Association between mortality and phone-line waiting time for non-urgent medical care: a Danish registry-based cohort study

BACKGROUND AND IMPORTANCE

Telephone calls are often patients' first healthcare service contact, outcomes associated with waiting times are unknown.

OBJECTIVES

Examine the association between waiting time to answer for a medical helpline and 1- and 30-day mortality.

DESIGN, SETTING AND PARTICIPANTS

Registry-based cohort study using phone calls data (January 2014 to December 2018) to the Capital Region of Denmark's medical helpline. The service refers to hospital assessment/treatment, dispatches ambulances, or suggests self-care guidance.

EXPOSURE

Waiting time was grouped into the following time intervals in accordance with political service targets for waiting time in the Capital Region: <30 s, 0:30-2:59, 3-9:59, and ≥10 min.

OUTCOME MEASURES AND ANALYSIS

The association between time intervals and 1- and 30-day mortality per call was calculated using logistic regression with strata defined by age and sex.

MAIN RESULTS

In total, 1 244 252 callers were included, phoning 3 956 243 times, and 78% of calls waited <10 min. Among callers, 30-day mortality was 1% (16 560 deaths). For calls by females aged 85-110 30-day mortality increased with longer waiting time, particularly within the first minute: 9.6% for waiting time <30 s, 10.8% between 30 s and 1 minute and 9.1% between 1 and 2 minutes. For calls by males aged 85-110 30-day mortality was 11.1%, 12.9% and 11.1%, respectively. Additionally, among calls with a Charlson score of 2 or higher, longer waiting times were likewise associated with increased mortality. For calls by females aged 85-110 30-day mortality was 11.6% for waiting time <30 s, 12.9% between 30 s and 1 minute and 11.2% between 1 and 2 minutes. For calls by males aged 85-110 30-day mortality was 12.7%, 14.1% and 12.6%, respectively. Fewer ambulances were dispatched with longer waiting times (4%/2%) with waiting times <30 s and >10 min.

CONCLUSION

Longer waiting times for telephone contact to a medical helpline were associated with increased 1- and 30-day mortality within the first minute, especially among elderly or more comorbid callers.

Long-Term Quality of Life After Out-of-Hospital Cardiac Arrest

Importance

Allocating resources to increase survival after cardiac arrest requires survivors to have a good quality of life, but long-term data are lacking.

Objective

To determine the quality of life of survivors of out-of-hospital cardiac arrest from 2001 to 2019.

Design, Setting, and Participants

This survey study used the EuroQol Health Questionnaire, 12-Item Short Form Health Survey (SF-12), and Hospital Anxiety and Depression Scale (HADS) to assess the health-related quality of life of all adult survivors of out-of-hospital cardiac arrest included in the Danish Cardiac Arrest Registry between June 1, 2001, and August 31, 2019, who were alive in October 2020 (follow-up periods, 0-1, >1-2, >2-4, >4-6, >6-8, >8-10, >10-15, and >15-20 years since arrest). The survey was conducted from October 1, 2020, through May 31, 2021.

Exposure

All patients who experienced an out-of-hospital cardiac arrest.

Main Outcome and Measures

Self-reported health was measured using the EuroQol Health Questionnaire index (EQ index) score and EQ visual analog scale. Physical and mental health were measured using the SF-12, and anxiety and depression were measured using the HADS. Descriptive statistics were used for the analysis.

Results

Of 4545 survivors, 2552 (56.1%) completed the survey, with a median follow-up since their event of 5.5 years (IQR, 2.9-8.9 years). Age was comparable between responders and nonresponders (median [IQR], 67 [58-74] years vs 68 [56-78] years), and 2075 responders (81.3%) were men and 477 (18.7%) women (vs 1473 male [73.9%] and 520 female [26.1%] nonresponders). For the shortest follow-up (0-1 year) and longest follow-up (>15-20 years) groups, the median EQ index score was 0.9 (IQR, 0.7-1.0) and 0.9 (0.8-1.0), respectively. For all responders, the mean (SD) SF-12 physical health score was 43.3 (12.3) and SF-12 mental health score, 52.9 (8.3). All 3 scores were comparable to a general Danish reference population. Based on HADS scores, a low risk for anxiety was reported by 73.0% (54 of 74) of 0- to 1-year survivors vs 89.3% (100 of 112) of greater than 15- to 20-year survivors; for symptoms of depression, these proportions were 79.7% (n = 59) and 87.5% (n = 98), respectively. Health-related quality of life was similar in survivor groups across all follow-up periods.

Conclusions and Relevance

Among this survey study's responders, who comprised more than 50% of survivors of out-of-hospital cardiac arrest in Denmark, long-term health-related quality of life up to 20 years after their event was consistently high and comparable to that of the general population. These findings support resource allocation and efforts targeted to increasing survival after out-of-hospital cardiac arrest.

"I just haven't experienced anything like this before": A qualitative exploration of callers' interpretation of experienced conditions in telephone consultations preceding a myocardial infarction

OBJECTIVES

Callers with myocardial infarction presenting atypical symptoms in telephone consultations when calling out-of-hours medical services risk misrecognition. We investigated characteristics in callers' interpretation of experienced conditions through communication with call-takers.

METHODS

Recording of calls resulting in not having an ambulance dispatched for 21 callers who contacted a non-emergency medical helpline, Copenhagen (Denmark), up to one week before they were diagnosed with myocardial infarction. Qualitative content analysis was applied.

RESULTS

Awareness of illness, remedial actions and previous experiences contributed to callers' interpretation of the experienced condition. Unclear symptoms resulted in callers reacting to their interpretation by being unsure and worried. Negotiation of the interpretation was seen when callers tested the call-taker's interpretation of the condition and when either caller or call-taker suggested: "wait and see".

CONCLUSION

Callers sought to interpret the experienced conditions but faced challenges when the conditions appeared unclear and did not correspond to the health system's understanding of symptoms associated with myocardial infarction. It affected the communicative interaction with the call-taker and influenced the call-taker's choice of response.

PRACTICE IMPLICATIONS

Call-takers, as part of the decision-making process, could ask further questions about the caller's insecurity and worry. It might facilitate faster recognition of conditions warranting hospital referral.

Registered prodromal symptoms of out-of-hospital cardiac arrest among patients calling the medical helpline services

Background Early identification of warning symptoms among out-of-hospital cardiac arrest (OHCA) patients remains challenging. Thus, we examined the registered prodromal symptoms of patients who called medical helpline services within 30-days before OHCA. Methods Patients unwitnessed by emergency medical services (EMS) aged ≥18 years during their OHCA were identified from the Danish Cardiac Arrest Registry (2014-2018) and linked to phone records from the 24-h emergency helpline (1-1-2) and out-of-hours medical helpline (1813-Medical Helpline) in Copenhagen before the arrest. The registered symptoms were categorized into chest pain; breathing problems; central nervous system (CNS)-related/unconsciousness; abdominal/back/urinary; psychiatric/addiction; infection/fever; trauma/exposure; and unspecified (diverse from the beforementioned categories). Analyses were divided by the time-period of calls (0-7 days/8-30 days preceding OHCA) and call type (1-1-2/1813-Medical Helpline). Results Of all OHCA patients, 18% (974/5442) called helpline services (males 56%, median age 76 years[Q1-Q3:65-84]). Among these, 816 had 1145 calls with registered symptoms. The most common symptom categories (except for unspecified, 33%) were breathing problems (17%), trauma/exposure (17%), CNS/unconsciousness (15%), abdominal/back/urinary (12%), and chest pain (9%). Most patients (61%) called 1813-Medical Helpline, especially for abdominal/back/urinary (17%). Patients calling 1-1-2 had breathing problems (24%) and CNS/unconsciousness (23%). Nearly half of the patients called within 7 days before their OHCA, and CNS/unconsciousness (19%) was the most registered. The unspecified category remained the most common during both time periods (32%;33%) and call type (24%;39%). Conclusions Among patients who called medical helplines services up to 30-days before their OHCA, besides symptoms being highly varied (unspecified (33%)), breathing problems (17%) were the most registered symptom-specific category.

Symptoms reported in calls to emergency medical services within 24 hours prior to out-of-hospital cardiac arrest

AIM

There is limited evidence regarding prodromal symptoms of out-of-hospital cardiac arrest (OHCA). We aimed to describe patient characteristics, prodromal symptoms, and prognosis of patients contacting emergency medical services (EMS) within 24 hours before OHCA.

METHODS

We identified all OHCA treated by Copenhagen EMS from 2016 through 2018 using the Danish Cardiac Arrest Registry and linked them to emergency calls. We included all pre-arrest calls by patients or bystanders if they were performed 1) within 24 hours before the OHCA call or 2) during the OHCA event for EMS-witnessed OHCA. Calls were reviewed by healthcare professionals using a survey guide.

RESULTS

Among 4,071 patients, 481 patients (12 %) had 539 calls within 24 hours prior to OHCA (60 % male, median age 74 years of age). The patient spoke on the phone in 25 % of calls. The most common symptoms were breathing problems (59 %), confusion (23 %), unconsciousness (20 %), chest pain (20 %), and paleness (19 %). Patients with breathing problems compared to chest pain were more likely to be ≤ 75 years of age (55 % versus 35 %), less likely to be male (52 % versus 73 %), have shockable rhythm (10 % versus 38 %), receive bystander defibrillation (6 % versus 19 %) or EMS defibrillation (15 % versus 65 %), achieve return of spontaneous circulation (37 % versus 68 %) and survive 30 days following OHCA (10 % versus 50 %).

CONCLUSION

More than 10% of patients with OHCA had a call to EMS within 24 hours before OHCA. The most common symptom was breathing problems which compared to chest pain had lower 30-day survival.

"Like a rainy weather inside of me": Qualitative content analysis of telephone consultations concerning back pain preceding out-of-hospital cardiac arrest

INTRODUCTION

Cardiac arrest patients presenting with back pain are at risk of not receiving the appropriate help when calling emergency medical services. In telephone consultations regarding patients with back pain preceding an out-of-hospital cardiac arrest, we investigated how communication between caller and call-taker influenced the call-taker's interpretation of back pain descriptions and decision-making about choice of response.

METHOD

The study was conducted using 20 recorded phone calls from 17 patients who contacted the Copenhagen Emergency Medical Services (Denmark) reporting back pain up to 24 hours before an out-of-hospital cardiac arrest. Qualitative content analysis was applied.

RESULTS

Two main categories emerged: (1) reasons, including subcategories: reported conditions, descriptions of conditions, patient's interpretation of condition and patient's own remedial actions; and (2) considerations, including subcategories: assessment of the severity, call-taker's interpretation of the condition, arguments for chosen response and conditions not facilitating further communication by the call-taker.

CONCLUSION

In telephone consultations regarding patients with back pain preceding an out-of-hospital cardiac arrest the communication was influenced by the communicative preconditions of the call-taker. Communication in consultations where ambulances were not dispatched was characterized by complex descriptions of symptoms not easily fitting into the health system's interpretations of conditions warranting an urgent response.

POS0298 OCCURRENCE AND PREDICTION OF FLARE AFTER TAPERING OF TNF INHIBITORS IN PATIENTS WITH AXIAL SPONDYLOARTHRITIS

Background

Patients with axial spondyloarthritis (axSpA) in clinical remission tapered Tumor Necrosis Factor inhibitor (TNFi) therapy according to a clinical guideline and had 2 years´ follow-up [1].

Objectives

We aimed to investigate flare frequency, dose at which flare occurred, type of flare (clinical/ Bath ankylosing spondylitis disease activity index (BASDAI)/magnetic resonance imaging (MRI)) and predictors of flare.

Methods

Patients in clinical remission (BASDAI<40, physician global score<40 and without disease activity the previous year) tapered TNFi to 2/3 standard dose at baseline, 1/2 at week (w)16, 1/3 at w32 and 0 (discontinuation) at w48. Patients who flared were increased to previous dose. Predictors of flare at each dose step were investigated by regression analyses.

Results

Of 108 patients, 106 (99%) flared before year 2 (flare occurring mean (SD) 99(44.3) days after last tapering). Twenty-nine patients (27%) flared at 2/3 standard dose, 21 (20%) at 1/2 dose, 29 (27%) at 1/3 dose and 27 (25%) after discontinuation. One-hundred-and-five (99%) had clinical flare, 25 (24%) BASDAI flare and 23 (29% of patients with MRI at flare) MRI flare; and forty-one patients (41%) fulfilled the ASAS-definition of clinically important worsening (≥0.9 increase since baseline) (Figure 1). Most common flare symptoms were back/buttock pain (n=93 (89%)) and pain in peripheral joints/entheseal regions (n=48 (46%)). Higher baseline physician global score was an independent predictor of flare after tapering to 2/3 (Odds ratio=1.19 (95% Confidence Interval=1.05-1.41); p=0.011) (Table 1). Changes in clinical and/or imaging variables in the 16 weeks prior to tapering did not predict flare (data not shown).

Table 1.

Prediction of flare within 16 weeks after tapering to 2/3 dose (n=74)

Values are from timepoint of tapering from full dose to 2/3 doseUnivariate analysesFinal multivariable analyses*OR(95% CI)p-valueOR(95% CI)p-valueMale gender0.96(0.25 - 4.14)0.955Age1.00(0.96 - 1.04)0.880Time since diagnosis1.00(0.95 - 1.06)0.863Current smoker0.70(0.20 - 2.20)0.543HLA-B27 positive0.66(0.18 - 2.41)0.515Previous bDMARDs1.28(0.66 - 2.49)0.458Patient pain VAS1.02(0.98 - 1.06)0.310Physician global VAS1.19(1.04 - 1.41)0.0121.19(1.04 - 1.41)0.011ASDAS1.66(0.70 - 4.10)0.251mNYc positive0.78(0.29 - 2.09)0.615SPARCC SIJ Inflammation Index1.01(0.90 - 1.12)0.861CANDEN Total inflammation0.95(0.65 - 1.25)0.702SPARCC SSS Erosion1.11(0.91 - 1.37)0.293CANDEN Fat0.99(0.96 - 1.02)0.705AUC (95% CI)0.66 (0.54 - 0.78)

Predictors were selected by applying backward selection in stacked data. p-values by likelihood ratio tests. Bold indicates p-values<0.1 in univariate analyses. Predictors were selected by backward selection in stacked imputed datasets after applying a fixed weight to all observations, accounting for the average fraction of missing data across all variables under consideration. *Results were derived in non-imputed data (no missing values in selected predictors). CIs given as profile likelihood CIs. AUC estimated based on internal validation by bootstrapping with 1000 samples.

ASDAS, Ankylosing Spondylitis Disease Activity Score; bDMARDs, biological disease modifying anti-rheumatic drugs; AUC, Area Under the receiver operating characteristic Curve; CANDEN, Canada-Denmark MRI scoring system of the spine in patients with axial spondyloarthritis; CI, confidence interval; mNYc, modified New York criteria; SIJ, sacroiliac joint; SPARCC SIJ inflammation, Spondyloarthritis Research Consortium of Canada Sacroiliac joint inflammation; SPARCC SSS, Spondyloarthritis Research Consortium of Canada Sacroiliac joint Structural Score; VAS, visual analogue scale.

Conclusion

Almost all (99%) axSpA patients in clinical remission flared during tapering to discontinuation, but above half not before receiving 1/3 dose or less. Higher physician global score was the only independent predictor of flare.

References

[1]Wetterslev M, et al. Rheumatology (Oxford) 2021;10.1093/rheumatology/keab755.

Disclosure of Interests

Marie Wetterslev: None declared, Stylianos Georgiadis: None declared, Sara Nysom Christiansen Speakers bureau: BMS and GE, Grant/research support from: Novartis, Susanne Juhl Pedersen Speakers bureau: MSD, Pfizer, AbbVie, Novartis and UCB, Consultant of: AbbVie and Novartis, Grant/research support from: AbbVie, MSD, and Novartis, Inge Juul Sørensen: None declared, Merete Lund Hetland Consultant of: MSD, Biogen, Pfizer, Eli Lilly, Orion Pharma, CellTrion, Samsung Bioepis, and Janssen Biologics BV, Grant/research support from: MSD, Biogen, Pfizer, Bristol-Myers Squibb, AbbVie, Roche and Novartis, Anne Duer: None declared, Mikael Boesen Speakers bureau: Image Analysis Group, Esaote, AbbVie, Celgene, Eli-Lilly, Janssen, Novartis, Pfizer, UCB, Novo, GSK, Takeda, Geurbet, Biogen, Radiobotics and Chondrometrics, Consultant of: Image Analysis Group, Esaote, AbbVie, Celgene, Eli-Lilly, Janssen, Novartis, Pfizer, UCB, Novo, GSK, Takeda, Geurbet, Biogen, Radiobotics and Chondrometrics, Grant/research support from: Image Analysis Group, Esaote, AbbVie, Celgene, Eli-Lilly, Janssen, Novartis, Pfizer, UCB, Novo, GSK, Takeda, Geurbet, Biogen, Radiobotics and Chondrometrics, Kasper K Gosvig: None declared, Jakob Møllenbach Møller: None declared, Mads Bakkegaard: None declared, Cecilie Heegaard Brahe: None declared, Niels Steen Krogh: None declared, Bente Jensen: None declared, Ole Madsen: None declared, Jan Christensen: None declared, Annette Hansen Speakers bureau: speaker fees from Elly Lilly, Jesper Noerregaard: None declared, Henrik Røgind: None declared, Mikkel Østergaard Speakers bureau: Abbvie, BMS, Boehringer-Ingelheim, Celgene, Eli-Lilly, Hospira, Janssen, Merck, Novartis, Pfizer, Regeneron, Roche, Sandoz, Sanofi and UCB, Consultant of: Abbvie, BMS, Boehringer-Ingelheim, Celgene, Eli-Lilly, Hospira, Janssen, Merck, Novartis, Pfizer, Regeneron, Roche, Sandoz, Sanofi and UCB, Grant/research support from: Abbvie, BMS, Boehringer-Ingelheim, Celgene, Eli-Lilly, Hospira, Janssen, Merck, Novartis, Pfizer, Regeneron, Roche, Sandoz, Sanofi and UCB

AB0801 The ASAS Health Index (HI): Construct validity and responsiveness in relation to TNF inhibitor (TNFi) treatment in patients with axial spondyloarthritis (axSpA)

Background

The Assessment of Spondyloarthritis International Society (ASAS) has developed the ASAS HI aiming to capture the full range of functioning and disability in patients with axSpA.

Objectives

To examine the construct validity and responsiveness of ASAS HI in relation to TNFi treatment.

Methods

In this investigator-initiated 52-week prospective observational study (MANGO study; NCT02011386)(3) axSpA patients initiated sc. Golimumab 50 mg every month. Key inclusion criteria were BASDAI >4.0 and sacroiliitis on radiography and/or MRI.

Results

45 of 53 TNFi naïve patients completed ASAS HI at weeks 0, 4, 16 and 52. 55.6% were male, 75.6% HLA-B27 positive, median age 34.6 yrs (IQR 28.3;46.1) and symptom duration 5.1 yrs. (2;13)(Table 1A). ASAS HI decreased from week 0 to weeks 4, 16 and 52, from median 10.0 (IQR 8;11)) to 7.0 (2.3;10), 5.5 (1.3;8) and 4.0 (1;7.5)(Wilcoxon-Pratt; all p<0.001). Patients with low ASAS HI (score 0-5, good heath state(4)) at week 16 and 52 had significantly lower ASDAS, BASDAI, BASFI, pain, pt. global and CRP than patients with moderate to high ASAS HI (6-17) (Table 1B). Patients with a decrease of >3 (clinically meaningful change(3)) or >30%(5) in ASAS HI from week 0-16 had significantly larger reductions in ASDAS, BASDAI, BASFI, pain, pt. global and SPARCC MRI spine inflammation score (Table 1C). At baseline, ASAS HI correlated with BASFI and SPARCC SIJ inflammation score (rho: 0.37-0.38, p<0.05), and changes in ASAS HI from week 0-16 correlated with changes in ASDAS, BASDAI, BASFI, pain, pt. global (0.51-0.67, p<0.001) and change in MRI SIJ inflammation score (0.30, p<0.05). ASAS HI had high responsiveness (Table 1D).

Table 1.

Diseases measures at baseline (Table 1A), stratified according to ASAS HI states at week 16 and 52 (Table 1B), changes from week 0 to 16 and 52 (Table 1C) and responsiveness (Table 1D).

Table 1ATable 1BTable 1CTable 1DBaselineASAS HI at week 16ASAS HI at week 52Absolute change in ASAS HI week 0 to 16Percentage change in ASAS HI week 0 to 16Responsiveness week 0-160-56-170-56-17<3≥3<30%≥30%SRMESn=45n=22n=22n=26n=16n=18n=26n=16n=28n=45n=45ASAS HI10.0 (8;11)1.5*** (1;4)8.0 (7;10)2.0*** (0.8;3.3)9.5 (7;10.8)-1.5*** (-2;2)-6.0 (-12;-3)-1*** (-2;2)-5.5 (-12;-2)1.61.3ASDAS3.7 (3.1;4.2)1*** (0.9;1.5)2.1 (1.1;3.1)1.2*** (0.8;1.5)2.2 (1.8;3.3)-1.3*** (-2.5;1)-2.2 (-4.6;-1.3)-1.2*** (-2.5;1)-2.2 (-4.6;-1.3)2.51.7BASDAI6.1 (5;7.20.9*** (0.5;2.3)3.2 (1.8;5.1)1.3*** (0.3;2.3)3.8 (2.9;5.7)-1.7*** (-5.3;0.9)-4.9 (-6.7;-1.9)-1.6*** (-5.3;0.9)-4.8 (-6.7;-1.9)2.71.8BASFI4.4 (3;5.90.6*** (0.3;1.4)2.3 (1.4;4)0.3*** (0.1;1.4)2.5 (1.5;3.3)-1.2*** (-4.4;1.2)-3.5 (-6.7;-0.2)-1.1*** (-3.9;1.2)-3.5 (-6.7;-0.15)1.41.4BASMI2;0 (1;3)1.0 (0;2)1.0 (0;2)1.0 (0;2)1.0 (0;3)0 (-3;2)-1.0 (-4;2)0 (-3;2)-1.0 (-4;2)0.40.6Pain7.0 (5.6;8.1)0.8*** (0.3;1.2)2.9 (1.3;5.5)0.7** (0.3;2.6)3.3 (1.1;6.3)-2.6** (-8.8;1.9)-5.6 (-8.6;-1.1)-1.8*** (-6.8;1.9)-5.6 (-8.8;-1.1)2.71.8Pt. global7.5 (6.4;8.4)1.0*** (0.4;1.9)3.0 (1.3;6.7)0.6*** (0.2;2.1)4.4 (2.3;6.9)-3.4*** (-6.5;0.8)-6.7 (-8.8;-1.1)-2.8*** (-6.3;0.8)-6.5 (-8.8;-1.1)3.31.8CRP (mg/l)7.7 (0.9;22)0.3* (0.3;2.2)1.3 (0.3;8.5)0.3** (0.3;2.5)1.0 (0.3;5)-1.7 (-39.6;6.9)-5.2 (-79.7;19)-1.7 (-39.6;6.9)-5.2 (-79.7;19)0.50.6SPARCC MRI SIJ inflammation14 (4;24.5)4.0 (0;6.5)2.0 (0;7.8)2.0 (0;4.3)2.0 (1;6)-5.5 (-30;2)-12.5 (-36;0)-5.5 (-30;2)-12.5 (-36;0)0.91.1SPARCC MRI spine infl.8 (4;15)0 (0;3.5)1.0 (0;4.3)0(0;2)1.0 (0;3)-2.5** (-98;2)-8 (-55;0)-2.5* (-98;2)-8 (-55;0)0.50.7

Median (IQR). Mann-Whitney test. * p<0.05. ** p<0.01. *** p<0.001. Standardized response mean (SRM) and effect size (ES) ≥0.50 to <0.80 and ≥0.80 represents moderate and high responsiveness.

Conclusion

ASAS HI showed good construct validity and responsiveness.

References

[1]Kiltz U. ARD 2015;74:830

[2]Kiltz U. ARD 2018;77:1311

[3]Krabbe. Rheumatology 2020;59:3358

[4]Walsh. ACR 2020 doi: 10.1002/acr.24482

[5]Molto. ARD 2021;80(11):1436

Disclosure of Interests

Susanne Juhl Pedersen Speakers bureau: MSD, Pfizer, AbbVie, Novartis and UCB.

Grant/research support from: AbbVie, MSD, and Novartis., Inge Juul Sørensen: None declared, Bente Jensen: None declared, Ole Madsen: None declared, Mette Klarlund: None declared, Jakob Møllenbach Møller: None declared, Mats Peter Johansson: None declared, Kasper K Gosvig: None declared, Mikkel Østergaard Speakers bureau: Abbvie, BMS, Celgene, Eli-Lilly, Galapagos, Gilead, Janssen, Merck, Novartis, Orion, Pfizer, Roche and UCB., Consultant of: Abbvie, BMS, Boehringer-Ingelheim, Celgene, Eli-Lilly, Hospira, Janssen, Merck, Novartis, Novo, Orion, Pfizer, Regeneron, Roche, Sandoz, Sanofi and UCB., Grant/research support from: Abbvie, Amgen, BMS, Merck, Celgene and Novartis.

POS0550 LONG TERM EFFICACY OF A 2-YEAR MRI TREAT-TO-TARGET STRATEGY ON DISEASE ACTIVITY, MRI INFLAMMATION AND PHYSICAL FUNCTION IN RHEUMATOID ARTHRITIS PATIENTS IN CLINICAL REMISSION: FIVE YEAR FOLLOW-UP OF THE IMAGINE RA-COHORT

Background

Targeting MRI remission in rheumatoid arthritis (RA) patients in clinical remission may improve long term clinical, functional and MRI outcomes.

Objectives

To investigate whether a 2-year treat-to-target (T2T) strategy, based on structured MRI assessments targeting absence of osteitis combined with clinical remission, compared with a conventional clinical T2T strategy targeting clinical remission only, improves disease activity, physical function and suppresses MRI-inflammation over 5 years in RA patients.

Methods

The IMAGINE-more trial was designed as an extension protocol to the 2-year IMAGINE-RA randomised controlled trial (RCT). IMAGINE-RA included 200 RA patients, in clinical remission (DAS28-CRP<3.2 and no swollen joints), who received conventional synthetic disease-modifying antirheumatic drugs (csDMARD) and investigated whether an MRI T2T strategy targeting absence of osteitis in combination with clinical remission (DAS28-CRP≤3.2 and no swollen joints) could increase remission rates and prevent erosive progression compared with a conventional T2T strategy targeting clinical remission only. If target was not met, treatment was escalated according to a predefined treatment algorithm starting with increment in csDMARDs and then adding biologics. At the end of the study, participants were invited to participate in the IMAGINE-more follow-up study. Patients were managed in routine outpatient clinic and had three IMAGINE-more visits including clinical examination (year 3, 4 and 5) and contrast-enhanced MRI of the dominant wrist and 2nd-5th metacarpophalangeal joints (year 3 and 5). The primary clinical endpoint was the proportion of patients achieving DAS28-CRP remission (DAS28-CRP<2.6) at year 5. Predefined key secondary outcomes were disease activity (DAS28-CRP), and changes in MRI osteitis (OMERACT RA MRI scoring system (RAMRIS)) and functional level (Health Assessment Questionnaire (HAQ)) from baseline to 5-years follow up. Endpoints were analysed by logistic regression models and repeated measures mixed effects models adjusted for propensity scores corresponding to (remaining in) group allocation.

Results

Fifty-nine patients in the MRI T2T arm and 72 patients in conventional T2T arm consented to participate. Of these, 47 patients (80%) in the MRI T2T group and 54 patients (75%) in the conventional T2T group reached the primary clinical endpoint (p=0.161) (Table 1 and Figure 1). No statistically significant differences between treatment strategies in key secondary outcomes were seen.

Table 1.

Primary and key secondary outcomes at 5 years

MRI T2TConventional T2TDifference between groupsP valueN=59N=72Primary endpointDAS28-CRP remission (DAS28-CRP<2.6), No. (%)47 (80%)54 (75%)2.00 (0.76 to 5.28)0.161Key secondary endpointsDAS28-CRP1.79 (0.08)1.94 (0.08)-0.15 (-0.38 to 0.07)0.176Change from baseline in MRI osteitis (RAMRIS)-0.17 (0.58)0.18 (0.54)-0.35 (-1.96 to 1.25)0.663Change from baseline in HAQ-0.02 (0.03)0.05 (0.03)-0.07 (-0.15 to 0.01)0.080

Group estimates are presented as No. (%) for dichotomous data and least squares means (SE) for continuous data. For the primary endpoint, adjusted odds ratio and 95%CI between groups were calculated from a logistic regression model including a fixed factor for treatment arm, and an adjustment for propensity score as a covariate. For endpoints with continuous data, least squares mean differences between groups were calculated based on repeated-measures mixed linear models adjusted for baseline values and propensity scores.

Conclusion

A 2-year MRI T2T strategy targeting absence of MRI osteitis combined with clinical remission as compared to a conventional clinical T2T strategy in RA patients had no effect on the long-term probability of achieving DAS28-CRP remission. These findnings do not support the use of an MRI-guided strategy for treating patients with RA.

References

[1]Møller-Bisgaard S et al: JAMA 2019, 321(5):461-472.

Disclosure of Interests

Signe Møller-Bisgaard Grant/research support from: AbbVie, Kim Hørslev-Petersen: None declared, Daniel Glinatsi: None declared, Bo Ejbjerg: None declared, Merete L. Hetland: None declared, Jakob Møllenbach Møller: None declared, Robin Christensen: None declared, Sabrina Mai Nielsen: None declared, Mikael Boesen: None declared, Kristian Stengaard-Pedersen: None declared, Ole Madsen: None declared, Bente Jensen: None declared, Jan Alexander Villadsen: None declared, Ellen Margrethe Hauge: None declared, Oliver Hendricks: None declared, Hanne Merete Lindegaard: None declared, Niels Steen Krogh: None declared, Anne Grethe Jurik: None declared, Henrik Thomsen: None declared, Mikkel Østergaard Speakers bureau: Abbvie, BMS, Celgene, Eli-Lilly, Galapagos, Gilead, Janssen, Merck, Novartis, Orion, Pfizer, Roche and UCB, Consultant of: Abbvie, BMS, Boehringer-Ingelheim, Celgene, Eli-Lilly, Hospira, Janssen, Merck, Novartis, Novo, Orion, Pfizer, Regeneron, Roche, Sandoz, Sanofi and UCB, Grant/research support from: Abbvie, Amgen, BMS, Merck, Celgene and Novartis.

Clinical presentation, disease course, and outcome of COVID-19 in hospitalized patients with and without pre-existing cardiac disease: a cohort study across 18 countries

AIMS

Patients with cardiac disease are considered high risk for poor outcomes following hospitalization with COVID-19. The primary aim of this study was to evaluate heterogeneity in associations between various heart disease subtypes and in-hospital mortality.

METHODS AND RESULTS

We used data from the CAPACITY-COVID registry and LEOSS study. Multivariable Poisson regression models were fitted to assess the association between different types of pre-existing heart disease and in-hospital mortality. A total of 16 511 patients with COVID-19 were included (21.1% aged 66-75 years; 40.2% female) and 31.5% had a history of heart disease. Patients with heart disease were older, predominantly male, and often had other comorbid conditions when compared with those without. Mortality was higher in patients with cardiac disease (29.7%; n = 1545 vs. 15.9%; n = 1797). However, following multivariable adjustment, this difference was not significant [adjusted risk ratio (aRR) 1.08, 95% confidence interval (CI) 1.02-1.15; P = 0.12 (corrected for multiple testing)]. Associations with in-hospital mortality by heart disease subtypes differed considerably, with the strongest association for heart failure (aRR 1.19, 95% CI 1.10-1.30; P < 0.018) particularly for severe (New York Heart Association class III/IV) heart failure (aRR 1.41, 95% CI 1.20-1.64; P < 0.018). None of the other heart disease subtypes, including ischaemic heart disease, remained significant after multivariable adjustment. Serious cardiac complications were diagnosed in <1% of patients.

CONCLUSION

Considerable heterogeneity exists in the strength of association between heart disease subtypes and in-hospital mortality. Of all patients with heart disease, those with heart failure are at greatest risk of death when hospitalized with COVID-19. Serious cardiac complications are rare during hospitalization.

Contacts With the Health Care System Before Out-of-Hospital Cardiac Arrest

Background It remains challenging to identify patients at risk of out-of-hospital cardiac arrest (OHCA). We aimed to examine health care contacts in patients before OHCA compared with the general population that did not experience an OHCA. Methods and Results Patients with OHCA with a presumed cardiac cause were identified from the Danish Cardiac Arrest Registry (2001-2014) and their health care contacts (general practitioner [GP]/hospital) were examined up to 1 year before OHCA. In a case-control study (1:9), OHCA contacts were compared with an age- and sex-matched background population. Separately, patients with OHCA were examined by the contact type (GP/hospital/both/no contact) within 2 weeks before OHCA. We included 28 955 patients with OHCA. The weekly percentages of patient contacts with GP the year before OHCA were constant (25%) until 1 week before OHCA when they markedly increased (42%). Weekly percentages of patient contacts with hospitals the year before OHCA gradually increased during the last 6 months (3.5%-6.6%), peaking at the second week (6.8%) before OHCA; mostly attributable to cardiovascular diseases (21%). In comparison, there were fewer weekly contacts among controls with 13% for GP and 2% for hospital contacts (P<0.001). Within 2 weeks before OHCA, 57.8% of patients with OHCA had a health care contact, and these patients had more contacts with GP (odds ratio [OR], 3.17; 95% CI, 3.09-3.26) and hospital (OR, 2.32; 95% CI, 2.21-2.43) compared with controls. Conclusions The health care contacts of patients with OHCA nearly doubled leading up to the OHCA event, with more than half of patients having health care contacts within 2 weeks before arrest. This could have implications for future preventive strategies.

Prodromal symptoms of out-of-hospital cardiac arrest among patients calling emergency and non-emergency medical help services

Background

Early identification of individuals at risk of out-of-hospital cardiac arrest (OHCA) remains difficult. Little is known about symptoms presented when contacting a medical helpline prior to OHCA.

Aim

To examine the registered prodromal symptoms when patients phoned to seek medical help prior to OHCA.

Methods

OHCA patients (≥18 years) were identified from the Danish Cardiac Arrest Registry (2014–2018) and linked with calls to the non-emergency (1813-Medical Helpline) and Emergency Medical Services 1–1-2 (112). We examined (1) symptoms registered within 30 days before OHCA, categorized into eight groups and stratified by time-period and call-type; (2) hospital diagnoses and medical prescriptions according to symptom groups within 180 days before these calls.

Results

Among 974 OHCA patients who called in total within 30 days before OHCA, 816 OHCA patients (males 57%, median age 76 years [Q1-Q3: 65–84]) had a registered symptom and some of them called more than once (1,145 calls by 816 patients). Overall, the most reported group of symptoms was “Other” (29%), containing a diverse group of prodromal symptoms registered by the caregiver that did not fit into the other categories (Figure), followed by breathing problems (15%). When stratified by time-period (Figure) the most common symptom group remained “Other”. This was followed by symptoms related to the Central Nervous System (CNS)/Unconsciousness (17%) for the time-period within 0–7 days before OHCA, and by breathing problems (19%) and trauma/exposure (17%) for the time-period within 8–30 days before OHCA (Figure). When stratified by call-type, most patients (60.8%) called the 1813-Medical Helpline, where “Other” (35%) and abdominal/back/urinary (14%) symptom groups were the most common. While breathing problems (24%) and CNS/Unconsciousness (21%) were highly reported among calls to 112. Within 180-days before contact with the medical helpline, independently of the symptom group presented, respiratory-related hospital diagnoses and antibiotic medications were common.

Conclusions

Patients with OHCA who called emergency and non-emergency medical helpline 30 days before OHCA had diverse prodromal symptoms; the largest category were “Other” symptoms, followed by breathing-related symptoms.

Funding Acknowledgement

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): European Union's Horizon 2020 under the ESCAPE-NET program;Helsefonden Figure 1. Classification of the prodromal symptoms among patients that called for medical assistance. Stratified by the time-period within 0–7 days and 8–30 days before OHCA. The number of calls within 0–7 days before OHCA = 471 (399 patients), and the number of calls within 8–30 days before OHCA = 674 (500 patients).

Symptoms reported in calls to emergency medical services 24 hours prior to out-of-hospital cardiac arrest

Background and purpose

It remains unknown whether patients with out-of-hospital cardiac arrest (OHCA) experience prodromal symptoms. We aimed to investigate symptoms reported by patients with OHCA contacting emergency medical services (EMS) within 24 hours prior to arrest.

Methods

We linked OHCAs occurring from 2016 through 2018 to corresponding emergency calls occurring within 24 hours prior to arrest (defined as “pre-arrest calls”). These calls were included and evenly split and evaluated by authors.

Results

Among 4071 patients with OHCA, 481 patients (11.8%) had pre-arrest calls (59.9% males, median age 74 years) with a total of 539 calls. Figure 1 shows the reported symptoms across calls. The most commonly reported symptoms were breathing problems (59.4%), confusion (23.0%), unconsciousness (20.2%), chest pain (19.5%) and paleness (19.1%). The most common co-occurring symptom pairs were breathing problems in combination with paleness (14.5%), confusion (14.1%), unconsciousness (13.5%), sweating (13.0%) and chest pain (11.9%), respectively. An urgent response was dispatched in 68.7% of calls containing breathing problems compared to 83.0% of calls containing chest pain.

Conclusion

Among patients with OHCA, 11.8% had a call to EMS within 24 hours prior to arrest and breathing problems was the most commonly reported symptom occurring in 59.4% of calls.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): The Danish Heart FoundationResearch Grant from Nordsjællands Hospital Figure 1

Effect of initiating biologics compared to intensifying conventional DMARDs on clinical and MRI outcomes in established rheumatoid arthritis patients in clinical remission: Secondary analyses of the IMAGINE-RA trial

Objectives: To compare the effect of treat-to-target-based escalations in conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) and biologics on clinical disease activity and magnetic resonance imaging (MRI) inflammation in a rheumatoid arthritis (RA) cohort in clinical remission.Method: One-hundred patients with established RA, Disease Activity Score based on 28-joint count-C-reactive protein (DAS28-CRP) < 3.2, and no swollen joints (hereafter referred to as 'in clinical remission') who received csDMARDs underwent clinical evaluation and MRI of the wrist and second to fifth metacarpophalangeal joints every 4 months. They followed a 2 year MRI treatment strategy targeting DAS28-CRP ≤ 3.2, no swollen joints, and absence of MRI osteitis, with predefined algorithmic treatment escalation: first: increase in csDMARDs; second: adding a biologic; third: switch biologic. MRI osteitis and Health Assessment Questionnaire (HAQ) (co-primary outcomes) and MRI combined inflammation and Simplified Disease Activity Index (SDAI) (key secondary outcomes) were assessed 4 months after treatment change and expressed as estimates of group differences. Statistical analyses were based on the intention-to-treat population analysed using repeated-measures mixed models.Escalation to first biologic compared to csDMARD escalation more effectively reduced MRI osteitis (difference between least squares means 1.8, 95% confidence interval 1.0-2.6), HAQ score (0.08, 0.03-0.1), MRI combined inflammation (2.5, 0.9-4.1), and SDAI scores (2.7, 1.9-3.5).Treat-to-target-based treatment escalations to biologics compared to escalation in csDMARDs more effectively improved MRI inflammation, physical function, and clinical disease activity in patients with established RA in clinical remission. Treatment escalation in RA patients in clinical remission reduces clinical and MRI-assessed disease activity.Trial registration: Clinicaltrials.gov identifier: NCT01656278.

Symptom presentation of SARS-CoV-2-positive and negative patients: a nested case-control study among patients calling the emergency medical service and medical helpline

OBJECTIVE

Currently effective symptom-based screening of patients suspected of COVID-19 is limited. We aimed to investigate age-related differences in symptom presentations of patients tested positive and negative for SARS-CoV-2.

DESIGN

SETTING: Calls to the medical helpline (1-8-1-3) and emergency number (1-1-2) in Copenhagen, Denmark. At both medical services all calls are recorded.

PARTICIPANTS

We included calls for patients who called for help/guidance at the medical helpline or emergency number prior to receiving a test for SARS-CoV-2 between April 1^st and 20^th 2020 (8423 patients). Among these calls, we randomly sampled recorded calls from 350 patients who later tested positive and 250 patients tested negative and registered symptoms described in the call.

OUTCOME

RESULTS: After exclusions, 544 calls (312 SARS-CoV-2 positive and 232 negative) were included in the analysis. Fever and cough remained the two most common of COVID-19 symptoms across all age groups and approximately 42% of SARS-CoV-2 positive and 20% of negative presented with both fever and cough. Symptoms including nasal congestion, irritation/pain in throat, muscle/joint pain, loss of taste and smell, and headache were common symptoms of COVID-19 for patients younger than 60 years; whereas loss of appetite and feeling unwell were more commonly seen among patients over 60 years. Headache and loss of taste and smell were rare symptoms of COVID-19 among patients over 60 years.

CONCLUSION

Our study identified age-related differences in symptom presentations of SARS-CoV-2-positive patients calling for help or medical advice. The specific symptoms of loss of smell or taste almost exclusively reported by patients younger than 60 years. Differences in symptom presentation across age groups must be considered when screening for COVID-19.

Impact of myocardial infarction symptom presentation on emergency response and survival

AIMS

We examined associations between symptom presentation and chance of receiving an emergency dispatch and 30-day mortality among patients with acute myocardial infarction (MI).

METHODS AND RESULTS

Copenhagen, Denmark has a 24-h non-emergency medical helpline and an emergency number 1-1-2 (equivalent to 9-1-1). Both services register symptoms/purpose of calls. Among patients with MI as either hospital diagnosis or cause of death within 72 h after a call, the primary symptom was categorized as chest pain, atypical symptoms (breathing problems, unclear problem, central nervous system symptoms, abdominal/back/urinary, other cardiac symptoms, and other atypical symptoms), unconsciousness, non-informative symptoms, and no recorded symptoms. We identified 4880 emergency and 3456 non-emergency calls from patients with MI. The most common symptom was chest pain (N = 5219) followed by breathing problems (N = 556). Among patients with chest pain, 95% (3337/3508) of emergency calls and 76% (1306/1711) of non-emergency calls received emergency dispatch. Mortality was 5% (163/3508) and 3% (49/1711) for emergency/non-emergency calls, respectively. For atypical symptoms 62% (554/900) and 17% (137/813) of emergency/non-emergency calls received emergency dispatch and mortality was 23% (206/900) and 15% (125/813). Among unconscious, patients 99%/100% received emergency dispatch and mortality was 71%/75% for emergency/non-emergency calls. Standardized 30-day mortality was 4.3% for chest pain and 15.6% for atypical symptoms, and associations between symptoms and emergency dispatch remained in subgroups of age and sex.

CONCLUSION

Myocardial infarction patients presenting with atypical symptoms when calling for help have a reduced chance of receiving an emergency dispatch and increased 30-day mortality compared to MI patients with chest pain.

Care & custody: E-sport and patient-professional power-relations in forensic psychiatry. A qualitative study

Introduction

Recovery orientated care emphasizes equality in relations. Forensic psychiatric professionals need to engage in care-relationships with patients in ways where power is symmetrically distributed among them. However, professionals also need to focus on security at the ward. This promotes patient-professional power-relations that are asymmetrically skewed towards professionals. New practical ways of balancing between the power-relations defined by a care and custody dichotomy in forensic care need to be developed and studied to guide clinical practice.

Objectives

To study how power-relations are articulated between patient-professional within a social gaming activity (E – sport) in a Danish medium secure forensic psychiatric ward.

Methods

Three months of observational data, collected via anthropological fieldwork Interviews with 3 professionals and 6 patients Data was analyzed using sociologist Pierre Bourdieu’s notions of field, capital and power

Results

The E-sport intervention consists of two fields “in-game” and “over-game” In-game concerns the practice of gaming Over-game concerns the interventions organization Power in each field is driven by specific values and access to certain competencies Power in-game was equally open to patients and professionals leading to symmetric power relations Power over-game was open to professionals only leading to asymmetrical power relations Professionals may allow power distribution to patients during gameplay, while still retaining the overall power over the intervention

Conclusions

It is possible to balance between care-and-custody in forensic psychiatry. This study provides important insights to guide further practice.

Tidier. e-sport; a recovery oriented intervention in forensic psychiatry

Introduction

Recently video gaming, have attracted considerable attention for its possible beneficial therapeutic effects, the possibility for testing behavior in safe artificial environments and as a tool for professionals and patients to build specific competencies for the everyday life. Also, a substantial amount of research suggests that videogaming might improve the participants social and cognitive skills and emotional regulation. There is little or no evidence that videogaming increases long term aggression or leads to physical aggression. At a medium secure forensic psychiatric in-patient ward, the patients and staff engage in weekly E – Sport sessions (primarily counterstrike) to further the recovery process.

Objectives

To provide a standardized description of how E-sport is organized and used in the recovery process among forensic psychiatric patients.

Methods

The Template for Intervention Description and Replication (TIDieR) checklist and guide is widely used to in health research to describe interventions in clinical trials and other health research contexts. By use of TIDieR we describe a newly developed E-sport intervention, in which staff members and patients in a medium secure forensic psychiatric ward engage in weekly E-Sport sessions (primarily counterstrike) to improve patient–staff relationship.

Results

The E-sport intervention is detailed by use of the 12 TIDieR items and practical experiences and insights will be described.

Conclusions

This standardized and detailed description of how is used in a recovery-oriented process in forensic psychiatry can be used for future studies that wishes to implement the intervention or for research studies replicating the treatment.

Conflict of interest

No significant relationships.

Rapid dispatch for out-of-hospital cardiac arrest is associated with improved survival

AIM

As proxy for initiation of the first link in the Chain of Survival by the dispatcher, we aimed to investigate the effect of time to first dispatch on 30-day survival among patients with OHCA ultimately receiving the highest-level emergency medical response.

METHODS

We linked data on all OHCA unwitnessed by emergency medical services (EMS) treated by Copenhagen EMS from 2016 through 2018 to corresponding emergency call records. Among patients receiving highest priority emergency response, we calculated time to dispatch as time from start of call to time of first dispatch.

RESULTS

We included 3548 patients with OHCA. Of these, 94.1% received the highest priority response (median time to dispatch 0.84 min, 25th-75th percentile 0.58-1.24 min). Patients with time to dispatch within one minute compared to three or more minutes were more likely to receive bystander cardiopulmonary resuscitation (77.3 vs 54.2%), bystander defibrillation (11.5 vs 6.5%) and defibrillation by emergency medical services (24.1 vs 7.5%) and were 2.6-fold more likely to survive 30 days after the OHCA (P = 0.004). Results from multivariate logistic regression were similar: odds ratio (OR) of survival 0.83 per minute increase (95% confidence interval 0.70-1.00, P = 0.04). However, survival was similar between those who received highest priority response and those who did not: OR of survival 0.88 (95% confidence interval 0.53-1.46, P = 0.61).

CONCLUSION

Rapid time to dispatch among patients with highest priority response was significantly associated with a higher probability of 30-day survival following OHCA.

Sweet Corn Sentinel Monitoring for Lepidopteran Field-Evolved Resistance to Bt Toxins

As part of an insect resistance management plan to preserve Bt transgenic technology, annual monitoring of target pests is mandated to detect susceptibility changes to Bt toxins. Currently Helicoverpa zea (Boddie) monitoring involves investigating unexpected injury in Bt crop fields and collecting larvae from non-Bt host plants for laboratory diet bioassays to determine mortality responses to diagnostic concentrations of Bt toxins. To date, this monitoring approach has not detected any significant change from the known range of baseline susceptibility to Bt toxins, yet practical field-evolved resistance in H. zea populations and numerous occurrences of unexpected injury occur in Bt crops. In this study, we implemented a network of 73 sentinel sweet corn trials, spanning 16 U.S. states and 4 Canadian provinces, for monitoring changes in H. zea susceptibility to Cry and Vip3A toxins by measuring differences in ear damage and larval infestations between isogenic pairs of non-Bt and Bt hybrids over three years. This approach can monitor susceptibility changes and regional differences in other ear-feeding lepidopteran pests. Temporal changes in the field efficacy of each toxin were evidenced by comparing our current results with earlier published studies, including baseline data for each Bt trait when first commercialized. Changes in amount of ear damage showed significant increases in H. zea resistance to Cry toxins and possibly lower susceptibility to Vip3a. Our findings demonstrate that the sentinel plot approach as an in-field screen can effectively monitor phenotypic resistance and document field-evolved resistance in target pest populations, improving resistance monitoring for Bt crops.

Phase angle and vector analysis from multifrequency segmental bioelectrical impedance analysis: new reference data for older adults

Phase angle (PA) and bioelectrical impedance vector analysis (BIVA) have been recommended as useful prognostic markers in various clinical settings. However, reference data for older adults measured by the novel segmental multifrequency bioelectrical impedance analysis (SMF-BIA) technique are currently lacking. This study examined 567 (286 men, 281 women) healthy older adults (65 - 97 years) and new SMF-BIA-based PA and BIVA reference values were generated stratified according to gender and 3 age groups (65 - 75 years, 76 - 85 years, > 85 years). Mean PA-values (women: 4.30 ± 0.6°, men: 4.77 ± 0.7°) were significantly lower than those previously reported for a younger reference population. Age and gender were significant determinants of PA and BIVA. PA showed a significant decrease with increasing age in both genders. The greatest changes occurred in the age group > 85 years. Men had higher Pas compared to women (except for the oldest age group), but showed a substantially steeper decline in PA, possibly due to a more pronounced reduction of muscle mass. Compared to published reference data for younger adults, there was a clear downward migration of the BIVA vector points in older adults, indicating an age-related reduction of body cell mass. Accordingly, the equation for the BIVA chart generation was modified by adding the factor age. In conclusion, this is the first study to present SMF-BIA-determined PA and BIVA reference data for healthy subjects aged ≥ 65 years. These data can be used for clinical purposes to identify individuals at increased risk for adverse health events or to monitor treatment responses.

Rapid recognition of out-of-hospital cardiac arrest by emergency medical dispatchers is associated with improved survival

Background

Emergency medical dispatchers' (EMD) recognition of out-of-hospital cardiac arrest (OHCA) is an essential part of the first link in the Chain of Survival. However, it is unknown whether the time-to-recognition of OHCA by EMD during an emergency call is associated with survival.

Purpose

To investigate the effect of time-to-recognition on 30-day survival among patients with recognised OHCA.

Methods

We linked data on OHCAs occurring in the Capital Region of Denmark from 2016 through 2017 to records of corresponding emergency calls. We defined recognition as dispatching an ambulance with an appropriate priority level and subsequently defined time-to-recognition as the time from start of the call to the time of dispatching the ambulance. Among patients with recognised OHCA, we performed uni- and multivariate logistic regression to investigate the association of time-to-recognition and 30-day survival and reported odds ratios (OR) with 95% confidence intervals (CI).

Results

Among 2,382 patients with OHCA, 94.2% were recognised, in which median age was 73.6 years, 61.6% were males and median time-to-recognition was 0.8 minutes (interquartile range 0.7 minutes). Patients for whom time-to-recognition was up to (but not including) one minute had more than three-fold higher probability of surviving 30 days (15.5%) compared to patients for whom time-to-recognition was three or more minutes (4.5%) (Figure 1). Time-to-recognition was significantly associated with 30-day survival: OR 0.75 per minute (95% CI 0.62–0.91, P&lt;0.005), and results were similar in the adjusted analysis: OR 0.72 per minute (95% CI 0.58–0.90, P&lt;0.005).

Conclusion

Rapid recognition of OHCA by EMD resulted in improved survival rate of patients. This was particularly evident when time-to-recognition was three or more minutes.

Figure 1

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): Hjerteforeningen

National all-cause mortality during the COVID-19 pandemic: a Danish registry-based study

Denmark implemented early widespread social distancing to reduce pressure on the healthcare system from the coronavirus disease 2019 (COVID-19) pandemic, with the aims to reduce mortality. Unintended consequences might be delays in treatment for other diseases and subsequent mortality. We examined national all-cause mortality comparing weeks 1–27 in 2020 and 2015–2019. This registry-based study used Danish national registry data until 5 July 2020. We examined all-cause mortality rates among all deaths recorded from 2015 to 2020 and among chronic conditions (cardiovascular (cardiac & circulatory), chronic pulmonary, chronic kidney disease, cancer, and diabetes), comparing each week in 2020 to weeks in 2015–2019. In 2020, there were 28,363 deaths in weeks 1–27 (30 December 2019–5 July 2020), the mean deaths in 2015–2019 were 28,630 deaths (standard deviation 784). Compared to previous years, the mortality rate in weeks 3–10 of 2020 was low, peaking in week 14 (17.6 per 100,000 persons in week 9, 19.9 per 100,000 in week 14). Comorbidity prevalence among deceased individuals was similar in 2020 and 2015–2019: 71.1% of all deceased had a prior cardiovascular diagnosis, 30.0% of all deceased had a prior cardiac diagnosis. There were 493 deaths with COVID-19 in weeks 11–27, (59.8% male), and 75.1% had a prior cardiovascular diagnosis. Weekly mortality rates for pre-existing chronic conditions peaked in week 14, and then declined. During the COVID-19 pandemic, due to timely lockdown measures, the mortality rate in Denmark has not increased compared to the mortality rates in the same period during 2015–2019.

AB0209 PREDICTORS OF ACHIEVING STRINGENT REMISSION IN PATIENTS WITH ESTABLISHED RHEUMATOID ARTHRITIS IN CLINICAL REMISSION FOLLOWING A TREAT-TO-TARGET STRATEGY

Background:

Achieving remission according to stringent criteria such as Simplified Disease Activity Index (SDAI) and ACR/EULAR Boolean remission is associated with a better long-term outcome in patients with RA1. Possible predictors of achieving stringent remission in patients in clinical remission, following targeted treatment strategies, have not been investigated.

Objectives:

To investigate the predictive value of clinical, radiographic and MRI variables on achieving more stringent remission in RA patients in clinical remission, following MRI and conventional treat-to-target (T2T) strategies.

Methods:

In this post-hoc study, data were used from 171 RA patients in clinical remission (DAS28-CRP< 3.2 and no swollen joints) on conventional synthetic DMARDs, included in the IMAGINE-RA randomized clinical trial2, where they followed an MRI T2T strategy (targeting absence of osteitis) combined with clinical remission (DAS28-CRP≤3.2 and no swollen joints) or a conventional T2T strategy (targeting clinical remission only). Baseline contrast-enhanced MRIs of the dominant wrist and 2nd-5thMCP joints and radiographs of hands and feet were evaluated according to the OMERACT RAMRIS scoring system and Sharp/van der Heijde method, respectively, by two experienced readers. Potential clinical, radiographic and MRI baseline predictors of remission were first tested in univariate logistic regression analyses with achievement of Clinical Disease Activity Index (CDAI), SDAI, and ACR/EULAR Boolean remission at 24 months as dependent variables. Variables with p<0.25 were subsequently tested in multivariate logistic regression analyses with backward selection, adjusted for age, gender and strategy group. Missing values of covariates were imputed using chained equations.

Results:

Based on the univariate analyses, tender joint count, patient VAS global, VAS pain, VAS fatigue, physician VAS global, HAQ, MRI osteitis, radiographic and MRI erosion and joint space narrowing scores were included in multivariate analyses (Table).

Following the MRI T2T strategy was a positive predictor and high patient VAS global a negative predictor of achieving all definitions of remission. Furthermore, high patient VAS pain was negatively associated with achieving SDAI and ACR/EULAR Boolean remission and high tender joint count negatively associated with achieving CDAI and SDAI remission.

Multivariate logistic regression analyses with backward selection, final modelsDependent variables, remission at 24 monthsCDAISDAIACR/EULAR BooleanOR95% CIp-valueOR95% CIp-valueOR95% CIp-valueCovariatesMRI T2T strategy group2.941.25-7.520.0132.461.03-6.350.0435.472.33-14.11<0.001Female0.900.36-2.250.820.800.31-2.050.640.800.32-1.970.63Age1.020.98-1.070.321.020.98-1.070.331.030.99-1.070.15Tender joint count (0-28)0.330.12-0.860.0230.290.10-0.780.013Patient VAS global0.910.88-0.94<0.0010.930.88-0.97<0.0010.930.88-0.980.003Patient VAS pain0.950.91-1.000.0490.920.87-0.980.004

Conclusion:

In RA patients in clinical remission, poor patient reported outcomes and tender joint count were associated with decreased chance of achieving stringent remission, while following an MRI T2T strategy predicted stringent remission across all definitions thereof.

References:

[1]Smolen et al. Ann Rheum Dis 2017

[2]Møller-Bisgaard et al. JAMA 2019

Disclosure of Interests:

Signe Møller-Bisgaard Grant/research support from: AbbVie, Consultant of: BMS, Speakers bureau: BMS, Celgene, Pfizer, Stylianos Georgiadis Grant/research support from: Novartis, Kim Hørslev-Petersen: None declared, Bo Ejbjerg: None declared, Merete L. Hetland Grant/research support from: BMS, MSD, AbbVie, Roche, Novartis, Biogen and Pfizer, Consultant of: Eli Lilly, Speakers bureau: Orion Pharma, Biogen, Pfizer, CellTrion, Merck and Samsung Bioepis, Lykke Ørnbjerg: None declared, Daniel Glinatsi: None declared, Jakob Møllenbach Møller: None declared, Mikael Boesen Consultant of: AbbVie, AstraZeneca, Eli Lilly, Esaote, Glenmark, Novartis, Pfizer, UCB, Paid instructor for: IAG, Image Analysis Group, AbbVie, Eli Lilly, AstraZeneca, esaote, Glenmark, Novartis, Pfizer, UCB (scientific advisor)., Speakers bureau: Eli Lilly, Esaote, Novartis, Pfizer, UCB, Kristian Stengaard-Pedersen: None declared, Ole Rintek Madsen: None declared, Bente Jensen: None declared, Jan Villadsen: None declared, Ellen Margrethe Hauge: None declared, Philip Bennett: None declared, Oliver Hendricks: None declared, Karsten Asmussen: None declared, Marcin Kowalski: None declared, Hanne Merete Lindegaard: None declared, Henning Bliddal Grant/research support from: received research grant fra NOVO Nordic, Consultant of: consultant fee fra NOVO Nordic, Niels Steen Krogh: None declared, Torkell Ellingsen: None declared, Agnete Nielsen: None declared, Lone Balding: None declared, Anne Grethe Jurik: None declared, Henrik Thomsen: None declared, Mikkel Ǿstergaard Grant/research support from: AbbVie, Bristol-Myers Squibb, Celgene, Merck, and Novartis, Consultant of: AbbVie, Bristol-Myers Squibb, Boehringer Ingelheim, Celgene, Eli Lilly, Hospira, Janssen, Merck, Novartis, Novo Nordisk, Orion, Pfizer, Regeneron, Roche, Sandoz, Sanofi, and UCB, Speakers bureau: AbbVie, Bristol-Myers Squibb, Boehringer Ingelheim, Celgene, Eli Lilly, Hospira, Janssen, Merck, Novartis, Novo Nordisk, Orion, Pfizer, Regeneron, Roche, Sandoz, Sanofi, and UCB

FRI0019 MRI INFLAMMATION, DISEASE ACTIVITY AND FUNCTIONAL IMPAIRMENT ARE MORE EFFECTIVELY REDUCED BY ESCALATION TO BIOLOGICS COMPARED TO CSDMARD-ESCALATION IN RHEUMATOID ARTHRITIS PATIENTS IN CLINICAL REMISSION FOLLOWING A TREAT-TO-TARGET STRATEGY: SECONDARY ANALYSES OF THE IMAGINE-RA TRIAL

Background:

The effect of different treatment escalations on MRI inflammation in rheumatoid arthritis (RA) patients following an MRI treat-to-target (T2T) strategy has not previously been investigated.

Objectives:

To compare the effect of different treatment escalations on MRI inflammation, physical function and disease activity in RA patients in clinical remission, following an MRI T2T strategy.

Methods:

One hundred RA patients in clinical remission (DAS28-CRP<3.2 and no swollen joints), on conventional synthetic (cs) DMARDs following an MRI T2T strategy targeting DAS28-CRP≤3.2, no swollen joints plus absence of MRI osteitis, were followed for 2 years with clinical and MRI (wrist and 2nd-5thMCP joints) evaluation every 4 months1. If target was not met, a predefined treatment escalation algorithm dictated: First: increase in csDMARDs (A), second: adding a TNF inhibitor (TNFi) (B), third and onwards: switch between biologics (C). If target was met, no change in baseline csDMARDs was done (D). Outcomes were assessed 4 months after treatment change. MRIs were evaluated with known chronology by one experienced reader. Repeated measures mixed linear models were used to express estimates of group differences on predefined co-primary outcomes (MRI osteitis, HAQ) and key secondary outcomes (MRI combined inflammation, Simplified Disease Activity Index (SDAI)).

Results:

Escalation to first TNFi (B) or to 2ndor later biologic (C) compared to csDMARDs (A) was consistently more effective on all outcomes (e.g. in group B osteitis was reduced with 1.8 units more than A) (Table). Unchanged (D) compared to escalation in csDMARD (A) treatment did not differ, except for HAQ-score. Escalation to a 2ndor later biologics (C) compared to the first TNFi (B) was more effective suppressing MRI inflammation. Escalation to TNFi treatment (B) or to 2ndor later biologic (C) compared to unchanged treatment (D) was more effective on all outcomes except from HAQ-score (no difference between groups).

Comparisons of treatment escalations1A: Increment in csDMARD mono/combination therapy (n=73)); B: Switch from csDMARD combination therapy to TNFi (n=39); C: Switch from TNFi to 2ndbiologic/switch between biologics (n=21); D: No change in csDMARDs from baseline (n=58)A vs BA vs CA vs DB vs CB vs DC vs DOutcomesPrimaryMRIOsteitis1.8 (1.0; 2.6) p<.00013.6 (2.3; 4.8) p<.00010.3 (−0.3; 1.0)p=.321.8 (0.8; 2.9) p=.0006−1.4 (−2.4; −0.5) p=.0045−3.3 (−4.6; −1.9) p<.0001HAQ0.081(0.033; 0.13) p=.00110.091(0.031; 0.15) p=.00320.054(0.014; 0.095) p=.00910.0092(−0.051; 0.070) p=.77−0.027(−0.082; 0.028) p=.33−0.037(−0.10; 0.031) p=.29Key secondaryMRI combined inflammationa2.5 (0.9; 4.1) p=.00185.4 (3.1; 7.7) p<.00010.4 (−0.9; 1.8)p=.522.9 (0.8; 4.9) p=.0064−2.1 (−4.0; −0.2) p=.032−5.0 (−7.5; −2.4) p=.0002SDAI2.7 (1.9; 3.5) p<.00012.4 (1.4; 3.4) p<.00010.5 (−0.2; 1.2)p=.14−0.3 (−1.3; 0.7)p=.60−2.2 (−3.1; −1.3) p<.0001−1.9 (−3.0; 0.8) p=.0006

1Estimates of group differences (least squares means (95% CI)).

aSum score of synovitis, osteitis and tenosynovitis

Conclusion:

T2T-based treatment escalations to biologics compared to csDMARD-escalations more effectively improved MRI inflammation, physical function and disease activity. Further optimization of the treatment in RA patients in clinical remission may improve long-term outcomes.

References:

[1]Møller-Bisgaard et al. JAMA 2019

Disclosure of Interests:

Signe Møller-Bisgaard Grant/research support from: AbbVie, Consultant of: BMS, Speakers bureau: BMS, Celgene, Pfizer, Kim Hørslev-Petersen: None declared, Bo Ejbjerg: None declared, Merete L. Hetland Grant/research support from: BMS, MSD, AbbVie, Roche, Novartis, Biogen and Pfizer, Consultant of: Eli Lilly, Speakers bureau: Orion Pharma, Biogen, Pfizer, CellTrion, Merck and Samsung Bioepis, Robin Christensen: None declared, Lykke Ørnbjerg: None declared, Daniel Glinatsi: None declared, Jakob Møllenbach Møller: None declared, Mikael Boesen Consultant of: AbbVie, AstraZeneca, Eli Lilly, Esaote, Glenmark, Novartis, Pfizer, UCB, Paid instructor for: IAG, Image Analysis Group, AbbVie, Eli Lilly, AstraZeneca, esaote, Glenmark, Novartis, Pfizer, UCB (scientific advisor)., Speakers bureau: Eli Lilly, Esaote, Novartis, Pfizer, UCB, Kristian Stengaard-Pedersen: None declared, Ole Rintek Madsen: None declared, Bente Jensen: None declared, Jan Villadsen: None declared, Ellen Margrethe Hauge: None declared, Philip Bennett: None declared, Oliver Hendricks: None declared, Karsten Asmussen: None declared, Marcin Kowalski: None declared, Hanne Merete Lindegaard: None declared, Henning Bliddal Grant/research support from: received research grant fra NOVO Nordic, Consultant of: consultant fee fra NOVO Nordic, Niels Steen Krogh: None declared, Torkell Ellingsen: None declared, Agnete Nielsen: None declared, Anne Grethe Jurik: None declared, Lone Balding: None declared, Henrik Thomsen: None declared, Mikkel Ǿstergaard Grant/research support from: AbbVie, Bristol-Myers Squibb, Celgene, Merck, and Novartis, Consultant of: AbbVie, Bristol-Myers Squibb, Boehringer Ingelheim, Celgene, Eli Lilly, Hospira, Janssen, Merck, Novartis, Novo Nordisk, Orion, Pfizer, Regeneron, Roche, Sandoz, Sanofi, and UCB, Speakers bureau: AbbVie, Bristol-Myers Squibb, Boehringer Ingelheim, Celgene, Eli Lilly, Hospira, Janssen, Merck, Novartis, Novo Nordisk, Orion, Pfizer, Regeneron, Roche, Sandoz, Sanofi, and UCB

Scoring magnetic resonance imaging (MRI) inflammation and structural lesions in sacroiliac joints of patients with axial spondyloarthritis: assessment of all MRI slices of the cartilaginous compartment versus standardized six or five slices

Objectives: The Spondyloarthritis Research Consortium of Canada (SPARCC) sacroiliac joint (SIJ) scoring system assesses six or five (6/5) semicoronal magnetic resonance imaging (MRI) slices for inflammation/structural lesions in patients with axial spondyloarthritis (axSpA). However, the cartilaginous SIJ compartment may be visible in a few additional slices. The objective was to investigate interreader reliability, sensitivity to change, and classification of MRI scans as positive or negative for various lesion types using an 'all slices' approach versus standard SPARCC scoring of 6/5 slices.Method: Fifty-three axSpA patients were treated with the tumour necrosis factor inhibitor golimumab and followed with serial MRI scans at weeks 0, 4, 16, and 52. The most anterior and posterior slices covering the cartilaginous compartment and the transitional slice were identified. Scores for inflammation, fat metaplasia, erosion, backfill, and ankylosis in the cartilaginous SIJ compartment were calculated for the 'all slices' approach and the 6/5 slices standard.Results: By the 'all slices' approach, three readers scored mean 7.2, 7.7, and 7.0 slices per MRI scan. Baseline and change scores for the various lesion types closely correlated between the two approaches (Pearson's rho ≥ 0.95). Inflammation score was median 13 (interquartile range 6-21, range 0-49) for 6/5 slices versus 14 (interquartile range 6-23, range 0-69) for all slices at baseline. Interreader reliability, sensitivity to change, and classification of MRI scans as positive or negative for various lesion types were similar.Conclusion: The standardized 6/5 slices approach showed no relevant differences from the 'all slices' approach and, therefore, is equally suited for monitoring purposes.

Automatic Time Sequence Filter Sampling of Aerosols for Rapid Multi-Element Analysis by Proton-Induced X-Ray Emission

An automatic time sequence filter sampler has been developed for atmospheric aerosol particle sampling of ambient air and subsequent analysis for elemental composition using the proton, beam of a Van de Graaff accelerator. Some features of the operation of the sampler are given, the retention of particles by the filter material are discussed, examples of the type of data obtained are presented, and some approaches to the numerical analysis of data for environmental interpretation are considered. Lines for further development and improvement in this type of sampler are indicated.

Decomposer diversity increases biomass production and shifts aboveground-belowground biomass allocation of common wheat

Biodiversity is well known to enhance many ecosystem functions, but empirical evidence for the role of soil biodiversity for plant biomass production and allocation is scarce. Here we studied the effects of animal decomposer diversity (1, 2, and 4 species as well as a control without any decomposers) on the biomass production and aboveground-belowground biomass allocation of common wheat using two earthworm and two Collembola species using an additive design in two soil management types (organic and mineral fertilizer treatments) in a microcosm experiment. Shoot (+11%), spike (+7%), and root biomass (+56%), increased significantly with increasing decomposer diversity, and these effects were consistent across the two soil management types. Notably, decomposer diversity effects were stronger on root than on shoot biomass, significantly decreasing the shoot-to-root ratio (−27%). Increased plant biomass production was positively correlated with a decomposer richness-induced increase in soil water nitrate concentrations five weeks after the start of the experiment. However, elevated soil nitrate concentrations did not cause significantly higher plant tissue nitrogen concentrations and nitrogen amounts, suggesting that additional mechanisms might be at play. Consistent decomposer diversity effects across soil management types indicate that maintaining soil biodiversity is a robust and sustainable strategy to enhance crop yield.

Severe pulmonary haemorrhage syndrome in leptospirosis in a returning traveller

Clinical presentation of leptospirosis ranges from asymptomatic infection to fulminant, life-threatening disease. Pulmonary involvement in terms of severe pulmonary haemorrhage syndrome (SPHS) has recently become a more frequently reported facet of leptospirosis and correlates with high mortality rates. It has not yet been described in returning German travellers. We present a case of a healthy young man developing massive pulmonary haemorrhage and severe ARDS requiring mechanical ventilation and high-dose catecholamines after travelling to Indonesia. Leptospirosis was verified by blood PCR as well as serology and treated with high-dose, intravenous penicillin. Outcome was favourable, the patient recovered completely. Leptospirosis and SPHS should be taken into account as an emerging infectious disease in patients with fever and lung involvement.

Omalizumab prevents anaphylaxis and improves symptoms in systemic mastocytosis: Efficacy and safety observations

BACKGROUND

Patients with systemic mastocytosis (SM) may suffer from mast cell (MC) mediator-related symptoms insufficiently controlled by conventional therapy. Omalizumab is an established treatment in other MC-driven diseases, but experiences in SM are limited.

OBJECTIVE

To assess the efficacy and safety of omalizumab in SM.

METHODS

In our patient cohort, we evaluated all SM patients treated with omalizumab. A physician global assessment of type and severity of symptoms was performed at baseline, at 3 and 6 months and at latest follow-up. Quality of life was assessed by visual analogue scale. S-tryptase and KIT D816V allele burden were monitored.

RESULTS

A total of 14 adult SM patients (10 ISM, 2 BMM, 1 SSM, and 1 ASM-AHN) received omalizumab with a median duration of 17 months (range: 1-73 months). One patient was excluded due to concomitant cytoreductive therapy. In the remaining 13 patients, we observed a significant reduction in symptoms, with complete symptom control in five (38.5%), major response in three (23.1%), and a partial response in three (23.1%) patients, whereas two patients (15.4%) withdrew due to subjective side-effects at first dose. The treatment was most effective for recurrent anaphylaxis and skin symptoms, less for gastrointestinal, musculoskeletal, and neuropsychiatric symptoms. Patient-reported quality of life showed significant improvement. No significant changes in s-tryptase/KIT D816V allele burden were observed. No severe adverse events were recorded.

CONCLUSIONS

Omalizumab appears to be a promising treatment option in SM, effectively preventing anaphylaxis and improving chronic MC mediator-related symptoms, insufficiently controlled by conventional therapy. Controlled studies are needed to substantiate findings.

PEPDar: A randomized prospective noninferiority study of ritonavir-boosted darunavir for HIV post-exposure prophylaxis

OBJECTIVES

PEPDar compared the tolerability and safety of ritonavir-boosted darunavir (DRV/r)-based post-exposure prophylaxis (PEP) with the tolerability and safety of standard of care (SOC). The primary endpoint was the early discontinuation rate among the per-protocol population.

METHODS

PEPDar was an open-label, randomized, multicentre, prospective, noninferiority safety study. Subjects were stratified by type of event (occupational vs. nonoccupational, i.e. sexual) and were randomized to receive DRV/r plus two nucleoside reverse transcriptase inhibitors (NRTIs) or SOC PEP. Twenty-two private or university HIV clinics in Germany participated. Subjects were ≥ 18 years old and had documented or potential HIV exposure and indication for HIV PEP. They initiated PEP not later than 72 h after the event and were HIV negative.

RESULTS

A total of 324 subjects were screened, the per-protocol population was 305, and 273 subjects completed the study. One hundred and fifty-five subjects received DRV/r-based PEP and 150 subjects received ritonavir-boosted lopinavir (LPV/r)-based PEP for 28-30 days; 298 subjects also received tenofovir/emtricitabine. The early discontinuation rate in the DRV/r arm was 6.5% compared with 10.0% in the SOC arm (P = 0.243). Adverse drug reactions (ADRs) were reported in 68% of DRV/r subjects and 75% of SOC subjects (P = 0.169). Fewer DRV/r subjects (16.1%) had at least one grade 2 or 3 ADR compared with SOC subjects (29.3%) (P = 0.006). All grades of diarrhoea, nausea, and sleep disorders were significantly less frequent with DRV/r, while headache was significantly more frequent. No HIV seroconversion was reported during follow-up.

CONCLUSIONS

Noninferiority of DRV/r to SOC was demonstrated. DRV/r should be included as a standard component of recommended regimens in PEP guidelines.

Convergence of soil microbial properties after plant colonization of an experimental plant diversity gradient

Background

Several studies have examined the effects of plant colonization on aboveground communities and processes. However, the effects of plant colonization on soil microbial communities are less known. We addressed this gap by studying effects of plant colonization within an experimental plant diversity gradient in subplots that had not been weeded for 2 and 5 years. This study was part of a long-term grassland biodiversity experiment (Jena Experiment) with a gradient in plant species richness (1, 2, 4, 8, 16, and 60 sown species per plot). We measured plant species richness and productivity (aboveground cover and biomass) as well as soil microbial basal respiration and biomass in non-weeded subplots and compared the results with those of weeded subplots of the same plots.

Results

After 2 and 5 years of plant colonization, the number of colonizing plant species decreased with increasing plant diversity, i.e., low-diversity plant communities were most vulnerable to colonization. Plant colonization offset the significant relationship between sown plant diversity and plant biomass production. In line with plant community responses, soil basal respiration and microbial biomass increased with increasing sown plant diversity in weeded subplots, but soil microbial properties converged in non-weeded subplots and were not significantly affected by the initial plant species richness gradient.

Conclusion

Colonizing plant species change the quantity and quality of inputs to the soil, thereby altering soil microbial properties. Thus, plant community convergence is likely to be rapidly followed by the convergence of microbial properties in the soil.

Electronic supplementary material

The online version of this article (doi:10.1186/s12898-016-0073-0) contains supplementary material, which is available to authorized users.

Patient preferences for timing and access to radiation therapy

PURPOSE

Patient preferences for radiation therapy (rt) access were investigated.

METHODS

Patients completing a course of rt at 6 centres received a 17-item survey that rated preferences for time of day; day of week; actual, ideal, and reasonable travel times for rt; and actual, ideal, and reasonable times between referral and first oncologic consultation. Patients receiving single-fraction rt or brachytherapy alone were excluded.

RESULTS

Of the respondents who returned surveys (n = 1053), 54% were women, and 74% had received more than 15 rt fractions. With respect to appointment times, 88% agreed or strongly agreed that rt between 08h00 and 16h30 was preferred; 14%-15% preferred 07h30-08h00 or 16h30-17h00; 10% preferred 17h00-18h00; and 6% or fewer preferred times before 07h30 or after 18h00. A preference not to receive rt before 07h30 or after 18h00 was expressed by 30% or more of the respondents. When days of the week were considered, 18% and 11% would have preferred to receive rt on a Saturday or Sunday respectively; 52% and 55% would have preferred not to receive rt on those days. A travel time of 1 hour or less for rt was reported by 82%, but 61% felt that a travel time of 1 hour or more was reasonable. A first consultation within 2 weeks of referral was felt to be ideal or reasonable by 88% and 73% of patients respectively.

CONCLUSIONS

An rt service designed to meet patient preferences would make most capacity available between 08h00 and 16h30 on weekdays and provide 10%-20% of rt capacity on weekends and during 07h30-08h00 and 16h30-18h00 on weekdays. Approximately 80%, but not all, of the responding patients preferred a 2-week or shorter interval between referral and first oncologic consultation.

Pseudo-outbreak ofMycobacterium abscessusInfection Caused by Laboratory Contamination

Objective.

To investigate the cause(s) of an increased incidence of clinical cultures growingMycobacterium abscessusat a hospital in Florida.

Design.

Outbreak investigation.

Setting.

University-affiliated, tertiary-care hospital.

Methods.

A site visit was done during the first week of September 2006. We reviewed the medical records of patients from whomM. abscessuswas recovered during the period from January 1, 2003, through June 30, 2006. We collected environmental samples from various sites and evaluated specimen processing procedures in the microbiology laboratory. Isolates ofM. abscessusrecovered from the environment and from 12 randomly selected patients who sought medical care in 2006 were compared by pulsed-field gel electrophoresis (PFGE). Follow-up case surveillance was continued through March 31, 2007.

Results.

Specimens from 143 patients obtained from various anatomical sites grewM. abscessuson culture in 2005-2006, compared with specimens from 21 patients in 2003-2004. The 12 isolates from patients that were selected for molecular typing had indistinguishable PFGE patterns. Observations revealed no major breaches in the processing of mycobacterial specimens in the laboratory. Isolates grew only after prolonged incubation (mean ± SD, 45 ± 15 days) in test tubes containing diagonally oriented Middlebrook and Cohn 7H10 agar or Lowenstein-Jensen medium. Environmental samples obtained from the inside of the specimen incubator grewM. abscessuson culture. A test tube containing diagonally oriented, uninoculated Middlebrook and Cohn 7H10 agar that was incubated in the same incubator as clinical specimens grewM. abscessuswith a PFGE pattern that matched the pattern of the patient isolates. Cases ofM. abscessusinfection decreased to baseline after the hospital changed suppliers of mycobacterial media and cleaned the incubator.

Conclusions.

Although the source was never confirmed, our investigation suggests that this was a pseudo-outbreak ofM. abscessusinfection that resulted from contamination of mycobacterial cultures during incubation. Our findings emphasize the need for guidance on the disinfection of specimen incubators.

Hodgkin lymphoma is as common as non-Hodgkin lymphoma in HIV-positive patients with sustained viral suppression and limited immune deficiency: a prospective cohort study

OBJECTIVES

The incidence of HIV-related non-Hodgkin lymphoma (NHL) but not that of Hodgkin lymphoma (HL) has been declining. The aim of the study was to compare HIV-infected patients with NHL and HL with respect to antiretroviral therapy (ART) exposure at the time of lymphoma diagnosis.

METHODS

HIV-infected patients with NHL and HL included in a prospective multicentre cohort study since January 2005 were compared with respect to ART exposure and viral load at the time of lymphoma diagnosis.

RESULTS

As of 31 December 2012, data for 329 patients with NHL and 86 patients with HL from 31 participating centres were available. Patients with HL were more likely to be on ART (73.5% vs. 39.1%, respectively; P < 0.001) and more frequently had a viral load below the detection limit (57.3% vs. 27.9%, respectively; P < 0.001) than patients with NHL. The proportion of patients with HL was 8.0% in ART-naïve patients, 34.8% in patients with current HIV RNA < 50 HIV-1 RNA copies/mL, and 50.0% in patients with both HIV RNA < 50 copies/mL for > 12 months and a CD4 cell count of > 200 cells/μL. Of note, 45.8% of all patients with NHL were not currently on ART and had a CD4 count of < 350 cells/μL.

CONCLUSIONS

This prospective cohort study shows that HL was as common as NHL in patients with sustained viral suppression and limited immune deficiency. In contrast to NHL, the majority of patients with HL were on effective ART, suggesting that ART provides insufficient protection from developing HL. The high proportion of untreated patients with NHL suggests missed opportunities for earlier initiation of ART.

Extensive double humanization of both liver and hematopoiesis in FRGN mice

Preclinical research in animals often fails to adequately predict the outcomes observed in human patients. Chimeric animals bearing individual human tissues have been developed to provide improved models of human-specific cellular processes. Mice transplanted with human hematopoietic stem cells can be used to study human immune responses, infections of blood cells and processes of hematopoiesis. Animals with humanized livers are useful for modeling hepatotropic infections as well as drug metabolism and hepatotoxicity. However, many pathophysiologic processes involve both the liver and the hematolymphoid system. Examples include hepatitis C/HIV co-infection, immune mediated liver diseases, liver injuries with inflammation such as steatohepatitis and alcoholic liver disease.

We developed a robust protocol enabling the concurrent double-humanization of mice with mature hepatocytes and human blood. Immune-deficient, fumarylacetoacetate hydrolase (Fah^−/−), Rag2^−/− and Il2rg^−/− deficient animals on the NOD-strain background (FRGN) were simultaneously co-transplanted with adult human hepatocytes and hematopoietic stem cells after busulfan and Ad:uPA pre-conditioning. Four months after transplantation the average human liver repopulation exceeded 80% and hematopoietic chimerism also was high (40–80% in bone marrow). Importantly, human macrophages (Kupffer cells) were present in the chimeric livers.

Double-chimeric FRGN mice will serve as a new model for disease processes that involve interactions between hepatocytes and hematolymphoid cells.

First Report of Stemphylium globuliferum Causing Stemphylium Leaf Spot on Alfalfa (Medicago sativa) in the United States

Stemphylium leaf spot occurs in most areas where alfalfa (Medicago sativa) is grown. In the United States, Stemphylium botryosum is reported to be the predominant pathogen (1), although S. vesicarium and S. herbarum are also observed. S. alfalfae was isolated on alfalfa in Australia (4) and S. globuliferum was reported in Egypt and Korea. In April and May 2012, alfalfa plants with leaf spot symptoms were observed in Rosemount and Waseca, MN, and in Arlington, Tomah, and Waupaca, WI. Initial symptoms consisted of white to tan spots with a brown border, 2 to 3 mm in diameter, circular to oval, enlarging to 5 to 8 mm in diameter. Large lesions often coalesced. Small, narrow, brown lesions occurred on petioles. Lower killed leaves remained attached to the primary stem. Spots were larger than those caused by the cool temperature biotype of S. botryosum. Conidia formed on lesions after 48 h in a moist chamber. Conidia were removed with a fine glass rod, germinated on 1% water agar, and single hyphae transferred to V8 agar (V8A). After 2 weeks under room light, plates were placed under UV light to stimulate spore production. Conidia on host material were borne singly on straight, unbranched, smooth conidiophores, medium brown at the apex. Conidia were medium to dark brown with small papillae, subspherical with 3 to 4 transverse and 3 to 4 complete or near complete longitudinal septa, with a distinct constriction at the median transverse septum. Conidia were 27.5 to 32.5 μm long × 20 to 22.5 μm wide with a length/width (L/W) ratio of 1.2 to 1.5. Conidia on V8A were smaller, 25 to 30 μm long × 12.5 to 19 μm wide with a L/W of 1.6 to 1.8. Ascostromata 300 μm in diameter formed on leaves held at 4°C for 2 months as well as on culture plates after 1 month. Ascospores from leaves were golden brown to reddish, 40 to 42.5 × 20 μm, slightly broader in the upper half of the spore, with 7 to 8 transverse septa and one complete longitudinal septum with several incomplete septa. Ascospores from culture were smaller, 27.5 to 30 × 12.5 to 15 μm wide. These morphological features are consistent with the description for S. globuliferum (3). DNA was extracted from pure cultures of SAr301 and SWp202, isolated from plants grown in Arlington and Waupaca, respectively, and used to amplify ITS1-5.8S-ITS2 rDNA using primers ITS1 and ITS4, GPD with primers GPD1 and GPD2, EF-1α with EF446f and EF1473R, and the intergenic spacer between vmaA and vpsA with primers ATPF2 and GTP604R (2). In sequence comparisons made by BLASTn searches of GenBank, the ITS (KF479193), GPD (KF479194), and EF-1α (KF479195) sequences from S. globuliferum were different from the gene sequences of S. botryosum but identical to those from S. vesicarium, S. herbarum, and S. alfalfae. The vmaA-vpsA spacer sequence (KF479196) of S. globuliferum had 3 nucleotide differences from S. vesicarium and S. herbarum and 4 nucleotide differences from S. alfalfae, demonstrating that this sequence is useful for species discrimination. Conidia from strains SAr301 and SWp 202 were suspended at 10⁴/ml in sterile water with 0.01% Tween 20 and used to inoculate 12 alfalfa plants using a handheld sprayer. Plants were kept at 100% RH for 48 h, then grown at 20°C with a 16-h photoperiod. After 2 weeks, lesions similar to those seen in the field were observed on leaves of all plants. Symptomatic leaves placed in moist chambers produced conidia with the size and morphology of S. globuliferum within 48 h. This is the first report to our knowledge of S. globuliferum causing disease on alfalfa in the United States. Cultures were deposited in the University of Minnesota Mycological Culture Collection. References: (1) W. A. Cowling et al. Phytopathology 71:679, 1981. (2) P. Inderbitzin et al. Mycologia 101:320, 2009. (3) E. G. Simmons. Mycologia 61:1, 1969. (4) E. G. Simmons. Sydowia 38:284, 1985.