavirus disease 2019 (COVID-19) a public health emergency of international concern. By 11 March 2020, it was designated a pandemic owing to its rapid worldwide spread. In this short article we provide some information that might be useful and help equip colleagues to reduce medical error during a pandemic.

We advocate a systems-based approach, rather than an individual’s sole responsibility, and, look at ways to provide safer healthcare.