A Repurposing Programme Evaluating Transdermal Oestradiol Patches for the Treatment of Prostate Cancer Within the PATCH and STAMPEDE Trials: Current Results and Adapting Trial Design

AIMS

Androgen deprivation therapy (ADT), usually achieved with luteinising hormone releasing hormone analogues (LHRHa), is central to prostate cancer management. LHRHa reduce both testosterone and oestrogen and are associated with significant long-term toxicity. Previous use of oral oestrogens as ADT was curtailed because of cardiovascular toxicity. Transdermal oestrogen (tE2) patches are a potential alternative ADT, supressing testosterone without the associated oestrogen-depletion toxicities (osteoporosis, hot flushes, metabolic abnormalities) and avoiding cardiovascular toxicity, and we here describe their evaluation in men with prostate cancer.

MATERIALS AND METHODS

The PATCH (NCT00303784) adaptive trials programme (incorporating recruitment through the STAMPEDE [NCT00268476] platform) is evaluating the safety and efficacy of tE2 patches as ADT for men with prostate cancer. An initial randomised (LHRHa versus tE2) phase II study (n = 251) with cardiovascular toxicity as the primary outcome measure has expanded into a phase III evaluation. Those with locally advanced (M0) or metastatic (M1) prostate cancer are eligible. To reflect changes in both management and prognosis, the PATCH programme is now evaluating these cohorts separately.

RESULTS

Recruitment is complete, with 1362 and 1128 in the M0 and M1 cohorts, respectively. Rates of androgen suppression with tE2 were equivalent to LHRHa, with improved metabolic parameters, quality of life and bone health indices (mean absolute change in lumbar spine bone mineral density of -3.0% for LHRHa and +7.9% for tE2 with an estimated difference between arms of 9.3% (95% confidence interval 5.3-13.4). Importantly, rates of cardiovascular events were not significantly different between the two arms and the time to first cardiovascular event did not differ between treatment groups (hazard ratio 1.11, 95% confidence interval 0.80-1.53; P = 0.54). Oncological outcomes are awaited.

FUTURE

Efficacy results for the M0 cohort (primary outcome measure metastases-free survival) are expected in the final quarter of 2023. For M1 patients (primary outcome measure - overall survival), analysis using restricted mean survival time is being explored. Allied translational work on longitudinal samples is underway.

Quality care close to home: Objectives and early outcomes of a second paediatric heart transplant service in Australia

AIM

We describe the experience of a new paediatric heart transplant (HT) centre in Australia. New South Wales offers quaternary paediatric cardiac services including comprehensive care pre- and post-HT; however, perioperative HT care has previously occurred at the national paediatric centre or in adult centres. Internationally, perioperative HT care is highly protocol-driven and a majority of HT occurs in low volume centres. Establishing a low volume paediatric HT centre in New South Wales offers potential for quality HT care close to home.

METHODS

Retrospective review of programme data for the first 12 months was undertaken. Patient selection was audited against the programme's intended initiation criteria. Longitudinal patient data on outcomes and complications were obtained from patient medical records.

RESULTS

The programme's initial phase offered HT to children with non-congenital heart disease and no requirement for durable mechanical circulatory support. Eight patients met criteria for HT referral. Three underwent interstate transfer to the national paediatric centre. Five children (13-15 years, weight 36-85 kg) underwent HT in the new programme. Individual predicted 90-day mortality was 1.3-11.6%, with increased risk for recipients transplanted from veno-arterial extracorporeal membrane oxygenation (VA-ECMO) and with restrictive/hypertrophic cardiomyopathies. Survival at 90 days and for duration of follow-up is 100%. Observed programme benefits include mitigation of family dislocation and improved continuity of care within a family-centred programme.

CONCLUSION

Audit of the first 12 months' activity of a second paediatric HT centre in Australia demonstrates adherence to proposed patient selection criteria and excellent 90-day patient outcomes. The programme demonstrates feasibility of care close to home, providing continuity for all patients including those requiring increased rehabilitation and psychosocial support post-transplantation.

A39 HEALTHY FIRST-DEGREE RELATIVES FROM MULTIPLEX FAMILIES VERSUS SIMPLEX HARBOR A HIGHER RISK OF DEVELOPING CROHN'S DISEASE AND ARE ASSOCIATED WITH SUBCLINICAL INFLAMMATION AND ALTERED MICROBIOME COMPOSITION

Background

Healthy individuals within families with multiple affected members (multiplex families) with Crohn’s disease (CD) have a notably high risk of developing CD. No large prospective pre-disease cohort has assessed differences in preclinical intestinal inflammation, permeability, fecal microbiome, and genetics in healthy at-risk subjects from multiplex families.

Purpose

We aimed to assess differences in subclinical gut inflammation, genetic risk, gut barrier function, and fecal microbiota composition between first-degree relatives (FDRs) from families with 2 or more affected members (multiplex) and families with only one affected member (simplex). Also, we aimed to assess the risk of future CD onset in subjects from multiplex versus simplex families.

Method

We utilized the GEM Project cohort of healthy FDRs of CD patients. Subclinical gut inflammation was assessed using fecal calprotectin (FCP) at recruitment. Gut barrier function was assessed using the lactulose-to-mannitol ratio (LMR). For assessment of the CD-related genetic risk, CD-polygenic risk scores (CD-PRS) were calculated. Microbiome composition was assessed by sequencing fecal 16S ribosomal RNA. Generalized estimating equations logistic regression and LEfSe (PMID: 21702898) were used to assess the associations between multiplex status and different outcomes. A Cox proportional hazards model was used to assess time-related risk of future onset of CD.

Result(s)

4385 subjects were included. Median age was 17 [IQR 12-24] years, 52.9% were female, 69.4% were siblings and 30.6% were offspring. 4052 (92.4%) and 333 (7.6 %) were simplex and multiplex subjects, respectively. After adjusting for age, sex, family size, and relation to proband, multiplex status was significantly associated with higher baseline FCP (p=0.038), but was not associated with either baseline LMR or CD-PRS (p=0.19 and p=0.33, respectively).

We found no significant differences in alpha diversity (Shannon index) (p=0.57) between simplex and multiplex subjects. Beta diversity analysis assessed by the Bray-Curtis dissimilarity index did not reveal significant differences (R2=3e-04, p=0.607). The genera Eisenbergiella, Eggerthellaceae uncultured, and Morganella, were significantly more abundant in multiplex subjects, whereas Lachnospira, Sutterella, Lachnospiraceae_NK4A136_group, and Lachnospiraceae_UCG_004 less abundant.

The risk of CD onset was significantly higher in multiplex subjects. In multivariable analysis, multiplex status at recruitment was associated with increased risk of CD onset (adjusted HR 3.41, 95% CI 1.70-6.87, p=0.00055), after adjusting for demographics, FCP, LMR, and CD-PRS.

Conclusion(s)

Multiplex status compared to simplex is associated with a 3.4-fold increased risk of CD onset, a higher FCP, and fecal bacterial composition. A comprehensive assessment of environmental factors that increase CD risk in multiplex families remains to be elucidated in future studies.

Disclosure of Interest

None Declared

A267 IDENTIFYING ENTEROBACTERIACEAE VIRULENCE GENES ASSOCIATED WITH ACTIVE DISEASE IN ULCERATIVE COLITIS PATIENTS USING CULTURE-DEPENDENT AND -INDEPENDENT APPROACHES

Background

The prevalence of inflammatory bowel disease (IBD) in Canada is among the highest in the world and is estimated to affect 1 in 100 Canadians by 2030. Ulcerative colitis (UC) is a type of IBD characterized by mucosal inflammation of the large intestine. UC is believed to arise through a complex interplay of the host immune responses and changes in the gut microbiota in a genetically susceptible individual. Therapies targeting the gut microbiota, such as antibiotics and fecal microbiota transplantation (FMT), have been effective in treating UC, suggesting infectious triggers should be explored.

Purpose

Some data suggests the development of UC can be driven by pathogenic bacteria of the family Enterobacteriaceae, which can carry virulence genes important for colonizing the gut (e.g. fimH) and disrupting the intestinal epithelium (e.g. hylA). However, many studies have focused on a single species (e.g. Escherichia coli) and thereby underestimate the importance of these virulence genes that are shared across the Enterobacteriaceae family. I aim to investigate whether specific virulence genes contribute to disease activity in some patients with UC and to show that these virulence genes are carried by strains of many Enterobacteriaceae species.

Method

UC patient stool samples were collected throughout enrolment in randomized control trials of FMT for adult UC and microbiome studies in early-onset pediatric UC. The stool samples were cultured on MacConkey agar to enrich for Enterobacteriaceae. Samples from before and after treatment were sent for targetted cultured-enriched metagenomic sequencing and strains were isolated from baseline samples only for whole genome sequencing. The taxonomy of each genome and taxonomic composition of each metagenome were annotated along with virulence genes and antimicrobial resistance genes. Phenotypic assays of cultured isolates were used to capture diversity and virulence activity.

Result(s)

Approximately 7500 colonies from UC patient stool samples were isolated and phenotyped. Based on the initial screens, 130 isolates were selected to comprise our Enterobacteriaceae strain collection. Across all patient samples, we detected 19 different species of the Enterobacteriaceae family across six genera from the genomic and metagenomic data. We identified virulence genes found across multiple species from the Enterobacteriaceae family within genomes and metagenomes, and by performing phenotypic assays of the cultured isolates.

Conclusion(s)

Further exploration of the distribution of these virulence genes in UC patients during active disease or remission and healthy controls can provide insight into the pathogenesis of UC. Identifying infectious agents in even a subset of UC patients will allow for more targeted diagnosis and treatment approaches.

Disclosure of Interest

None Declared

Developing and testing a case-management intervention to support the return to work of health care workers with common mental health disorders

BACKGROUND

To assess the feasibility and acceptability of conducting a trial of the clinical effectiveness and cost-effectiveness of a new case-management intervention to facilitate the return to work of health care workers, on sick leave, having a common mental disorder (CMD).

METHODS

A mixed methods feasibility study.

RESULTS

Systematic review examined 40 articles and 2 guidelines. Forty-nine National Health Service Occupational Health (OH) providers completed a usual care survey. We trained six OH nurses as case managers and established six recruitment sites. Forty-two out of 1938 staff on sick leave with a CMD were screened for eligibility, and 24 participants were recruited. Out of them, 94% were female. Eleven participants received the intervention and 13 received usual care. Engagement with most intervention components was excellent. Return-to-work self-efficacy improved more in the intervention group than in the usual care group. Qualitative feedback showed the intervention was acceptable.

CONCLUSIONS

The intervention was acceptable, feasible and low cost to deliver, but it was not considered feasible to recommend a large-scale effectiveness trial unless an effective method could be devised to improve the early OH referral of staff sick with CMD. Alternatively, the intervention could be trialled as a new stand-alone OH intervention initiated at the time of usual OH referral.

A176 UTILITY OF MACHINE LEARNING FOR SERUM METABOLOMIC DATA ANALYSIS IN PEDIATRIC CROHN DISEASE

Background

The pathogenesis of pCD remains poorly understood, but evidence suggests roles for genetics, environment, immune response, and gut microbes. Microbial changes can contribute to chronic inflammation and correlate with disease severity. Metabolomics reflects interactions between host immune and gut microbial function by quantifying compounds in biological samples. Therefore, metabolomics provides a unique opportunity to gain insight into pCD pathogenesis.

Aims

To correlate disease severity, metabolites, and clinical data by applying machine learning algorithms in pediatric Crohn Disease (pCD).

Methods

ImageKids is a multicenter, prospective, cohort observational study, conducted to develop magnetic resonance enterography (MRE) indices for pCD. Paired serum specimens were collected at study initiation (Visit One; V1) and completion (Visit Four; V4; 18 months) for 120 pCD patients. Serum from patients with representative clinical scenarios and paired samples was analyzed at The Metabolomics Innovation Centre (TMIC; University of Alberta) and 131 metabolites were identified. Metabolites were analyzed via Unsupervised (U.ML) and Supervised (S.ML) Machine Learning algorithms based on Scikit-learn library in Python. Principal Component Analysis (PCA) was used to identify the variation pattern of the patients’ metabolome. Classifiers and regression algorithms were trained to assess correlation with disease activity.

Results

Results were available for the 56 paired samples. U.ML demonstrated distinct metabolome profiles with V1 clustering mainly attributed to aspartic acid, glutamic acid, and kynurenine. V4 clustering was mainly attributed to spermidine, spermine, total dimethylarginine. Furthermore, demographics was found as an important environmental factor driving distinct patterns of the metabolomics profile.

After training different classifiers and regressors with S. ML algorithms, metabolome data were correlated with disease severity (defined by C-reactive protein and fecal calprotectin). Isoleucine, p-hydroxyhippuric acid, and putrescine were the top three compounds associated with disease severity. The accuracy of our classification models was of 80% and the coefficient of determination of our regression models was 0.5

Conclusions

Metabolomic analysis can provide insight into disease pathogenesis and help predict disease severity among pCD patients. The correlation between metabolomics and disease severity might allow a better understanding of changes in host-microbe interactions and introduce new diagnostic or therapeutic options.

Funding Agencies

CIHR

A23 ESTIMATING INDIRECT AND OUT-OF-POCKET COSTS IN PEDIATRIC INFLAMMATORY BOWEL DISEASE: A NATION-WIDE CROSS-SECTIONAL ANALYSIS

Background

Identifying disease-related costs is a crucial step to plan for proper allocation of resources and future healthcare services for persons with inflammatory bowel disease (IBD). Data on pediatric inflammatory bowel disease-associated costs are limited.

Aims

We aimed to estimate indirect and out of pocket (OOP) pediatric IBD-associated costs in Canada.

Methods

In a nation-wide cross-sectional analysis, caregivers of children and young adults (<17 years) with IBD were invited to complete a questionnaire on lost work hours and OOP costs related to IBD in the 4 weeks prior to the survey. Participants were re-invited to periodically answer the same questionnaire every 3–9 months for 2 years. Lost productivity was calculated using the Human Capital method. Costs were reported in 2018 inflation-adjusted Canadian dollars. Predictors of high cost users (top 25%) were examined using negative binomial regression.

Results

Consecutive 243 (82 incident cases) of 262 (92.7%) approached participants completed the first survey with a total of 450 surveys longitudinally completed over 2 years. The annual median indirect costs per patient were $5,951 (IQR $1,812- $12,278), with $5,776 (IQR $1,465-$11,733) for Crohn’s disease (CD) and $6,084 (IQR $2,470-$13,371) for ulcerative colitis (UC) (p=0.77). The annual median per patient OOP costs were $2,925 (IQR $978- $8,125) with $3,021 (IQR $978- $8,125) for CD and $2,600 (IQR $975- $8,125) for UC (p=0.55). Older age (10-17y) at diagnosis (p=0.04) and parents in part-time employment (p=0.01) were predictors of higher indirect costs, while female sex (p<0.001), parents with a lower education level (p<0.001) and lower annual family income (p<0.01) were associated with higher OOP costs.

Conclusions

Indirect and OOP IBD-associated costs are substantial and more likely to affect families with unstable employment and lower annual income. Examining different strategies and interventions to reduce these costs such as virtual platforms, telephone and outreach clinics especially in poor communities and families with low annual income is warranted.

Funding Agencies

CIHRThe Children’s Hospital Research Institute of Manitoba

A238 ALTERED GUT MICROBIOME COMPOSITION AND FUNCTION ARE ASSOCIATED WITH GUT BARRIER DYSFUNCTION IN HEALTHY RELATIVES OF CROHN’S DISEASE PATIENTS

Background

The gut microbiome may play a role in gut barrier homeostasis including epithelial barrier function, but data are scarce and limited to animal studies

Aims

To assess if alterations in gut microbiome are associated with gut barrier function

Methods

We utilized the Genetic Environmental Microbial (CCC GEM) cohort of healthy first-degree relatives (FDRs) of Crohn’s disease (CD) patients. Gut barrier function was assessed using the ratio of urinary fractional excretion of lactulose to mannitol (LMR). Stool bacterial DNA was extracted and sequenced for the V4 hypervariable region of the 16S rRNA gene using MiSeq and processed using QIIME2. Microbial functions were imputed using PICRUSt2. The cohort was divided into a North American discovery cohort (n=2,472) and non-North American external validation cohort (n=655). LMR>0.025 was defined as abnormal. LMR-microbiome associations were assessed using multivariable regression model and Random Forest (RF) classifier algorithm. q<0.05 was considered significant when multiple tests were performed

Results

The median age of the entire cohort was 17.0 years [IQR 12.0; 24.0], 52.6% were females and 25.4% had LMR>0.025. In the discovery cohort, subjects with LMR>0.025 had markedly reduced alpha diversity (Chao1 index, estimate= -0.0037, p=4.0e-04) and altered beta diversity (Bray-Curtis dissimilarity index, PERMANOVA: pseudo-F statistic = 2.99, p=1.0e-03). We identified eight bacterial genera and 52 microbial pathways associated with LMR>0.025 (q<0.05). Four genera (decreased Adlercreutzia [odds ratio(OR)=0.74, 95% confidence interval (CI) 0.6–0.91], Clostridia-UCG-014 [OR=0.71, 95%CI 0.59–0.86], and Clostridium-sensu-stricto-1 [OR=0.75, 95%CI 0.61–0.92] and increased Colidextribacter [OR=1.65, 95%CI 1.2–2.26]) and eight pathways (including decreased biosynthesis of glutamate [OR=0.4, 95%CI 0.21–0.74], tryptophan [OR=0.06, 95%CI 0.01–0.27] and threonine [OR=0.038, 95%CI 0.003–0.41]) were replicated. Bacterial community composition was associated with gut barrier homeostasis as defined by the RF analysis (p= 1.4e-6)

Conclusions

Gut microbiome community and pathways are associated with gut barrier function. These findings may identify potential microbial targets to modulate barrier function

Submitted on behalf of the CCC-GEM Consortium

Funding Agencies

CCC, CIHRCrohn’s and Colitis Canada Genetics Environment Microbial (CCC-GEM) III; The Leona M. and Harry B. Helmsley Charitable Trust; Kenneth Croitoru is the recipient of the Canada Research Chair in Inflammatory Bowel Diseases

A42 HETEROGENEITY IN EFFICACY AND SAFETY ENDPOINTS FOR PEDIATRIC CLINICAL TRIALS IN INFLAMMATORY BOWEL DISEASE: A NEED FOR HARMONIZATION

NOT PUBLISHED AT AUTHOR’S REQUEST

Funding Agencies: None

A157 DEFINITIONS OF MEDITERRANEAN DIET INCONSISTENTLY ASSOCIATE WITH MARKERS OF GUT BARRIER FUNCTION OR SUBCLINICAL INFLAMMATION IN A POPULATION-BASED COHORT

Background

The Mediterranean Diet (MD) is proposed to reduce the risk of Crohn’s disease (CD) onset in cohort studies, with inconsistent results. This inconsistency may be due to heterogeneity in defining MD scores. Additionally, relationships between MD compliance and intestinal permeability or sub-clinical inflammation are not defined.

Aims

We examined correlations between different MD scores, and determined associations between MD compliance and intestinal permeability or subclinical inflammation in a cohort of first degree relatives of CD patients.

Methods

We used food frequency questionnaire data from 2,112 subjects of the Crohn’s Colitis Canada- Genes, Environment, Microbial (CCC-GEM) project. We obtained 12 MD definitions from the literature and calculated daily percent compliance, we further compared MD scores via pairwise correlations (Kendall’s Tau). We measured intestinal permeability via urinary fractional excretion ratio of lactulose to mannitol (LMR) (LMR≥0.03 defined abnormal), and subclinical inflammation via fecal calprotectin (FCP) measured with BÜHLMANN fCAL® ELISA (FCP≥250 defined abnormal). We fit multivariable regression models between MD compliance and abnormal LMR and FCP, respectively. Two-sided p&lt;0.05 defined significance.

Results

There was large variation in cross-correlations among MD scores, from nil (t=0.0, p=0.54) to highly significant (t=0.97, p&lt;2.2e-16). Associations of MD compliance and abnormal LMR or FCP were in both directions of effect, largely non-significant. Of the 12 MD scores, none associated with abnormal LMR, while 4 associated with abnormal FCP-Odds Ratios =1.22, 1.23, 1.24, and 1.30; p=0.02, 0.02, 0.01, and 0.009, and 95% Confidence Intervals = [1.03,1.45], [1.04,1.45], [1.05,1.47], and [1.07,1.59] respectively. No diet remained significant after correcting for multiple testing.

Conclusions

Currently MD definitions vary widely. Despite discrepancies, we expected consistent directions of effect for MD compliance on LMR or FCP. The largely non-significant associations between MDs suggest limitations in definition, interpretation, and relation to biological outcomes.

Submitted on behalf of the CCC-GEM consortium.

Funding Agencies

CIHRCrohn’s and Colitis Canada Genetics Environment Microbial (CCC-GEM) III;The Leona M. and Harry B. Helmsley Charitable Trust; Justine Timpano is a recipient of a fellowship award from Mount Sinai Hospital; Kenneth Croitoru is the recipient of the Canada Research Chair in Inflammatory Bowel Diseases

A236 ASSOCIATION OF STOOL METABOLOMIC PROFILE AND MICROBIOME COMPOSITION RISK SCORE WITH FUTURE ONSET OF CROHN’S DISEASE

Background

Microbial composition-based risk score (MRS) was recently developed and validated to predict future risk of developing Crohn’s disease (CD) among healthy first-degree relatives (FDR) of CD patients. We hypothesized that stool metabolomic profiles, some of which are linked to the gut microbiome, are associated with future risk of CD.

Aims

To assess the association of stool metabolomic profile with onset of CD and to determine the correlation between stool metabolites and the MRS

Methods

Healthy FDR of CD patients were recruited as part of the nested case-control cohort of the CCC-GEM Project. Healthy FDRs who later developed CD (n=56) were matched approximately 1:1 by age, sex, follow-up duration, and geographical location with control FDRs remaining healthy (n=66). Stool metabolomics were assessed using the Metabolon’s DiscoveryHD4™ platform, and the stool microbiome characterised by 16s rDNA amplicon sequencing. We fitted a multivariable conditional logistic regression model on the disease status as a function of individual stool metabolites. We additionally performed Spearman correlation between each stool metabolite and the MRS.

Results

Among 1,029 stool metabolites that were analyzed, 79 were associated with future risk of CD (p&lt;0.05); however, none remained significant after multiple testing correction (FDR correction). Considering the exploratory nature of this study with limited sample size, we focused on the top seven metabolites associated with CD onset (p&lt;0.01). Of these, two stool metabolites (dimethylglycine, methylmyristate) were associated with increased risk of CD onset while five (cytosine, guanine, cytidine, hydroxyglutarate, nervonate) were associated with decreased risk of developing CD. The two metabolites positively associated with CD onset were positively correlated with the MRS, while the five metabolites negatively associated with CD onset, were negatively correlated with the MRS. Meanwhile, 24 stool metabolites had significant correlation with MRS (FDR-corrected p&lt;0.2). Among those, a total of four stool metabolites (cytosine, guanine, methymyristate, cytidine) overlapped with the top seven stool metabolites associated with CD onset.

Conclusions

Stool metabolite profiles may predict future risk of CD. A subset of these metabolites have significant correlation with the MRS with consistent direction of effect. This may suggest that stool metabolites mediate the putative effect of the gut microbiome on CD risk. Further validation in the full GEM cohort is warranted.

Funding Agencies

CCC, CIHRThe Leona M. and Harry B. Helmsley Charitable Trust; Kenneth Croitoru is the recipient of the Canada Research Chair in Inflammatory Bowel Diseases; Sun-Ho Lee is a recipient of the Imagine/ CIHR/CAG Fellowship Award; Sun-Ho Lee, Juan Antonio Raygoza Garay, and Williams Turpin are recipients of fellowship awards from the Department of Medicine, Mount Sinai Hospital, Toronto, Canada.

Highly efficient and selective aqueous phase hydrogenation of aryl ketones, aldehydes, furfural and levulinic acid and its ethyl ester catalyzed by phosphine oxide-decorated polymer immobilized ionic liquid-stabilized ruthenium nanoparticles

Phosphine oxide-decorated polymer immobilized ionic liquid stabilized RuNPs catalyse the hydrogenation of aryl ketones with remarkable selectivity for the CO bond, complete hydrogenation to the cyclohexylalcohol and hydrogenation of levulinic acid to γ-valerolactone.

Retrieval of neonatal and paediatric patients on extracorporeal membrane oxygenation support in New South Wales, Australia

New South Wales has recently added the capability of extracorporeal membrane oxygenation to the neonatal and paediatric retrieval process and this paper describes the early experiences and protocol development for the first eight cases transported.

Evidence-based orthopaedic trauma care in the United Kingdom: Guidelines, registries, carrots and sticks

In the United Kingdom (UK), orthopaedic trauma surgeons utilise evidence-based practice through distillation of high-quality primary research, interrogation of registries and implementation of evidence-based guidelines. Concurrent with this ambition of providing exemplar care based on robust patient centred research, there has evolved a culture of remuneration 'by results'. Therefore, there is a drive for excellence combined with a system of collation and validation of data input as well as remuneration where care excels. There are several organisations involved in each stage of this process, the output of which has much that is pertinent to the globally similar consequences of physical injury. However, their relevance and impact within the UK is magnified as they are written against the backdrop of a unified healthcare system. In this article, we will describe the roles of the different organisations guiding and regulating trauma practice across the UK and discuss how the interplay of these impacts on clinical care.

A178 USTEKINUMAB FOLLOWING PRIMARY ANTI-TNF FAILURE AND SECONDARY LOSS OF RESPONSE TO VEDOLIZUMAB IN AN ADOLESCENT WITH ULCERATIVE PANCOLITIS

Background

Infliximab is, to date, the only biologic therapy approved for the treatment of ulcerative colitis (UC) in paediatric patients. Although often effective, primary mechanistic failure is more common in UC than in luminal inflammatory paediatric Crohn’s disease (CD). Alternate pathway biologics, specifically vedolizumab (anti-α4β7 integrin) and ustekinumab (anti-interleukins 12/23) are increasingly used in adults with UC. Emerging data from head to head trials of biologics and network meta-analyses of placebo-controlled trial data are being used to guide choice and sequencing of therapeutic agents. Even among adults with UC data concerning combination biologics are very limited.

Aims

To report the outcomes of addition of ustekinumab to vedolizumab in a patient with steroid dependent colitis, previous primary non-response to infliximab and secondary loss of response to vedolizumab monotherapy.

Methods

Case report

Results

A 17 years old girl was hospitalized with acute severe colitis (PUCAI 85) developing as oral prednisone was tapered below 30 mg daily despite ongoing intensified vedolizumab therapy (300 mg q4 weekly) and per rectal steroids. First presentation 2 years earlier with UC pancolitis, responsive to oral prednisone, maintained on oral 5-ASA until first exacerbation 8 months later. Responsive then to IV steroids, but unable to maintain steroid-free remission despite intensified infliximab with therapeutic levels. Vedolizumab initiated in setting of primary mechanistic anti-TNF failure. Steroid-free clinical remission for 7 months of q 8 weekly dosing with normalization of fecal calprotectin (16, 115 µg/g) when symptoms recurred and persisted despite shortening of vedolizumab dosing interval to 4 weeks. Vedolizumab level 34 µg/mL. Symptomatic response to oral prednisone 40 mg, but unsustained with tapering. Hospitalized with up to 10 bloody stools per day, nocturnal stools, abdominal pain and anemia requiring blood transfusion. High doses of IV steroids were given with slow response. Colectomy refused by family. IV ustekinumab 390 mg given. Vedolizumab continued q 8 weekly in view of prior responsiveness. Ustekinumab subcutaneous maintenance therapy initiated at week 8 and continuing q 4 weekly (levels 3.3 mg/L). Oral prednisone tapered and discontinued. At 5 months post ustekinumab initiation, patient is in steroid-free clinical remission (PUCAI 0). Fecal calprotectin has declined from &gt;1800 to 723 µg/g.

Conclusions

In this patient with UC and primary failure of anti-TNF, ustekinumab has demonstrated short-term efficacy in alleviating steroid-dependency. The contribution of continued vedolizumab, to which there had previously been secondary loss of response, is unknown. Nevertheless, the safety profile of vedolizumab allows it to be combined with other therapies in selected treatment-refractory patients.

Funding Agencies

None

Nurses' illness perceptions during presenteeism and absenteeism

BACKGROUND

Presenteeism has been linked with lost productivity, impaired health and absence. Whilst much research has focused on types of diseases associated with presenteeism and absenteeism, there has been little investigation into the role of individuals' illness perceptions in these episodes.

AIMS

To assess how illness perceptions vary between presenteeism and absenteeism episodes.

METHODS

A cross-sectional questionnaire was distributed to ward-based nurses working with older adults. Data on illness perceptions during presenteeism and absenteeism episodes were collected. Data were analysed via the Paired-Samples t-test, Wilcoxon test and McNemar test.

RESULTS

Two hundred and seventy cases were analysed (88% response rate). Compared with presenteeism, illnesses during absenteeism were thought to affect lives more (P < 0.001), to have more serious symptoms (P < 0.001), to be more concerning (P = 0.003), more likely to be treated (P = 0.009), more infectious (P < 0.001) and perceived as more legitimate reasons for absenteeism (P < 0.001). Treatment was considered more effective during absenteeism (P < 0.001), whilst workability was better during presenteeism (P < 0.001). Presenteeism was perceived as harmful and absenteeism beneficial for illness. Individuals attended work when presenteeism was expected to be less harmful (P < 0.001) and avoided work when absenteeism was expected to be more beneficial for illness (P < 0.001).

CONCLUSIONS

Illness perceptions varied significantly between presenteeism and absenteeism episodes and should be included in models of illness behaviour. Findings also highlight that policy may influence illness behaviour and that nurses may attend work despite concerning levels of illness.

A26 PEDIATRIC-ONSET INFLAMMATORY BOWEL DISEASE INCREASES THE RISK OF VENOUS THROMBOEMBOLISM: A CANGIEC POPULATION-BASED STUDY

Background

Inflammatory bowel disease (IBD) increases the risk of venous thromboembolism (VTE) in patients of all ages but the risk of VTE among Canadian children with IBD has not previously been investigated.

Aims

Report the incidence of VTE and subtypes pulmonary embolism (PE) and deep vein thrombosis (DVT) in children with and without IBD.

Methods

Children diagnosed with IBD &lt;16y were identified from health administrative data in Ontario (2002–2014), Alberta (2007–2015), and Nova Scotia (2002–2012) using validated algorithms and matched by age and sex to children without IBD (1:5 ratio). Validated ICD-10 codes identified hospitalizations for incident VTE (DVT, PE, and sinovenous thrombosis). Province-specific 5-year cumulative incidence per 1000 person-years (PY) of VTEs were pooled using fixed-effects generalized linear mixed models with a Freeman-Tukey double arcsine transformation. Incidence rate ratios (IRR) within 5 years of diagnosis were pooled using fixed-effects generalized linear mixed models to compare children with and without IBD, and children with Crohn’s disease (CD) and ulcerative colitis (UC).

Results

3127 children with IBD (1826 CD; 1045 UC) were matched to 15,635 children without IBD. The cumulative incidence of VTE within 5 years of IBD diagnosis was 2.8 (95% CI 2.1–3.8) per 1000 PYs compared to 0.13 (95% CI 0.07–0.24) per 1000 PYs in children without IBD (Table). The 5-year cumulative incidences of VTE, DVT, and PE were significantly higher in children with IBD than in children without IBD (VTE: IRR 21.44, 95% CI 10.73–42.82; DVT: IRR 25.15, 95% CI 11.12–56.89; PE: IRR 4.01, 95% CI 1.22–13.18). Compared to UC patients, children with CD were at lower risk of VTE (IRR 0.53, 95% CI 0.29–0.96) and numerically, but not statistically, lower risk of DVT (IRR 0.59, 95% CI 0.30–1.14).

Conclusions

Although VTEs are relatively rare among children with IBD, these children are at much greater risk than children without IBD. Gastroenterologists caring for these patients should be cognizant of VTE risk and provide appropriate prophylaxis to those at high risk of VTE.

Funding Agencies

CCC

A228 EVOLUTION OF MRE FINDINGS IN PAEDIATRIC PATIENTS WITH SMALL BOWEL CROHN’S DISEASE ON MAINTENANCE METHOTREXATE

Background

Observational data in children and RCT data in adults indicate that methotrexate (MTX) is associated with induction and maintenance of clinical remission in luminal Crohn’s disease, but efficacy in achieving intestinal healing has not been examined.

Aims

To examine the evolution of MRE signs of inflammation in children treated with MTX.

Methods

In this retrospective cohort study, we reviewed paediatric CD patients on maintenance MTX monotherapy for &gt;4 months who underwent serial MREs between July 2010 and October 2015. MREs were reviewed by a radiologist blind to clinical data. Overall inflammatory activity on each MRE was scored as minimal, mild, moderate or severe, informed by the presence of bowel wall thickness, wall enhancement, T2 hyperintensity, comb sign, mesenteric edema, penetrating disease, stricturing, diffusion restriction and motility. The radiologist’s global assessment of change from MRE 1 to MRE 2 was scored as improved, unchanged or worsened. Clinical findings, disease activity (assessed by weighted paediatric CD activity index [wPCDAI]) and surgical history were also extracted from medical records by a clinician blind to MRE results.

Results

Thirty-five patients were included (median age at diagnosis 12 [IQR 11–14] years; 77% male; 60% inflammatory (B1), 17% stricturing (B2), 23% penetrating (B3) disease). Between baseline and follow-up MRE, wPCDAI (median 15 [IQR 7–43] decreased to 8 [IQR 0–18]; p=0.006) and CRP (median 9 [IQR 2–36] decreased to 5 [IQR 5–9]; p=0.013) and 74% (N=26) were in clinical remission (wPCDAI &lt; 12.5) at MRE 2. MRE features that significantly improved from MRE 1 to 2 were comb sign from 63% (N=37) to 38% (N=14) (p=0.02) and penetrating disease from 14% (N=8) to 0 (p=0.03). After a median of 17 months (IQR 13–23), 51% (N=18) of patients improved, 29% (N=10) worsened and 20% (N=7) had no change based on the radiologist’s global assessment. Of the 21 patients with moderate/severe disease at MRE 1, 33% (N=7) had minimal/mild disease by MRE 2. 66% (N=14/21) continued to have moderate/severe disease at MRE 2. Additionally, a further 14% (N=2/14) of those with minimal/mild disease at baseline MRE progressed to moderate/severe disease at MRE 2. Complete details of change between MRE 1 and MRE 2 are displayed in Figure 1.

Conclusions

Despite signs of clinical improvement, many paediatric CD patients on maintenance MTX therapy for &gt;4 months have unchanged or worsened MRE findings. This underscores the need for follow-up imaging in these cases.

Funding Agencies

None

Menopause and work: an overview of UK guidance

Background

Recent evidence suggests that some women experience menopausal symptoms that impact on their working lives, and that work environments can impact upon the experience of menopause. As a result, guidance for employers and other key stakeholders about this potential occupational health issue has emerged. To date there has not been a review of these documents to identify their main recommendations for policy and practice.

Aims

To provide a narrative overview of such guidance and summary of content.

Methods

Documents published in the UK and available in a major UK trade union library were searched systematically to identify guidance on the topic of menopause and work. An inductive thematic analysis was performed to identify the main themes addressed.

Results

Twenty-five relevant documents, on average eight pages long, were identified. A minority indicated that the use of scientific evidence informed the content. Five overarching themes were identified: (i) legislation; (ii) policy; (iii) information and training needs; (iv) workplace support; and (v) the physical work environment.

Conclusions

This overview of UK guidance revealed common areas of concern about reducing and managing difficulties experienced by working menopausal women. Possible areas for action were identified. Some recommendations were common across much of the guidance, whereas others were exclusive. Future guidance might include consideration of all these issues, while making reference both to the evidence base and sources of further information.

Managing employees with dementia: a systematic review

BACKGROUND

The experience of developing dementia while in employment has been explored from the point of view of the employee, but less is known about the perspectives, experiences and needs of employers.

AIMS

To review systematically literature about the management of employees who develop dementia whilst in employment.

METHODS

Databases searched included MEDLINE, EMBASE, PsycINFO, CINAHL, BNI, ABI Inform, ISI Web of Science, Open Grey and dementia journals database; 44 documents were identified for inclusion in the review: 22 journal papers, one PhD thesis and 21 articles, reports and webpages from the grey literature. As all documents were qualitative in nature a thematic synthesis of their content was undertaken.

RESULTS

Three main themes and ten sub-themes were identified. The main themes concerned early presentation and identification in the workplace; reasonable adjustments for people with working age dementia; and the provision of information to raise awareness and facilitate informed choice. The evidence suggested that there is a lack of awareness about working age dementia and that this may impact negatively on employees. Guidance for employers offered suggestions for good practice.

CONCLUSIONS

Guidance for employers is increasingly available although it rarely refers to the evidence base. There is a need for future studies that explore the effectiveness of guidance and training initiatives for employers. Examples of good practice where employees with dementia have been well supported in the workplace and who have been able to leave the workforce with dignity, would be helpful.

Multiplexed efficient on-chip sample preparation and sensitive amplification-free detection of Ebola virus

An automated microfluidic sample preparation multiplexer (SPM) has been developed and evaluated for Ebola virus detection. Metered air bubbles controlled by microvalves are used to improve bead-solution mixing thereby enhancing the hybridization of the target Ebola virus RNA with capture probes bound to the beads. The method uses thermally stable 4-formyl benzamide functionalized (4FB) magnetic beads rather than streptavidin coated beads with a high density of capture probes to improve the target capture efficiency. Exploiting an on-chip concentration protocol in the SPM and the single molecule detection capability of the antiresonant reflecting optical waveguide (ARROW) biosensor chip, a detection limit of 0.021pfu/mL for clinical samples is achieved without target amplification. This RNA target capture efficiency is two orders of magnitude higher than previous results using streptavidin beads and the limit of detection (LOD) improves 10×. The wide dynamic range of this technique covers the whole clinically applicable concentration range. In addition, the current sample preparation time is ~1h which is eight times faster than previous work. This multiplexed, miniaturized sample preparation microdevice establishes a key technology that intended to develop next generation point-of-care (POC) detection system.

The development of peer reflective supervision amongst nurse educator colleagues: An action research project

This action research study developed the use of peer reflective supervision (PRS) amongst eight nurse educators contributing to an undergraduate Adult Nursing programme at a UK University. During the academic year (2013-14), nurse educator co-researchers met for an introductory workshop and then met regularly in pairs to facilitate each other's reflection. This provided an opportunity for nurse educators to reflect on identified issues linked to their role with a facilitative peer. Educators met three additional times in a Reflexive Learning Group (RLG), to gather data on their use of PRS. Audio-recordings from the RLGs were transcribed and analysed using Norton's (2009) thematic analysis framework. Co-researchers iteratively validated the data and an external validation group critically viewed the evidence. Overall, seven themes were generated from the three research cycles. These were: PRS as a Valuable Affirming Experience; Time Issues; Facilitation- Support, Trust and Challenge; Developing a Flexible 'Toolbox'; To Write or Not to Write; Drawing on Literature; and Requirement for Action. Findings add new evidence regarding use of a flexible toolbox of resources to develop reflection and offer practical guidance on the development of PRS. Nurse educators often experienced similar concerns, and a facilitative supervision structure allowed co-researchers to positively explore these. Recognition of work pressures and requirement for time and space for reflection was highlighted, particularly regarding writing, and exploring the literature, to develop critical analysis of experiences. The importance of action as part of the reflective process was emphasised. Co-researchers reported positive personal change as well as the opportunity to highlight issues through their reflection for further action within the organisation. The study adds constructive evidence for the use of reflection to explore professional work, make sense of experiences and develop positive action. It has transferability to a wider international audience interested in the development of reflection amongst colleagues and the use of insider research techniques to challenge and develop practice.