Causes of Childhood Cancer: A Review of the Recent Literature: Part I-Childhood Factors

PURPOSE

To review the childhood risk factors for pediatric cancer (diagnosis before age 20).

METHODS

We conducted literature searches using Ovid Medline and Scopus to find primary research studies, review articles, and meta-analyses published from 2014 to 3 March 2021.

RESULTS

Strong evidence indicates that an array of genetic and epigenetic phenomena, structural birth defects, and chromosomal anomalies are associated with an increased risk of various childhood cancers. Increased risk is also associated with prior cancer, likely due to previous treatment agents and therapeutic ionizing radiation. Convincing evidence supports associations between several pediatric cancers and ionizing radiation, immunosuppression, and carcinogenic virus infection both in healthy children and in association with immune suppression following organ transplantation. Breastfeeding and a childhood diet rich in fruits and vegetables appears to reduce the risk of pediatric leukemia but the evidence is less strong. Childhood vaccination against carcinogenic viruses is associated with a lower risk of several cancers; there is less strong evidence that other childhood vaccinations more broadly may also lower risk. Ultraviolet (UV) radiation is associated with increased melanoma risk, although most melanomas following childhood UV exposure occur later, in adulthood. Evidence is weak or conflicting for the role of body mass index, other childhood infections, allergies, and certain treatments, including immunomodulator medications and human growth therapy.

"Oh My Sleeping Child" … Narcolepsy Type 1 in a 22-Month-Old Boy

Pediatric narcolepsy is a complex disorder with unique diagnostic challenges. It is diagnosed with a combination of clinical presentation, polysomnogram with multiple sleep latency test (PSG with MSLT), and occasionally, hypocretin-1 (orexin) levels in the cerebrospinal fluid (CSF). This report describes a 22-month-old boy experiencing excessive daytime sleepiness (EDS) and frequent falls. The patient was subsequently diagnosed with narcolepsy using hypocretin-1 (orexin) levels. The intent of this report is to establish the utility of using hypocretin-1 (orexin) levels to diagnose narcolepsy type 1 in children who are too young to undergo PSG with MSLT. To our knowledge, there are no reports of narcolepsy in a patient this young. Early recognition and treatment of narcolepsy in children younger than age five may lead to a substantial impact on their cognitive development and minimize potential long- term complications.

Universal PCR for bacteria, mycobacteria, and fungi: a 10-year retrospective review of clinical indications and patient outcomes

IMPORTANCE

Our work provides a retrospective analysis of universal PCR orders for bacteria, mycobacteria, and fungi across our institution across a 10-year period. We assessed the positivity rates for this diagnostic tool by test type and specimen type and, critically, studied whether and how the results influenced the outcomes from treatment change, to readmission, to death.

Emotional memories are enhanced when reactivated in slow wave sleep, but impaired when reactivated in REM

Sleep supports memory consolidation. However, it is not completely clear how different sleep stages contribute to this process. While rapid eye movement sleep (REM) has been traditionally implicated in the processing of emotionally charged material, recent studies indicate a role for slow wave sleep (SWS) in strengthening the memories of emotional stimuli. Here, to directly examine which sleep stage is primarily involved in emotional memory consolidation, we used targeted memory reactivation (TMR) in REM and SWS during a daytime nap. We also examined neural oscillations associated with TMR-related changes in memory. Contrary to our hypothesis, reactivation of emotional stimuli during REM led to impaired memory. Meanwhile, reactivation of emotional stimuli in SWS improved memory and was strongly correlated with the product of times spent in REM and SWS (%SWS Ã- %REM). When this variable was taken into account, reactivation significantly enhanced memory, with larger reactivation benefits compared to reactivation in REM. Notably, sleep spindle activity was modulated by emotional valence, and delta/theta activity was correlated with the memory benefit for both emotional and neutral items. Finally, we found no evidence that emotional memories benefited from TMR more than did neutral ones. Our results provide direct evidence for a complementary role of both REM and SWS in emotional memory consolidation, and suggest that REM may separately facilitate forgetting. In addition, our findings expand upon recent evidence indicating a link between sleep spindles and emotional processing.

Morphology and morphometry of the human obturator nerve in males and females

Peripheral nerve injury and the nerves' subsequent repair and regeneration continues to be marked clinically by poor functional recovery. The analysis of nerve morphology is an aspect which may provide an impact on successful clinical outcomes through better prediction of donor and recipient matching. In this study, we evaluated the morphological aspects of the human obturator nerve for a better understanding of its potential in nerve transplantation. Morphological characteristics of donor obturator nerves were analysed, including nerve diameter and length, fascicle count and the ratio of neural to non-neural tissue present within the cross-sectional area of the nerve's epineurium, with respect to laterality and sex. Statistical significance (p < 0.10) was determined for male obturator nerves having an average diameter of 2.67 mm compared to female obturator nerves at 1.91 mm, as well as left obturator nerves having an average of 11.21 fascicles compared to the right having an average of 10.17 fascicles. Strong positive correlations were determined between cross-sectional nerve area and limb size index, as well as between percentage of non-neural tissue and area of non-neural tissue, among males. Separately, strong correlation between percentage of non-neural tissue and area of non-neural tissue among right obturator nerves in males and females was determined . These findings indicate that there are associations and predictions that can be made about nerve morphology and that these when combined with other patient characteristics may enhance patient functional recovery following a peripheral nerve's repair.

Pineal Gland from the Cell Culture to Animal Models: A Review

This review demonstrates current literature on pineal gland physiology, pathology, and animal model experiments to concisely explore future needs in research development with respect to pineal gland function and neuro-regenerative properties. The pineal gland plays an integral role in sleep and recovery by promoting physiologic circadian rhythms via production and release of melatonin. Yet, the current literature shows that the pineal gland has neuroprotective effects that modulate both peripheral and central nerve injuries through several direct and indirect mechanisms, such as angiogenesis and induction of growth factors and anti-inflammatory mediators. Animal models have also shown correlations between pineal gland function and metabolic homeostasis. Studies have shown that a functional pineal gland is essential in preventing and slowing the progression of certain diseases such as diabetes, osteoporosis, vertebral osteoarthritis, and neurodegenerative processes. Lastly, the array of cell culturing methods and animal models that can be used to further develop the study of pineal gland function and nervous system injury were reviewed.

POS1229 THE IMPACT OF COVID-19 ON MEDICATION NON-ADHERENCE IN A RHEUMATOID AND PSORIATIC ARTHRITIS UK COHORT

Background

In March 2020, as part of the UK’s COVID-19 prevention strategy, those identified as ‘clinically extremely vulnerable’, were advised to shield. This included a number of patients prescribed anti-rheumatic drugs, who were asked to continue their current treatment unless they developed symptoms of infection. Suboptimal treatment adherence (16.0%-81.0%) has been reported in patients with arthritic diseases, and is associated with psychological factors, including anxiety (1). Previous literature in non-UK cohorts has highlighted suboptimal adherence levels in immunosuppressed patients during the pandemic, although many were single centre studies (2,3).

Objectives

The aim of this multi-centre study is to investigate the impact of the COVID-19 pandemic on adherence to anti-rheumatic medications in patients with established rheumatoid (RA) and psoriatic (PsA) arthritis in the UK who had recently commenced a biologic or targeted synthetic DMARD.

Methods

Between September 2020 and May 2021, RA and PsA patients prescribed biologic or targeted synthetic anti-rheumatic drugs from two multi-centre observational studies (BRAGGSS and OUTPASS) were sent a questionnaire on medication usage, adherence, and perceptions to establish the impact of COVID-19 on these parameters. Patients were asked about compliance during the COVID-19 pandemic using a 5-point Likert scale (always, often, sometimes, rarely, and never) and the reason for non-adherence. Adherence was defined as never missing or delaying a dose, unless medically advised. Descriptive summary statistics were calculated, and logistic regression and Pearson’s chi-squared tests were employed to investigate variables associated with self-reported non-adherence.

Results

In total 159 questionnaires were returned (81.1% RA and 18.9% PsA). Methotrexate (53.5%) was the most frequently prescribed agent, followed by etanercept (25.2%), sulfasalazine (22.6%), hydroxychloroquine (21.4%) and adalimumab (19.5%). Furthermore, 68.6% of patients were prescribed ≥2 drugs. During the pandemic, 42.1% of patients reported missing or delaying a treatment dose for any reason. Adherence information was available for 97.5% of patients with 25.8% reporting non-adherence which was not medically advised. Methotrexate non-adherence was 27.1%, with similar levels reported for etanercept (20.0%), sulfasalazine (27.8%), hydroxychloroquine (35.3%) and adalimumab (29.0%). No drugs had significantly different adherence compared to methotrexate. Furthermore, there was no association between disease type or perception of disease control and adherence. Of non-adherent patients, 17.5% reported increased anxiety, fear, and increased risk due to the COVID-19 pandemic as an influencing factor. Meanwhile, 37.5% of non-adherent patients listed non-COVID-19 intentional reasons and 45.0% reported non-intentional reasons, with forgetting and running out of treatment listed most frequently.

Conclusion

In a UK cohort self-reported non-adherence was reported in 25.8% of patients during the COVID-19 pandemic, despite medical advice, with reasons including increased anxiety due to COVID-19.

References

[1]Medication adherence and persistence in patients with rheumatoid arthritis, psoriasis, and psoriatic arthritis: a systematic literature review. Patient Prefer Adherence. 2018;12:1483–503.

[2]Vakirlis E, Bakirtzi K, Papadimitriou I, Vrani F, Sideris N, Lallas A, et al. Treatment adherence in psoriatic patients during COVID-19 pandemic: Real-world data from a tertiary hospital in Greece. J Eur Acad Dermatology Venereol. 2020;34(11):e673–5.

[3]Polat Ekinci A, Pehlivan G, Gökalp MO. Surveillance of psoriatic patients on biologic treatment during the COVID-19 pandemic: A single-center experience. Dermatol Ther. 2020;(December 2020):19–22.

Acknowledgements

on behalf of the BRAGGSS consortium

Disclosure of Interests

Philippa Curry: None declared, Hector Chinoy Speakers bureau: UCB, Biogen, Consultant of: Novartis, Eli Lilly, Orphazyme, Astra Zeneca, Grant/research support from: Eli Lilly, UCB, Meghna Jani: None declared, Darren Plant: None declared, Kimme Hyrich Consultant of: consultancy/honoraria from AbbVie, Grant/research support from: Pfizer, BMS, Ann Morgan Speakers bureau: Roche, Chugai, Consultant of: GSK, Roche, Chugai, AstraZeneka, Regeneron, Sanofi, Vifor, Grant/research support from: Roche, Kiniksa Pharmaceuticals, Anthony G Wilson: None declared, John Isaacs Speakers bureau: Abbvie, Gilead, Roche, UCB, Grant/research support from: GSK, Janssen, Pfizer, Andrew Morris: None declared, Anne Barton Grant/research support from: I have received grant funding from Pfizer, Galapagos, Scipher Medicine and Bristol Myers Squibb., James Bluett Grant/research support from: Pfizer Limited. JB has received travel/conference fees from UCB, Pfizer and Eli Lilly

POS0033 GENETIC INVESTIGATION OF TUMOUR NECROSIS FACTOR INHIBITOR IMMUNOGENICITY IN PATIENTS WITH RHEUMATOID ARTHRITIS

Background

Rheumatoid arthritis (RA) is a chronic inflammatory disease that primarily affects the synovial joints. Tumour Necrosis Factor inhibitor (TNFi) therapy has transformed the clinical management of RA. However, monoclonal antibody derived TNFi is associated with development of immunogenicity and subsequent loss of therapeutic effects. Previous studies have observed associations between certain HLA alleles and TNFi immunogenicity. For example HLA-DQA1 and HLA-DRB1 have been associated with immunogenicity in inflammatory bowel disease 1,2 and RA 3,4, respectively.

Objectives

The aims of this study were to identify associations between HLA alleles and immunogenicity to TNFi in an observational cohort of RA patients and to replicate findings from previous studies.

Methods

Anti-drug antibody titres were measured using radioimmunoassay in serum samples from RA patients participating in Biologics in Rheumatoid Arthritis Genetics and Genomics Study Syndicate (BRAGGSS). An anti-drug antibody titre of ≥12 AU/mL following six months on treatment was used to define positive immunogenicity. Genotype data were generated using Illumina HumanCoreExome Arrays. Standard quality control (QC) was applied prior to HLA imputation using SNP2HLA software before low minor allele frequency markers were removed. Logistic regression was used to study the association between HLA alleles and immunogenicity, whilst the omnibus test was applied to amino acid positions; sex and concurrent conventional synthetic DMARD use were included as a covariate in all the models.

Results

In total, 445 RA patients were analysed, 377 patients (70 immunogenicity events) were underdoing adalimumab therapy and 68 certolizumab (30 immunogenicity events) therapy. Following QC, 162 HLA alleles and 361 amino acids positions were available for analysis. The strongest HLA allele association was observed for HLA-DQA1*03 when all patients were analysed (OR = 0.61; 95% CI = 0.43 – 0.86; p-value = 5e-3). The amino acids positions 187 (p-value = 5e-3) and 26 (p-value = 5e-3) within the HLA-DQA1 gene were significantly associated with immunogenicity events. When both drugs were analysed separately, they produced similar effect size for HLA-DQA1*03 association; patients treated with adalimumab (OR = 0.59; 95% CI = 0.38 – 0.88; p-value = 1e-2) and certolizumab (OR = 0.52; 95% CI = 0.24 – 1.1; p-value = 1e-1). Another strong association was found in HLA-DRB1*04 (OR = 0.62; 95% CI = 0.44 – 0.88; p-value = =7e-3) and the amino acid position of 180 (p-value = 7e-3) and 33 (p-value = 7e-3) of HLA-DRB1 gene. Additionally, the similar protective effect between the two presented alleles suggested possibility of linkage disequilibrium, upon investigation the r2 between the 2 alleles is 0.69.

Conclusion

The current study increases the evidence for association between immunogenicity development with HLA-DQA1 and HLA-DRB1 alleles in patients receiving monoclonal antibody derived TNFi therapy. Further well powered studies are now required to determine the utility of HLA markers as a potential tool to aid the clinical management of RA.

References

[1]Sazonovs, A. et al. HLA-DQA1*05 Carriage Associated With Development of Anti-Drug Antibodies to Infliximab and Adalimumab in Patients With Crohn’s Disease. Gastroenterology158, 189–199 (2020).

[2]Billiet, T. et al. Immunogenicity to infliximab is associated with HLA-DRB1. Gut64, 1344–1345 (2015).

[3]Liu, M. et al. Identification of HLA-DRB1 association to adalimumab immunogenicity. PLoS One13, e0195325 (2018).

[4]Rigby, W. et al. HLA-DRB1 risk alleles for RA are associated with differential clinical responsiveness to abatacept and adalimumab: data from a head-to-head, randomized, single-blind study in autoantibody-positive early RA. Arthritis Res. Ther.23, 245 (2021).

Disclosure of Interests

Chuan Fu Yap: None declared, Nisha Nair: None declared, Kimme Hyrich Speakers bureau: Abbvie, Grant/research support from: Pfizer and BMS, Anthony G Wilson: None declared, John Isaacs Speakers bureau: Abbvie, Gilead, Roche, UCB, Grant/research support from: GSK, Janssen, Pfizer, Ann Morgan Speakers bureau: Roche, Chugai, Consultant of: GSK, Roche, Chugai, AstraZeneca, Regeneron, Sanofi, Vifor, Grant/research support from: Roche, Kiniksa Pharmaceuticals, Anne Barton Grant/research support from: I have received grant funding from Pfizer, Galapagos, Scipher Medicine and Bristol Myers Squibb., Darren Plant: None declared

AB0011 DNA METHYLATION AS A BIOMARKER OF TOCILIZUMAB RESPONSE IN RHEUMATOID ARTHRITIS PATIENTS

Background

Tocilizumab (TCZ) is a disease-modifying antirheumatic biologic drug, which targets the IL-6 signalling pathway and is effective in ameliorating disease activity in rheumatoid arthritis (RA). However, approximately 50% of patients do not respond adequately to TCZ and some patients report adverse events. Considering there is growing evidence that DNA methylation is implicated in RA susceptibility and response to some biologics (1, 2), we investigated DNA methylation as a candidate biomarker for response to TCZ in RA.

Objectives

To identify differential DNA methylation signatures in whole blood associated with TCZ response in patients with RA.

Methods

Epigenome-wide DNA methylation patterns were measured using the Infinium EPIC 850k BeadChip (Illumina) in whole blood-derived DNA samples from patients with RA. DNA was extracted from blood samples taken pre-treatment and following 3 months on therapy, and response was determined at 6 months using the Clinical Disease Activity Index (CDAI). Patients who had good response (n=10) or poor response (n=10) to TCZ by 6 months were selected. Samples from secondary poor responders (n=10) (patients who had an improvement of CDAI and were in remission at 3 months, followed by a worsening of CDAI at 6 months) were also analysed. Differentially methylated positions (DMPs) were identified using linear regression, adjusting for gender, age, cell composition, smoking status, and glucocorticoid use.

Results

In the pre-treatment samples, 20 DMPs were significantly associated with response status at 6 months (unadjusted p-value <10-6), whilst in the 3 month samples, 21 DMPs were associated with response. One DMP, cg03121467, was significantly less methylated in good responders compared to poor responders in the pre-treatment samples. This DMP is close to EPB41L4A and may play a role in β–catenin signalling. Interestingly, cg10136146 was significantly less methylated in secondary poor responders compared to both good and poor responders in the 3 month samples. This DMP maps close to CD81, which plays a role in mediating the development and activation of B and T lymphocytes.

Conclusion

These preliminary results provide evidence that DNA methylation patterns may predict response to TCZ. Further regional and pathway analyses is in progress and validation of these findings in other larger data sets is required.

References

[1]Liu,Y., Aryee,M.J., Padyukov,L., Fallin,M.D., Hesselberg,E., Runarsson,A., Reinius,L., Acevedo,N., Taub,M., Ronninger,M., et al. (2013) Epigenome-wide association data implicate DNA methylation as an intermediary of genetic risk in rheumatoid arthritis. Nat. Biotechnol., 31, 142–147.

[2]Plant,D., Webster,A., Nair,N., Oliver,J., Smith,S.L., Eyre,S., Hyrich,K.L., Wilson,A.G., Morgan,A.W., Isaacs,J.D., et al. (2016) Differential Methylation as a Biomarker of Response to Etanercept in Patients With Rheumatoid Arthritis. Arthritis Rheumatol. (Hoboken, N.J.), 68, 1353–60.

Disclosure of Interests

Nisha Nair: None declared, Darren Plant: None declared, John Isaacs Speakers bureau: Abbvie, Gilead, Roche, UCB, Grant/research support from: GSK, Janssen, Pfizer, Ann Morgan Speakers bureau: Roche/Chugai, Consultant of: GSK, Roche, Chugai, AstraZeneca, Regeneron, Sanofi, Vifor, Grant/research support from: Roche, Kiniksa Pharmaceuticals, Kimme Hyrich Consultant of: AbbVie, Grant/research support from: Pfizer, BMS, Anne Barton Grant/research support from: I have received grant funding from Pfizer, Galapagos, Scipher Medicine and Bristol Myers Squibb., Anthony G Wilson: None declared

AB0148 COULD THE RENIN-ANGIOTENSIN SYSTEM AFFECT THE PROGNOSIS OF GIANT CELL ARTERITIS? SINGLE-CENTRE RETROSPECTIVE OBSERVATIONAL STUDY

Background

About half of patients with giant cell arteritis (GCA) relapse while tapering glucocorticoid therapy1. A previous observational study reported that blockade of the renin-angiotensin system, with angiotensin II receptor blockers (ARBs), was associated with lower relapse risk2.

Objectives

To determine whether angiotensin blockade, with angiotensin converting enzyme inhibitor (ACEi) or ARB, is associated with differential relapse risk in GCA.

Methods

GCA patients from a tertiary centre diagnosed 2012–2020 with two years follow-up were identified from UK GCA Consortium. All provided written informed consent. Retrospective review of medical records included demographics, comorbidities, drug history, inflammatory markers and relapses. Relapse was defined as return of symptoms, raised inflammatory markers, or active vasculitis on imaging confirmed by the treating clinician. Relapse-free survival was analysed using Kaplan Meier (KM) curves and Cox proportional hazards.

Results

111 patients were included (Table 1: demographic data), all were initially treated with 40–60mg Prednisolone. 42% received further immunosuppressants due to relapse or disease severity. 50% patients relapsed in two years, presenting with cranial symptoms (72%), PMR-like symptoms (30%) and/or raised inflammatory markers (48%). There was no association between relapse and age, gender, comorbid HTN/IHD or pre-steroid inflammatory markers and relapse. Rate of steroid taper can affect relapse. EULAR recommend 15–20mg of steroid by three months3. 9 patients relapsed within that time and were excluded, there was no difference in steriod dose at three months between the two groups. KM analysis showed ACEi did not significantly affect time to relapse compared to no angiotensin blockade (HR 0.57, 95% CI 0.28 – 1.18, unadjusted p-value=0.128), and neither did an ARB (HR 0.78, 95% CI 0.31 – 1.98, unadjusted p-value=0.605).

Table 1.

demographic data at baseline.

Relapse (n = 56)No Relapse (n = 55)Patient FactorsAge median (IQR)70 (65-74)73 (67-78)Male Sex n (%)16 (29)20 (36.36)Medications n (%)ACEi9 (15)16 (29)ARB7 (12)7 (13)Comorbidities n (%)CKD4 (7)9 (16)IHD6 (11)5 (9)Prediabetes11 (20)10 (18)DM1 (2)5 (9)HTN22 (40)23 (42)Current Smoker6 (10)2 (4)GCA Factors median (IQR)CRP pre-treatment69 (32 – 131)64 (23 -115)ESR pre-treatment50 (37 -95)4 (22 -72)Steroid dose at 3 months19 (15 -20)15 (10-20)Figure 1.

Unadjusted KM survival curve showing probability of relapse in patients 1) taking ACEi, 2) taking ARB, 3) taking neither ACEi or ARB, 4) with no comorbid HTN or IHD at diagnosis, and 5) experienced comorbid HTN/IHD. There was no significant difference in relapse free survival in patients on an ACEi compared to those taking neither ACEi or ARB.

Conclusion

In the two years following GCA diagnosis 50% relapsed. There was no significant difference in the rate of relapse in patients taking an ACEi or ARB. The main limitation, in this retrospective, observational study was the inability to exclude a reluctance of clinicians to diagnose GCA relapse in the presence of cardiovascular comorbidity. A randomised controlled trial would be needed to determine whether starting an ACEi could reduce relapse risk in patients with new-onset GCA.

References

[1]Mainbourg, S. et al. Prevalence of Giant Cell Arteritis Relapse in Patients Treated With Glucocorticoids: A Meta-Analysis. Arthritis Care Res.72, 838–849 (2020).

[2]Alba, M. A. et al. Treatment with angiotensin II receptor blockers is associated with prolonged relapse-free survival, lower relapse rate, and corticosteroid-sparing effect in patients with giant cell arteritis. Semin. Arthritis Rheum.43, 772–777 (2014).

[3]Hellmich, B. et al. 2018 Update of the EULAR recommendations for the management of large vessel vasculitis. Ann Rheum Dis79, 19–30 (2020).

Disclosure of Interests

Ranjana Venkateswaran: None declared, Karan Gour: None declared, Louise Sorensen: None declared, Charlotte Harden: None declared, Sizheng Steven Zhao: None declared, Ann Morgan Speakers bureau: Roche/Chugai., Consultant of: GSK, Roche, Chugai, AstraZeneca, Regeneron, Sanofi, Vifor., Grant/research support from: Roche, Kiniksa Pharmaceuticals, Sarah Mackie Consultant of: Roche/Chugai, AbbVie, AstraZeneca, Sanofi, Pfizer., Grant/research support from: Attendance at ACR21 supported by Pfizer. Attendance at EULAR2019 supported by Roche.

AB0345 THERAPEUTIC DRUG LEVELS TO ACHIEVE GOOD EULAR RESPONSE IN PATIENTS WITH RHEUMATOID ARTHRITIS RECEIVING ADALIMUMAB: RESULTS FROM THE BIOLOGICS IN RHEUMATOID ARTHRITIS GENETICS AND GENOMICS STUDY SYNDICATE (BRAGGSS) COHORT

Background

Rheumatoid arthritis (RA) is a systemic inflammatory disease often treated with biologic disease-modifying anti-rheumatic drugs (bDMARDs) such as Adalimumab (ADL), a tumour-necrosis factor inhibitor (TNFi). However, it is known that about a third of patients do not respond to ADL treatment. Previous studies have reported associations between poor response, decreased serum drug levels (SDLs) and poor adherence, but a therapeutic SDL has not been defined nor applied in clinical practice.

Objectives

To assess median ADL SDLs in RA European Alliance of Associations for Rheumatology (EULAR) good vs non/moderate responders, and to determine cut-off SDLs associated with a “Good” response in fully adherent RA patients.

Methods

In a prospective observational cohort study, patients with RA were treated with ADL. At baseline, 3-, 6-, and 12-months patients had 4-component DAS28 scores, self-reported treatment adherence data and SDLs measured. Median drug levels and receiver-operator characteristics (ROC) curves were used to compare SDLs between responders and non-responders, and to establish cut-off SDLs in self-reported fully adherent patients. Serum drug levels were measured using a sandwich ELISA produced by Progenika Biopharma. Patients were considered fully adherent if they self-reported never having altered, forgotten or omitted any dose of their biologic drug at follow-up. Between group comparisons were assessed using Fisher’s exact test, with a threshold for significance set at p<0.05. Statistical analyses were performed in R Version 4.1.0 and RStudio Version 1.4.1106.

Results

A total of 283 RA patients taking ADL were included in the analysis. Baseline characteristics are shown in Table 1. Of these patients 93 (32.9%) self-reported being fully adherent to treatment at 3 months follow-up and had SDLs measured.

Table 1.

Baseline characteristics of patient cohort with RA taking ADL (n=283)

CharacteristicnMissing (%)Age at baseline, median years (IQR)58 (51, 64)0Disease duration, median years (IQR)7 (3, 16)0Female Sex, n (%)206 (73)0BMI, median (IQR)27.4 (23.7, 31.9)0Smoking Status132 (46)Current, n (%)57 (38)-Ex, n (%)32 (21)-Non, n (%)62 (41)-On concurrent DMARD(s)1 (0.4)No, n (%)34 (12)-Yes, n (%)248 (88)-Baseline DAS Score, median (IQR)5.61 (5.18, 6.14)On MTX at baseline38 (13)No, n (%)44 (18)Yes, n (%)201 (82)

In 93 fully adherent RA patients taking ADL at 3 months, good EULAR responders had significantly higher SDLs compared to non/moderate EULAR responders (p=0.0234). In 47/93 (50.5%) fully adherent good responders median SDL at 3 months was 10.94mg/L (IQR 7.75 to 12.0), whereas in 46/93 (49.5%) non/moderate responders, median SDL at 3 months was 9.014 (IQR 6.96 to 11.1).

ROC analysis (see Figure 1) reported a 3-month non-trough ADL SDL cut-off of 7.5mg/L in fully adherent RA patients which discriminated Good EULAR responders compared to non/moderate responders with an AUC of 0.63 (95% CI 0.52 – 0.75), 39.1% specificity, and 80.9% sensitivity.

Figure 1.

ROC curve analysis: EULAR non/moderate vs good responders with 3 month ADL SDLs.

Conclusion

In keeping with previous work, SDLs were higher in adherent compared with non-adherent patients, but this is the first study to demonstrate that SDLs are higher in fully adherent good EULAR responders compared with non/moderate responders. Based on our methods, cut-offs of 7.5mg/L for ADL may be useful targets in clinical practice to achieve good EULAR response.

References

[1]Jani M, Chinoy H, Warren RB, Griffiths CEM, Plant D, Fu B, et al. Clinical Utility of Random Anti–Tumor Necrosis Factor Drug–Level Testing and Measurement of Antidrug Antibodies on the Long-Term Treatment Response in Rheumatoid Arthritis. Arthritis & Rheumatology. 2015;67(8):2011-9.

[2]Pouw MF, Krieckaert CL, Nurmohamed MT, van der Kleij D, Aarden L, Rispens T, et al. Key findings towards optimising adalimumab treatment: the concentration-effect curve. Ann Rheum Dis. 2015;74(3):513-8.

Disclosure of Interests

None declared

POS0509 DEVELOPMENT OF A MULITNOMIAL PREDICTION MODEL OF TREATMENT RESPONSE TO ETANERCEPT IN A MULTI-CENTRE COHORT OF PATIENTS WITH ESTABLISHED RA

Background

Treatment response in rheumatoid arthritis (RA) is assessed through EULAR response groups of good, moderate, and poor response. Clinical prediction models from the literature typically frame this as a binary model, to differentiate poor from good and moderate responders. Here, we develop a multinomial model, to predict each group separately, after 3 months on the anti-TNF drug Etanercept (ETN).

Objectives

Develop and validate a multinomial prediction model of treatment response to ETN in RA, based on baseline clinical covariates.

Methods

We identified patients treated with ETN or biosimilars (N = 778) from the Biologics in RA Genetics and Genomics Study Syndicate (BRAGGSS). Response groups were derived from the CRP based 4C-DAS28 at baseline and 3 month follow up, yielding 310 good, 320 moderate, and 148 poor responders. A multinomial logistic regression model was fitted, using good responders as reference category. Multiple imputation by chained equations was used to impute missing data, and models were internally validated via bootstrapping. We report model accuracy, as well as calibration, and compare effect sizes across response groups. Table 1shows the baseline statistics, and odds ratios for the included covariates.

Table 1.

Baseline covariate statistics and odds ratios (in bold: significant at p < 0.05); HADS: Hospital Anxiety and Depression Scale

VariableMean (± SD)ORModerate [95% CI]pORPoor [95% CI]por % YesSwollen Joint8.84450.980.350.948e-3Count (SJC)(± 5.20)[0.95 1.02][0.89 0.98]Tender Joint14.68771.076e-61.050.01Count (TJC)(± 6.74)[1.04 1.10][1.01 1.08]General Health74.74291.000.60.981e-3Visual Analog Scale (GHVAS)(±17.79)[0.99 1.01][0.97 0.99]CRP19.07391.000.220.990.26(±25.07)[1.00 1.01][0.98 1.00]BMI30.30351.000.481.000.41(±23.28)[0.99 1.01][0.99 1.01]Age of47.33301.010.121.020.06onset(±13.86)[1.00 1.03][1.00 1.04]Disease9.94011.000.840.990.45duration(±10.35)[0.98 1.02][0.96 1.02]HAQ1.60851.480.022.951e-6(± 0.65)[1.06 2.08][1.91 4.54]HADS-Anxiety8.08681.040.191.060.12(± 4.54)[0.98 1.10][0.99 1.13]HADS-Depression7.38411.060.120.970.55(± 4.02)[0.99 1.13][0.89 1.06]Concurrent81.49%0.412e-40.520.03DMARD[0.26 0.66][0.28 0.94]Female78.66%1.390.121.110.71[0.92 2.10][0.65 1.87]Seropositive77.89%0.540.020.470.01[0.33 0.89][0.26 0.86]1st Biologic90.62%1.060.860.480.03[0.55 2.06][0.24 0.94]

Results

Adjusted for optimism, the multinomial model achieves an accuracy of 50.7% (IQR: 50 – 51.3%), with calibration slopes of 0.574 (IQR: 0.569 - 0.579) and 0.534 (IQR: 0.525 - 0.544) for moderate and poor response, respectively. Figure 1 shows a comparison of odds ratios (OR) for the different outcome groups. The Health Assessment Questionnaire (HAQ) score is the biggest driver of both moderate and poor response. Previous biologic treatment also predicts poor but not moderate response. Compared to the multinomial model, a binary model, that discriminates poor from moderate and good responders, underestimates the effect size of HAQ.

Figure 1.

Odds ratios of FIRSTBIO and HAQ for moderate and poor response. Size of crosses indicate 95% confidence intervals.

Conclusion

The model predicts EULAR response groups moderately well but is poorly calibrated, which can partly be explained by the generally higher sample size requirement of multinomial modelling. In the multinomial model, moderate and poor response is largely driven by the same covariates, which leads to blurred boundaries between good and poor responders, when response groups are merged to create a binary problem. Future research should consider the most appropriate model choice to describe data, including the use of multinomial instead of binomial models. More research and bigger sample sizes are required to improve on this multinomial model.

Disclosure of Interests

Michael Stadler: None declared, Stephanie Ling: None declared, Nisha Nair: None declared, John Isaacs Speakers bureau: Abbvie, Gilead, Roche, UCB, Grant/research support from: GSK, Janssen, Pfizer, Kimme Hyrich Speakers bureau: Abbvie, Grant/research support from: Pfizer and BMS, Ann Morgan Speakers bureau: Roche/ Chuga, Consultant of: GSK, Roche, Chugai, AstraZeneka, Regeneron, Sanofi, Vifor, Grant/research support from: Roche, Kiniksa Pharmaceuticals, Anthony G Wilson: None declared, Darren Plant: None declared, John Bowes: None declared, Anne Barton Grant/research support from: Pfizer, Galapagos, Scipher Medicine, and Bristol Myers Squibb.

Strategic placement of automated external defibrillators (AEDs) for cardiac arrests in public locations and private residences

•

We ranked businesses for their ability to fill gaps in the AED landscape.

•

23% of OHCAs in public, and 4% in homes, were within 100 m of an existing AED.

•

Many businesses can simultaneously improve coverage of arrests in public and homes.

•

Rankings were largely robust to the coverage radius used (100 m, 200 m, and 500 m).

•

Even if all 5006 business locations hosted AEDs, large gaps in OHCA coverage remain.

Aim

Methods

Results

Conclusion

AB0337 BASELINE C-REACTIVE PROTEIN PREDICTS ADHERENCE TO ADALIMUMAB THERAPY AT 3 MONTHS IN AN OBSERVATIONAL COHORT OF PATIENTS WITH RHEUMATOID ARTHRITIS

Background

Adherence to biologic treatment in rheumatoid arthritis (RA) is often self-reported and little is known about the predictors of adherence to biologic medications. Many studies have reported the predictors of adherence to be linked to psychological factors. A systematic review [1] identified several predictors of adherence to methotrexate in RA patients with the strongest predictors related to psychological factors including beliefs in medication necessity and absence of low mood. Mild disease activity was also found to be a significant predictor of adherence from this study. It is unknown whether similar factors will predict adherence in an established cohort of patients with RA starting biologic therapy.

Objectives

To investigate levels of self-reported adherence to adalimumab treatment and identify the contribution of demographic, physical and psychological factors to medication adherence in an RA cohort.

Methods

Patients with RA who were commencing on adalimumab were recruited through the Biologics in Rheumatoid Arthritis Genetics and Genomics Study Syndicate (BRAGGSS), a large UK multicentre prospective observational cohort study. Demographics, baseline clinical and psychological measures including illness and medication beliefs were collected. Self-reported adherence, defined as the patient has never stopped, altered, missed, forgot to take, or took a lower dose than prescribed of adalimumab, were recorded at 3 months. Potential baseline predictors of adherence to adalimumab therapy were determined using logistic regression analyses.

Results

202 patients were included; 76% female, median (IQR): age 59 (52-67) years, pre-treatment DAS28-CRP score 5.6 (5.1-6.1) and disease duration 5 (2-15) years. During the first 3 months following commencement of adalimumab, 176 (87%) patients reported full adherence. Univariable analyses found that high baseline C-reactive protein (CRP) [odds ratio (OR) 1.04 per mg/L, 95% CI 1.01, 1.09] was associated with adherence to adalimumab at 3 months. However, there were no associations identified from the psychological variables and this includes perceived necessity towards medication [OR 0.92, 95% CI 0.79, 1.05], hospital depression score [OR 0.94, 95% CI 0.84, 1.06] and hospital anxiety score [OR 0.97, 95% CI 0.88, 1.08].

Conclusion

These findings suggest that the psychological measures were less able to predict adherence to adalimumab therapy. The high percentage of adherence during the first three months of therapy may limit power to detect small effects in this cohort. Further research to investigate whether psychological variables correlate with drug levels as an alternative surrogate for adherence and to consider including other biological agents with a longer follow-up timeline are needed.

High baseline CRP levels were associated with adherence. This finding suggests active disease with higher levels of inflammation in RA may be a factor for adherence in patients who are commencing biologic therapy.

References

[1]Hope, H. F., Bluett, J., Barton, A., Hyrich, K. L., Cordingley, L., & Verstappen, S. M. M. (2016). Psychological factors predict adherence to methotrexate in rheumatoid arthritis; findings from a systematic review of rates, predictors and associations with patient-reported and clinical outcomes. RMD Open, 2(1), e000171. https://doi.org/10.1136/rmdopen-2015-000171

Disclosure of Interests

Adlan Wafi Ramli: None declared, Nisha Nair: None declared, Kimme Hyrich Consultant of: AbbVie, Grant/research support from: Pfizer, BMS, John Isaacs Speakers bureau: Abbvie, Gilead, Roche, UCB, Grant/research support from: GSK, Janssen, Pfizer, Ann Morgan Speakers bureau: Roche/Chugai, Consultant of: GSK, Roche, Chugai, AstraZeneca, Regeneron, Sanofi, Vifor, Grant/research support from: Roche, Kiniksa Pharmaceuticals, Darren Plant: None declared, Anthony G Wilson: None declared, Anne Barton Grant/research support from: I have received grant funding from Pfizer, Galapagos, Scipher Medicine and Bristol Myers Squibb.

OP0190 COMPREHENSIVE GENETIC AND FUNCTIONAL ANALYSES OF Fc GAMMA RECEPTORS EXPLAIN RESPONSE TO RITUXIMAB THERAPY FOR AUTOIMMUNE RHEUMATIC DISEASES

Background

Rituximab is widely used to treat rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE) but clinical response varies. Efficacy is determined by the efficiency of depletion, which may depend on a variety of Fc gamma receptor (FcγR)-dependent mechanisms. Previous research was limited by complexity of the FCGR locus, not integrating copy number variation with functional SNP, and small sample size.

Objectives

The study objectives were to assess the effect of the full range of FcγRs variants on depletion, clinical response and functional effect on NK-cell-mediated killing in two rheumatic diseases with a view to personalised B-cell depleting therapies.

Methods

A prospective longitudinal cohort study was conducted in 873 patients [RA=611; SLE=262] from four cohorts (BSRBR-RA and BILAG-BR registries, Leeds RA and Leeds SLE Biologics). For RA, the outcome measures were 3C-DAS28CRP and 2C-DAS28CRP at 6 (+/-3) months post-rituximab (adjusted for baseline DAS28). For SLE, major clinical response (MCR) was defined as improvement of active BILAG-2004 domains to grade C/better at 6 months. B-cell depletion was evaluated by highly-sensitive flow cytometry. Qualitative and quantitative polymorphisms for five major FcγRs were measured using a commercial multiplex ligation-dependent probe amplification. Median NK cell FcγRIIIa expression (CD3-CD56+CD16+) and NK-cell degranulation (CD107a) in the presence of rituximab-coated Daudi/Raji B-cell lines were assessed using flow cytometry.

Results

In RA, for FCGR3A, carriage of V allele (coefficient -0.25 (SE 0.11); p=0.02) and increased copies of V allele (-0.20 (0.09); p=0.02) were associated with greater 2C-DAS28 response. Irrespective of FCGR3A genotype, increased gene copies were associated with a better response. In SLE, 177/262 (67.6%) achieved BILAG response [MCR=34.4%; Partial=33.2%]. MCR was associated with increased copies of FCGR3A-158V allele, OR 1.64 (95% CI 1.12-2.41) and FCGR2C-ORF allele 1.93 (1.09-3.40). Of patients with B-cells data in the combined cohort, 236/413 (57%) achieved complete depletion post-rituximab. Only homozygosity for FCGR3A-158V and increased FCGR3A-158V copy number were associated with increased odds of complete depletion. Patients with complete depletion had higher NK cell FcγRIIIa expression at rituximab initiation than those with incomplete depletion (p=0.04) and this higher expression was associated with improved EULAR response in RA. Moreover, for FCGR3A, degranulation activity was increased in V allele carriers vs FF genotype in the combined cohort; p=0.02.

Conclusion

FcγRIIIa is the major low affinity FcγR and increased copies of the FCGR3A-158V allele, encoding the allotype with a higher affinity for IgG1, was associated with clinical and biological responses to rituximab in two autoimmune diseases. This was supported by functional data on NK cell-mediated cytotoxicity. In SLE, increased copies of the FCGR2C-ORF allele was also associated with improved response. Our findings indicate that enhancing FcγR-effector functions could improve the next generation of CD20-depleting therapies and genotyping could stratify patients for optimal treatment protocols.

References

None

Acknowledgements

This research was funded/supported by the joint funding from the Medical Research Council (MRC) and Versus Arthritis of MATURA (grant codes 36661 and MR/K015346/1). MASTERPLANS was funded by the MRC (grant code MR/M01665X/1). The Leeds Biologics Cohort was part funded by programme grants from Versus Arthritis (grant codes 18475 and 18387), the National Institute for Health Research (NIHR) Leeds Biomedical Research Centre (BRC) and Diagnostic Evaluation Co-operative and the Ann Wilks Charitable Foundation. The BILAG-BR has received funding support from Lupus UK, and unrestricted grants from Roche and GSK.

The functional studies were in part supported through a NIHR/HEFCE Clinical Senior Lectureship and a Versus Arthritis Foundation Fellowship (grant code 19764) to AWM, the Wellcome Trust Institutional Strategic Support Fund to JIR and MYMY (204825/Z/16/Z), NIHR Doctoral Research Fellowship to MYMY (DRF-2014-07-155) and NIHR Clinician Scientist to EMV (CS-2013-13-032). . AWM, INB, JDI and PE were supported by NIHR Senior Investigator awards. Work in JDI’s laboratory is supported by the NIHR Newcastle BRC, the Research Into Inflammatory Arthritis Centre Versus Arthritis, and Rheuma Tolerance for Cure (European Union Innovative Medicines Initiative 2, grant number 777357). INB is funded by the NIHR Manchester BRC.

This article/paper/report presents independent research funded/supported by the NIHR Leeds BRC and the NIHR Guy’s and St Thomas’ BRC. The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care.

Disclosure of Interests

Md Yuzaiful Md Yusof: None declared, James Robinson: None declared, Vinny Davies: None declared, Dawn Wild: None declared, Michael Morgan: None declared, John Taylor: None declared, Yasser El-Sherbiny: None declared, David Morris: None declared, Lu Liu: None declared, Andrew Rawstron: None declared, Maya H Buch: None declared, Darren Plant: None declared, Heather Cordell: None declared, John Isaacs: None declared, Ian N. Bruce: None declared, Paul Emery Speakers bureau: Roche, Consultant of: Roche, Grant/research support from: Roche, Anne Barton: None declared, Timothy Vyse: None declared, Jennifer Barrett: None declared, Edward Vital Consultant of: Roche, Grant/research support from: Roche, Ann Morgan Speakers bureau: Roche/Chugai, Consultant of: GSK, Roche, Chugai, AstraZeneka, Regeneron, Sanofi, Vifor, Grant/research support from: Roche, Kiniksa Pharmaceuticals

OP0033 REGULATORY T CELL CD39 EXPRESSION AS A PREDICTOR OF EARLY REMISSION-INDUCTION WITH METHOTREXATE IN NEW-ONSET RHEUMATOID ARTHRITIS

Background:

The long term outcomes for patients with rheumatoid arthritis (RA) depend on early and effective disease control. Methotrexate remains the key first line disease modifying therapy for the majority of patients, with 40% achieving an ACR50 on monotherapy(1). There are at present no effective biomarkers to predict treatment response, preventing effective personalisation of therapy. A putative mechanism of action of methotrexate, the potentiation of anti-inflammatory adenosine signalling, may inform biomarker discovery. By antagonism of the ATIC enzyme in the purine synthesis pathway, methotrexate has been proposed to increase the release of adenosine moieties from cells, which exert an anti-inflammatory effect through interaction with ADORA2 receptors(2). Lower expression of CD39 (a cell surface 5-’ectonucleotidase required for the first step in the conversion of ATP to adenosine) on circulating regulatory T-Lymphocytes (Tregs) was previously identified in patients already established on methotrexate who were not responding (DAS28 >4.0 vs <3.0)(3). We therefore hypothesised that pre-treatment CD39 expression on these cells may have clinical utility as a predictor of early methotrexate efficacy.

Objectives:

To characterise CD39 expression in peripheral blood mononuclear cells in RA patients naïve to disease modifying therapy commencing methotrexate, and relate this expression to 4 variable DAS28CRP remission (<2.6) at 6 months.

Methods:

68 treatment naïve early RA patients starting methotrexate were recruited from the Newcastle Early Arthritis Clinic and followed up for 6 months. Serial blood samples were taken before and during methotrexate therapy with peripheral blood mononuclear cells isolated by density centrifugation. Expression of CD39 by major immune subsets (CD4+ and CD8+ T-cells, B-lymphocytes, natural killer cells and monocytes) was determined by flow cytometry. The statistical analysis used was binomial logistic regression with baseline DAS28CRP used as a covariate due to the significant association of baseline disease activity with treatment response.

Results:

Higher pre-treatment CD39 expression was observed in circulating CD4+ T-cells of patients who subsequently achieved clinical remission at 6 months versus those who did not (median fluorescence 4854.0 vs 3324.2; p = 0.0108; Figure 1-A). This CD39 expression pattern was primarily accounted for by the CD4+CD25 high sub-population (median fluorescence 9804.7 vs 6455.5; p = 0.0065; Figure 1-B). These CD25 high cells were observed to have higher FoxP3 and lower CD127 expression than their CD39 negative counterparts, indicating a Treg phenotype. No significant associations were observed with any other circulating subset. A ROC curve demonstrates the discriminative utility of differential CD39 expression in the CD4+CD25 high population for the prediction of DAS28CRP remission in this cohort, showing greater specificity than sensitivity for remission prediction(AUC: 0.725; 95% CI: 0.53 - 0.92; Figure 1-C). Longitudinally, no significant induction or suppression of the CD39 marker was observed amongst patients who did or did not achieve remission over the 6 months follow-up period.

Figure 1.

Six month DAS28CRP remission versus pre-treatment median fluorescence of CD39 expression on CD4+ T-cells (A); CD25 High expressing CD4+ T-cells (B); and ROC curve of predictive utility of pre-treatment CD39 expression on CD25 High CD4+ T-cells (C).

Conclusion:

These findings support the potential role of CD39 in the mechanism of methotrexate response. Expression of CD39 on circulating Tregs in treatment-naïve RA patients may have particular value in identifying early RA patients likely to respond to methotrexate, and hence add value to evolving multi-parameter discriminatory algorithms.

References:

[1]Hazlewood GS, et al. BMJ. 2016 21;353:i1777

[2]Brown PM, et al. Nat Rev Rheumatol. 2016;12(12):731-742

[3]Peres RS, et al. Proc Natl Acad Sci U S A. 2015;112(8):2509-2514

Disclosure of Interests:

None declared

POS0357 MiRNAs CORRELATE WITH IMPROVEMENT IN DISEASE ACTIVITY IN PATIENTS WITH RHEUMATOID ARTHRITIS ON TUMOUR NECROSIS FACTOR INHIBITORS

Background:

Tumour necrosis factor inhibitors (TNFi) although effective in the treatment of rheumatoid arthritis (RA), show a variable response rate. Therefore, there is a need to identify treatment response predictors to inform therapy selection in order to practise precision medicine. MicroRNAs (miRNAs) are endogenous, single-stranded, non-coding RNAs that can alter gene expression by regulating messenger RNA translation. There is evidence for miRNA involvement in RA pathogenesis and they may serve as a useful biomarker of treatment response.

Objectives:

To identify miRNAs associated with response to TNFi in RA.

Methods:

Biologic naïve patients were selected from the Biologics in Rheumatoid Arthritis Genetics and Genomics Study Syndicate (BRAGGSS), a prospective multi-center UK study investigating treatment response biomarkers to TNFi with a primary outcome measure of change in DAS28 scores. Patients were stratified into European League Against Rheumatism (EULAR) good or non-responders based on their 3 or 6-month DAS28-CRP score.

Pre-treatment and 3-month post-treatment serum samples were substrates for miRNA profiling, which was conducted by FIRALIS using the HTG EdgeSeq miRNA whole transcriptome V2 targeted sequencing assay. Linear modelling using R package limma compared miRNA expression at (i) pre-treatment and at three-months, in EULAR good-responders and non-responders (ii) longitudinal change in expression from pre-treatment to three-months in EULAR good and non-responders.

A literature search was conducted to identify miRNAs associated with RA as a diagnostic and/or treatment response predictor. Data on these miRNAs were extracted from the miRNAs identified in the serum samples. A correction for multiple testing was applied to statistical tests.

Results:

A total of 54 patients were analysed; of these, 35 (65%) were female, median disease duration [inter-quartile range] was 6 years [2 – 14] (n=51), and 44/51 (86%) patients were on a concomitant disease modifying anti-rheumatic drug. Of the 54 patients, 39 (72%) were classified as EULAR good-responders and 15 (28%) as non-responders. 1880 miRNAs were detected in the serum samples. 64 miRNAs were identified to be associated with RA from the literature, of which, 26 were identified in the serum samples tested.

No difference in pre-treatment or three-month miRNA levels was seen comparing EULAR good-responders and non-responders (FDR p<0.05). There was a significant differential expression of four miRNAs at 3-months in good-responders compared with pre-treatment levels; miR-125a-3p (downregulated, p-value 0.002), miR-149-3p (upregulated, p-value 0.004), miR-766-3p (downregulated, p-value 0.008), miR-146b-5p (upregulated, p-value 0.006). No significant differences were observed between 3-months and baseline in non-responders.

Conclusion:

Although no pre-treatment miRNAs were associated with TNFi response, changes in the levels of four miRNAs were detected at 3-months compared to baseline in EULAR good-responders. Future work involves validation of these samples in a larger patient cohort and analysing miRNA levels at 6 and 12 months. Replication and validation of these results in larger studies are required to analyse the role of miRNAs in stratifying EULAR good-responders from non-responders at three-months, and as treatment response predictors to TNFi in RA.

Acknowledgements:

Joint last-author: Dr. Darren Plant

Disclosure of Interests:

Trixy David: None declared, Nisha Nair: None declared, James Oliver: None declared, Eric Schordan: None declared, Hüseyin Firat: None declared, Kimme Hyrich Consultant of: consultancy/honoraria from AbbVie, Grant/research support from: Pfizer, UCB, BMS, Ann Morgan: None declared, Anthony G Wilson: None declared, John D Isaacs Speakers bureau: consultancy/speaker fees from AbbVie, Gilead, Roche, UCB, Consultant of: consultancy/speaker fees from AbbVie, Gilead, Roche, UCB, Grant/research support from: Pfizer, Darren Plant: None declared, Anne Barton: None declared

Adult North Star Network (ANSN): Consensus Guideline For The Standard Of Care Of Adults With Duchenne Muscular Dystrophy

There are growing numbers of adults with Duchenne Muscular Dystrophy living well into their fourth decade. These patients have complex medical needs that to date have not been addressed in the International standards of care. We sought to create a consensus based standard of care through a series of multi-disciplinary workshops with specialists from a wide range of clinical areas: Neurology, Cardiology, Respiratory Medicine, Gastroenterology, Endocrinology, Palliative Care Medicine, Rehabilitation, Renal, Anaesthetics and Clinical Psychology. Detailed reports of evidence reviewed and the consensus building process were produced following each workshop and condensed into this final document which was approved by all members of the Adult North Star Network including service users. The aim of this document is to provide a framework to improve clinical services and multi-disciplinary care for adults living with Duchenne Muscular Dystrophy.

Right atrium to pulmonary capillary wedge pressure ratio is associated with right ventricular failure and mortality after left ventricular assist device surgery

Introduction

Right ventricular failure (RVF) is a major cause of morbidity and mortality after left ventricular assist device (LVAD) implantation. We investigated the role of right atrium to pulmonary capillary wedge pressure (RA/PCWP) ratio as a preoperative predictor of postoperative RVF after LVAD surgery.

Methods

A retrospective analysis of all consecutive patients who received continuous-flow LVADs (HeartMate 2, 3, and HVAD) between August 2012 and May 2018 in a single tertiary center. INTERMACS profile 1 patients were excluded. RA/PCWP ratio was calculated for the entire cohort and divided into quartiles (Q). Patients were stratified into high (Q4) vs. low (Q1–3) RA/PCWP ratio. The primary end point was the composite of in hospital mortality and RVF (defined as the need for a right ventricular assist device or inotrope dependence for &gt;7 days). The secondary endpoint was readmission within 14 days after discharge.

Results

The study cohort consisted of 59 patients (15 patients in the high RA/PCWP group and 44 patients in the low RA/PCWP group) with a median follow-up of 21 months (Interquartile range 14–31). The mean age was 56±11 years and the majority of patients were male (88%). Patients were classified as INTERMACS profile 2 (34%), 3 (19%) or 4 (47%).

Preoperative clinical, laboratory, and echocardiographic parameters were similar in both groups except for a larger proportion of patients with a dilated right ventricle and above moderate tricuspid regurgitation in the high compared to the low RA/PCWP group (73% vs. 29%; P=0.006 and 40% vs. 2%; P=0.001, respectively). Overall, 7 patients (12%) developed the primary end-point and 9 patients (15%) developed the secondary end-point.

Univariate analysis demonstrated that high RA/PCWP is associated with both primary and secondary end-points (odds ratio [OR], 7.6; 95% confidence interval [CI] 1.2–47.2, P=0.029 and OR, 6.25; 95% CI 1.3–28.5, P=0.018, respectively). On multivariable analysis, the association remained significant after adjustment for INTERMACS score (OR, 10.6; 95% CI 1.4–80.9, P=0.022 and OR, 7.9; 95% CI 1.5–42.2, P=0.015, respectively).

Using receiver operating characteristic curve (ROC) derived cut-points, RA/PCWP &gt;0.57 provided 67% sensitivity and 79% specificity (C-statistic = 0.73) for the prediction of in hospital mortality and RVF and 56% sensitivity and 84% specificity (C-statistic = 0.69) for the prediction of readmissions within 14 days after discharge. In comparison, in our cohort using ROC-derived cut points, pulmonary artery pulsatility index, an established RVF predictor, of less than 1.84 provided 40% sensitivity and 20% specificity (C-statistic = 0.3) for the prediction of inhospital death and RVF.

Conclusion

RA/PCWP ratio may help to identify patients at high risk of developing adverse clinical outcomes, including RVF and mortality, after LVAD surgery.

Funding Acknowledgement

Type of funding source: None

The roles of item exposure and visualization success in the consolidation of memories across wake and sleep

Memory consolidation during sleep does not benefit all memories equally. Initial encoding strength appears to play a role in governing where sleep effects are seen, but it is unclear whether sleep preferentially consolidates weaker or stronger memories. We manipulated encoding strength along two dimensions—the number of item presentations, and success at visualizing each item, in a sample of 82 participants. Sleep benefited memory of successfully visualized items only. Within these, the sleep–wake difference was largest for more weakly encoded information. These results suggest that the benefit of sleep on memory is seen most clearly for items that are encoded to a lower initial strength.

Improving the quality of maternal and newborn care in the Pacific region: A scoping review

Background

Quality care is essential for improving maternal and newborn health. Low- and middle-income Pacific Island nations face challenges in delivering quality maternal and newborn care. The aim of this review was to identify all published studies of interventions which sought to improve the quality of maternal and newborn care in Pacific low-and middle-income countries.

Methods

A scoping review framework was used. Databases and grey literature were searched for studies published between January 2000 and July 2019 which described actions to improve the quality of maternal and newborn care in Pacific low- and middle-income countries. Interventions were categorised using a four-level health system framework and the WHO quality of maternal and newborn care standards. An expert advisory group of Pacific Islander clinicians and researchers provided guidance throughout the review process.

Results

2010 citations were identified and 32 studies included. Most interventions focused on the clinical service or organisational level, such as healthcare worker training, audit processes and improvements to infrastructure. Few addressed patient experiences or system-wide improvements. Enablers to improving quality care included community engagement, collaborative partnerships, adequate staff education and training and alignment with local priorities.

Conclusions

There are several quality improvement initiatives in low- and middle-income Pacific Island nations, most at the point of health service delivery. To effectively strengthen quality maternal and newborn care in this region, efforts must broaden to improve health system leadership, deliver sustaining education programs and encompass learnings from women and their communities.

THU0022 DIFFERENTIAL DNA METHYLATION AS A PREDICTOR OF TOCILIZUMAB RESPONSE IN RHEUMATOID ARTHRITIS PATIENTS

Background:

Tocilizumab (TCZ) is a biological disease-modifying antirheumatic drug that blocks IL-6 signalling and is effective in ameliorating disease activity in rheumatoid arthritis (RA). However, approximately 50% of patients do not respond adequately to TCZ and some patients report adverse events. Considering there is growing evidence that DNA methylation is implicated in RA susceptibility and response to some biologics (1, 2), we investigated DNA methylation as a candidate biomarker for response to TCZ in RA.

Objectives:

To identify differential DNA methylation signatures in whole blood associated with TCZ response in patients with RA.

Methods:

Epigenome-wide DNA methylation patterns were measured using the Infinium EPIC BeadChip (Illumina) in whole blood-derived DNA samples from patients with RA. DNA was extracted from blood samples taken pre-treatment and following 3 months on therapy, and response was determined at 6 months using the Clinical Disease Activity Index (CDAI). Patients who had good response (n=10) or poor response (n=10) to TCZ by 6 months were selected. Samples from secondary poor responders (n=10) (patients who had an improvement of CDAI and were in remission at 3 months, followed by a worsening of CDAI at 6 months) were also analysed. Differentially methylated positions and regions (DMPs/DMRs) were identified using linear regression, adjusting for gender, age, cell composition, smoking status, and glucocorticoid use. Gene Set Enrichment Analysis (GSEA) was used to identify significant pathways associated with response and Functional Epigenetic Module analysis of interactome hotspots in regions of differential methylation.

Results:

20 DMPs were significantly associated with response status at 6 months in the pre-treatment samples. Another 21 DMPs were associated with response in the 3 month samples. Within good responders, 10 DMPs showed significant change in methylation level between pre-treatment and the 3 month samples (unadjusted P-value <10-6). One DMP, cg03121467, was significantly less methylated in good responders compared to poor responders in the pre-treatment samples. This DMP is close toEPB41L4Aand thought to have a role in β–catenin signalling. GSEA of DMRs in non- and secondary non- responders identified histone acetyltransferase pathways and included theKAT2Agene, which is a repressor of NF-κB. Additional analysis of interaction hotspots of differential methylation identified significant interactions withSTAMBPandPTPN12associated with response status.

Conclusion:

These preliminary results provide evidence that DNA methylation patterns may predict response to TCZ. Validation of these findings in other larger data sets is required.

References:

[1]Liu,Y., Aryee,M.J., Padyukov,L., Fallin,M.D., Hesselberg,E., Runarsson,A., Reinius,L., Acevedo,N., Taub,M., Ronninger,M.,et al.(2013) Epigenome-wide association data implicate DNA methylation as an intermediary of genetic risk in rheumatoid arthritis.Nat. Biotechnol.,31, 142–147.

[2]Plant,D., Webster,A., Nair,N., Oliver,J., Smith,S.L., Eyre,S., Hyrich,K.L., Wilson,A.G., Morgan,A.W., Isaacs,J.D.,et al.(2016) Differential Methylation as a Biomarker of Response to Etanercept in Patients With Rheumatoid Arthritis.Arthritis Rheumatol. (Hoboken, N.J.),68, 1353–60.

Disclosure of Interests:

Nisha Nair: None declared, Darren Plant: None declared, John Isaacs Consultant of: AbbVie, Bristol-Myers Squibb, Eli Lilly, Gilead, Janssen, Merck, Pfizer, Roche, Ann Morgan Grant/research support from: I have received a grant from Roche Products Ltd to establish a registry for GCA patients treated with tocilizumab., Consultant of: I have undertaken consultancy work for Roche, Chugai, Regeneron, Sanofi and GSK in the area of GCA therapeutics., Speakers bureau: I have presented on tocilizumab therapy for GCA and glucocorticoid toxicity on behalf of Roche products ltd., Kimme Hyrich Grant/research support from: Pfizer, UCB, BMS, Speakers bureau: Abbvie, Anne Barton Consultant of: AbbVie, Anthony G Wilson: None declared

Strategies to Improve Recruitment to a De-escalation Trial: A Mixed-Methods Study of the OPTIMA Prelim Trial in Early Breast Cancer

AIMS

De-escalation trials are challenging and sometimes may fail due to poor recruitment. The OPTIMA Prelim randomised controlled trial (ISRCTN42400492) randomised patients with early stage breast cancer to chemotherapy versus 'test-directed' chemotherapy, with a possible outcome of no chemotherapy, which could confer less treatment relative to routine practice. Despite encountering challenges, OPTIMA Prelim reached its recruitment target ahead of schedule. This study reports the root causes of recruitment challenges and the strategies used to successfully overcome them.

MATERIALS AND METHODS

A mixed-methods recruitment intervention (QuinteT Recruitment Intervention) was used to investigate the recruitment difficulties and feedback findings to inform interventions and optimise ongoing recruitment. Quantitative site-level recruitment data, audio-recorded recruitment appointments (n = 46), qualitative interviews (n = 22) with trialists/recruiting staff (oncologists/nurses) and patient-facing documentation were analysed using descriptive, thematic and conversation analyses. Findings were triangulated to inform a 'plan of action' to optimise recruitment.

RESULTS

Despite best intentions, oncologists' routine practices complicated recruitment. Discomfort about deviating from the usual practice of recommending chemotherapy according to tumour clinicopathological features meant that not all eligible patients were approached. Audio-recorded recruitment appointments revealed how routine practices undermined recruitment. A tendency to justify chemotherapy provision before presenting the randomised controlled trial and subtly indicating that chemotherapy would be more/less beneficial undermined equipoise and made it difficult for patients to engage with OPTIMA Prelim. To tackle these challenges, individual and group recruiter feedback focussed on communication issues and vignettes of eligible patients were discussed to address discomforts around approaching patients. 'Tips' documents concerning structuring discussions and conveying equipoise were disseminated across sites, together with revisions to the Patient Information Sheet.

CONCLUSIONS

This is the first study illuminating the tension between oncologists' routine practices and recruitment to de-escalation trials. Although time and resources are required, these challenges can be addressed through specific feedback and training as the trial is underway.

Visibility of age restriction warnings, harm reduction messages and terms and conditions: a content analysis of paid-for gambling advertising in the United Kingdom

OBJECTIVE

The inclusion and design of age restriction warnings, harm reduction messages and terms and conditions (T&Cs) in gambling advertising is self-regulated in the United Kingdom. Our study examines the visibility and nature of this information in a sample of paid-for gambling adverts.

STUDY DESIGN

A content analysis of a stratified random sample of gambling adverts (n = 300) in the United Kingdom from eight paid-for advertising channels (March 2018).

METHODS

For each advert, we assessed whether any age restriction warnings, harm reduction messages and T&Cs were present. If so, visibility was scored on a five-point scale ranging from very poor (≤10% of advert space) to very good (≥26% of advert), which had high inter-rater reliability. Descriptive information on position, design and tone of language was recorded.

RESULTS

One in seven adverts (14%) did not feature an age restriction warning or harm reduction message. In adverts that did, 84% of age restriction warnings and 54% of harm reduction messages had very poor visibility. At least one in ten adverts did not contain T&Cs. In adverts that did, 73% had very poor visibility. For age restriction warnings, harm reduction messages and T&Cs, most appeared in small fonts and outside the main advert frame. Most harm reduction messages did not actually reference gambling-related harms.

CONCLUSION

Age restriction warnings, harm reduction messages and T&Cs do not always appear in paid-for gambling advertising. When they do, visibility is often very poor and the messaging not clear. The findings do not support a self-regulatory approach to managing this information in gambling adverts.

Examining the frequency and nature of gambling marketing in televised broadcasts of professional sporting events in the United Kingdom

OBJECTIVE

Gambling operators in the United Kingdom have introduced a voluntary ban on adverts broadcast during televised sport before 21:00 (the 'whistle-to-whistle' ban). To inform debates around the potential effectiveness of this ban, we examine the frequency and nature of gambling marketing in televised broadcasts across professional sporting events.

STUDY DESIGN

Frequency analysis of verbal and visual gambling marketing references during television broadcasts of football (n = 5), tennis, Formula 1, boxing and rugby union (each n = 1) from 2018.

METHODS

For each gambling reference, we coded: whether it appeared in-play or out-of-play; location (e.g. pitch-side advertising); format (e.g. branded merchandise); duration (s); number of identical references visible simultaneously; brand; and presence of age restriction or harm-reduction messages.

RESULTS

Boxing contained the most gambling references, on average, per broadcast minute (4.70 references), followed by football (2.75), rugby union (0.55) and tennis (0.11). Formula 1 contained no gambling references. In boxing, references most frequently appeared within the area-of-play. For football and rugby union, references most frequently appeared around the pitch border or within the area-of-play (e.g. branded shirts). Only a small minority of references were for adverts during commercial breaks that would be subject to the whistle-to-whistle ban (e.g. 2% of references in football). Less than 1% of references in boxing and only 3% of references in football contained age restriction or harm-reduction messages.

CONCLUSIONS

As gambling sponsorship extends much beyond adverts in commercial breaks, the 'whistle-to-whistle' ban will have limited effect on gambling exposure. Gambling sponsorship activities rarely contain harm-reduction messages.

New age-related hearing loss candidate genes in humans: an ongoing challenge

Age-related hearing loss (ARHL) is the most frequent sensory disorder in the elderly, affecting approximately one-third of people aged more than 65 years. Despite a large number of people affected, ARHL is still an area of unmet clinical needs, and only a few ARHL susceptibility genes have been detected so far. In order to further investigate the genetics of ARHL, we analyzed a series of 46 ARHL candidate genes, selected according to previous Genome Wide Association Studies (GWAS) data, literature updates and animal models, in a large cohort of 464 Italian ARHL patients. We have filtered the variants according to a) pathogenicity prediction, b) allele frequency in public databases, c) allele frequency in an internal cohort of 113 healthy matched controls, and 81 healthy semi-supercentenarians. After data analysis, all the variants of interest have been tested by functional "in silico" or "in vitro" experiments (i.e., molecular dynamics simulations and protein translation analysis) to assess their pathogenic role, and the expression of the mutated genes have been checked in mouse or zebrafish inner ear. This multi-step approach led to the characterization of a series of ultra-rare likely pathogenic variants in DCLK1, SLC28A3, CEP104, and PCDH20 genes, contributing to describe the first association of these genes with ARHL in humans. These results provide essential insights on the understanding of the molecular bases of such a complex, heterogeneous and frequent disorder, unveiling new possible targets for the future development of innovative therapeutic and preventive approaches that could improve the quality of life of the millions of people affected worldwide.

Biosocial perspectives on adolescent wellbeing: time trends and cross-national patterns

Since 1985, the HBSC Study has conducted 9 quadrennial surveys. There has been a growing number of HBSC participating countries over the 3.5 decades - from 5 to almost 50, in Europe and North America. In total there have been 298 national HBSC surveys and data collected from more than 1.5 million 11, 13 and 15 year olds. This paper asks - ‘What have we found out about adolescent mental health’ from this enormous research endeavour?

1000 papers have been published from HBSC and of these, just over 10% (120) have a primary focus on mental health. Notwithstanding the complexity of how mental health is conceptualized in each case, the 120 abstracts were scanned and empirical evidence was organised according to Bronfenbrenner’s bio-ecological model in order to synthesise key findings, in order to evaluate: where there were significant contributions to knowledge/understanding of mental health; where this was limited and where real gaps existed.

A vast array of topics was explored on adolescent mental health with a strong focus on the effects of bullying, the school environment and social and economic inequalities. There was a lack of attention to the importance of friendship and prosocial behaviour. Apart from parents, the role of family members, including grandparents and siblings, in supporting or negatively impacting mental health, was neglected. It was concluded that a deeper investigation is needed into behaviours and social contexts that support positive mental health. The use of the bio-ecological model helped to systematise the evidence to provide an overview of what HBSC has achieved in terms of progressing our understanding of adolescent mental health and where gaps exist.

The implications of this review for HBSC’s future development are considered in addition to reflection on what contribution the research to date can make to policy development to improve adolescent health internationally.

The hippocampus is necessary for the consolidation of a task that does not require the hippocampus for initial learning

During sleep, the hippocampus plays an active role in consolidating memories that depend on it for initial encoding. There are hints in the literature that the hippocampus may have a broader influence, contributing to the consolidation of memories that may not initially require the area. We tested this possibility by evaluating learning and consolidation of the motor sequence task (MST) in hippocampal amnesics and demographically matched control participants. While the groups showed similar initial learning, only controls exhibited evidence of overnight consolidation. These results demonstrate that the hippocampus can be required for normal consolidation of a task without being required for its acquisition, suggesting that the area plays a broader role in coordinating memory consolidation than has previously been assumed.

Abstract OT1-05-02: OPTIMA: A prospective randomized trial to validate the clinical utility and cost-effectiveness of gene expression test-directed chemotherapy decisions in high clinical risk early breast cancer

Background:Multi-parameter tumour gene expression assays (MPAs) are widely used to estimate individual patient residual risk and to guide chemotherapy use in hormone-sensitive, HER2-negative early breast cancer. The TAILORx trial supports MPA use in a node-negative population. Evidence for MPA use in node-positive breast cancer is limited. OPTIMA (Optimal Personalised Treatment of early breast cancer usIng Multi-parameter Analysis) (ISRCTN42400492) aims to validate MPAs as predictors of chemotherapy sensitivity in a largely node-positive breast cancer population where prospective RCT (Randomised Controlled Trial) evidence is lacking.

Methods: OPTIMA is a partially blinded multi-center RCT with an adaptive two-stage design. The main eligibility criteria are women and men age 40 or older with resected ER-positive, HER2-negative invasive breast cancer and up to 9 involved axillary lymph nodes. Randomisation is to standard management (chemotherapy and endocrine therapy) or to MPA-directed treatment using the Prosigna (PAM50) test. Those with a Prosigna tumour score (ROR_PT) &gt;60 receive standard management whilst those with a low score (≤60) are treated with endocrine therapy alone. Endocrine therapy for pre-menopausal women includes ovarian suppression. The co-primary outcomes are (1) Invasive Disease Free Survival (IDFS) and (2) cost-effectiveness of test-directed treatment. Secondary outcomes include IDFS in patients with low-score tumours and quality of life. An integrated qualitative recruitment study addresses challenges to consent and recruitment and will build on experience from the feasibility study that a multidisciplinary approach at sites is important for recruitment success. Tumour blocks will be banked to allow evaluation of additional MPA technologies. Recruitment of 4500 patients over 5 years will permit demonstration of 3% non-inferiority of test-directed treatment, assuming 5-year IDFS of 85% with standard management, equivalent to a HR of 1.22. Inclusion of patients from the feasibility study will increase the power to test for non-inferiority.

Results: The OPTIMA main trial opened in January 2017. Overall recruitment (including the feasibility study) will reach 1000 in August 2018. Recruitment in Norway will commence in July 2018. Characteristics of the OPTIMA main participants recruited to 31st May 2018 are shown in the table.

Main study patient characteristicsCharacteristic %Median age in years (range)57 (40-80) Menopause statusPre34 Post66 Male1Tumour size&lt;30mm58 &gt;=30mm42Node statuspN04 pN1mi(sn)7 pN1(sn)20 pN155 pN214Historic grade16 258 336

Conclusion: OPTIMA is one of two large scale prospective trials validating the use of test-guided chemotherapy decisions in node-positive early breast cancer. It is expected to have a global impact on breast cancer treatment. Experience from the preliminary study and close engagement with centres will aid trial success.

Funding: OPTIMA is funded by the UK NIHR HTA Programme (10/34/501). Views expressed are those of the authors and not those of the HTA Programme, NIHR, NHS or the DoH.

Citation Format: Stein RC, Hughes-Davies L, Makris A, Macpherson IR, Conefrey C, Rooshenas L, Pinder SE, Thomas J, Hall PS, Cameron DA, Earl HM, Naume B, Poole CJ, Rea DW, MacIntosh SA, Harmer V, Morgan A, Hulme C, McCabe C, Stallard N, Higgins H, Donovan JL, Bartlett JM, Marshall A, Dunn JA. OPTIMA: A prospective randomized trial to validate the clinical utility and cost-effectiveness of gene expression test-directed chemotherapy decisions in high clinical risk early breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr OT1-05-02.

Incidence and risk factors for alopecia in survivors of critical illness: A multi-centre observational study

PURPOSE

To investigate the incidence, nature and risk factors for patient-reported alopecia in survivors of critical illness.

MATERIALS AND METHODS

A multi-centre, mixed methods observational study in the intensive care units (ICU) of ten hospitals in Wales. All patients with an ICU stay of 5 days or more, able to give consent were included. Demographic variables and risk factors were collected. A pre-designed survey was completed at three months post-ICU discharge. Statistical analysis included numbers and percentages (categorical variables) and medians and interquartile ranges (continuous variables). Comparisons between patients with and without alopecia were made using Fisher's Exact test (categorical variables) and Mann Whitney U test (continuous variables). Multivariate logistic regression analysis was used to determine the risk factors for alopecia.

RESULTS

The survey was completed by 123 patients with alopecia reported in 44 (36%) patients. The only risk factor for alopecia on analysis was sepsis / septic shock (p < .001; OR: 5.1, 95%CI: 2.1-12.4).

CONCLUSIONS

Limited research exists examining the incidence, nature and risk factors for patient-reported alopecia in adult survivors of critical illness. The results of this study highlight the need to discuss the potential for alopecia with survivors of critical illness, who had sepsis / septic shock.