[High-quality acceleration of the Chinese national schistosomiasis elimination programme to advance the building of Healthy China]

The goal of achieving elimination of schistosomiasis across all endemic counties in China by 2030 was proposed in the Outline of the Healthy China 2030 Plan. On June 16, 2023, the Action Plan to Accelerate the Elimination of Schistosomiasis in China (2023-2030) was jointly issued by National Disease Control and Prevention Administration and other 10 ministries, which deployed the targets and key tasks of the national schistosomiasis elimination programme in China. This article describes the progress of the national schistosomiasis control programme, analyzes the opportunities to eliminate schistosomiasis, and proposes targeted recommendations to tackle the challenges of schistosomiasis elimination, so as to accelerate the process towards schistosomiasis elimination and facilitate the building of a healthy China.

[Practice and development of schistosomiasis control culture in China: A case of Jiangxi Province]

Schistosomiasis control is not only a disease control programme, but also a great social practice activity in China. During the evolution of national schistosomiasis control programmes, the special schistosomiasis control culture has been cultivated and developed, which contains the spiritual connotation of government-led, people-oriented, respect for science and integration of all efforts. The publication of Chairman Mao Zedong's two poems entitled "Farewell to the God of Plague" and the post-script in 1958 was a sign for the formation and development of Chinese schistosomiasis control culture, which always lead the orientation of development and practice of schistosomiasis control culture building. The schistosomiasis control culture provides powerful spiritual motivation and supports to schistosomiasis control programmes in China, and improving the building of schistosomiasis control culture is of great significance to strengthen our belief in achieving the goal of schistosomiasis elimination, mobilize all social resources, accelerate the progress towards elimination of schistosomiasis and facilitate the high-quality development of healthcare services. Chinese schistosomiasis control spirit is the refinement from the cultural connotation of the long-term schistosomiasis control programmes in China, and is the most essential and concentrated embodiment of the schistosomiasis control culture. This article describes the great significance of two poems entitled "Farewell to the God of Plague", summarizes the connotation and role of schistosomiasis control spirit, and introduces the practice, development and innovation of schistosomiasis control culture building in Jiangxi Province.

HPV-positive clinically advanced squamous cell carcinoma of the urinary bladder (aBSCC): A comprehensive genomic profiling (CGP) study

BACKGROUND

Advanced bladder squamous cell carcinoma (aBSCC) is an uncommon form of urinary bladder malignancy when compared with the much higher urothelial carcinoma incidence. We studied the genomic alteration (GA) landscape in a series of aBSCC based on the association with human papilloma virus (HPV) to determine if differences in GA would be observed between the positive and negative groups.

METHODS

Using a hybrid capture-based FDA-approved CGP assay, a series of 171 aBSCC were sequenced to evaluate all classes of GA. Tumor mutational burden (TMB) was determined on up to 1.1 Mbp of sequenced DNA and microsatellite instability (MSI) was determined on up to 114 loci. Programmed cell death ligand -1 (PD-L1) expression was determined by IHC (Dako 22C3) with negative expression when PD-L1 was 0, lower expression of positivity set at 1 to 49%, and higher expression set at ≥50% expression.

RESULTS

Overall, 11 (6.4%) of the aBSCC were found to harbor HPV sequences (10 HPV16 and 1 HPV 11). HPV+ status was identified slightly more often in women (NS) and in younger patients (P = 0.04); 2 female patients with aBSCC had a prior history of SCC including 1 anal SCC and 1 vaginal SCC. HPV+ aBSCC had fewer GA/tumor (P < 0.0001), more inactivating mutations in RB1 (P = 0.032), and fewer inactivating GA in CDKN2A (P < 0.0001), CDKN2B (P = 0.05), TERT promoter (P = 0.0004) and TP53 (P < 0.0001). GA in genes associated with urothelial carcinoma including FGFR2 and FGFR3 were similar in both HPV+ and HPV- aBSCC groups. MTAP loss (homozygous deletion) which has emerged as a biomarker for PRMT5 inhibitor-based clinical trials was not identified in any of the 11 HPV+ aBSCC cases, which was significantly lower than the 28% positive frequency of MTAP loss in the HPV- aBSCC group (P < 0.0001). MTOR and PIK3CA pathway GA were not significantly different in the 2 groups. Putative biomarkers associated with immunotherapy (IO) response, including MSI and TMB status, were also similar in the 2 groups. PD-L1 expression data was available for a subset of both HPV+ and HPV- cases and showed high frequencies of positive staining which was not different in the 2 groups.

CONCLUSIONS

HPV+ aBSCC tends to occur more often in younger patients. As reported in other HPV-associated squamous cell carcinomas, HPV+ aBSCC demonstrates significantly reduced frequencies of inactivating mutations in cell cycle regulatory genes with similar GA in MTOR and PIK3CA pathways. The implication of HPV in the pathogenesis of bladder cancer remains unknown but warrants further exploration and clinical validation.

Changes in the Abundances of Cervical and Rectal Mycobiota during Chemoradiotherapy in Cervical Cancer

PURPOSE/OBJECTIVE(S)

Globally, cervical cancer is the fourth most frequent cancer in women. The local and gut microbiomes of cervical cancer patients primarily consist of bacteria, viruses, and fungi. Bacterial composition has been previously associated with response to chemoradiotherapy (CRT) and patient outcome. Recently, our group has demonstrated that the HPV virome dynamically shifts during treatment and was associated with treatment response. Although connections between fungi and cervicovaginal health have been established, little is known about the fungal microbiome during treatment of cervical cancer. In this study, we sought to explore changes in fungal distribution throughout CRT for a cohort of cervical cancer patients.

MATERIALS/METHODS

This study includes 57 patients diagnosed with cervical cancer at a single institution with samples collected throughout CRT timepoints: baseline, week 1, week 3, and week 5. 170 swab specimens were included in this analysis: 138 cervical swabs from 56 patients and 32 rectal swabs from 9 patients. Whole genome sequencing data was obtained from the swabs using the Illumina HiSeqX platform (2 × 150bp). Fungal reads were log transformed to reduce variability and skewness and normalized to the total library size resulting in log normalized fungal reads per million (RPM). Bacterial reads were normalized with the same methodology. Timepoint analysis was performed using Wilcoxon signed rank tests or Friedman tests (with Dunn's multiple comparisons test) when comparing two or more time points, respectively.

RESULTS

All swab samples contained reads mapped to fungi. Of the 3.70 × 109 total reads across all sequenced samples, 19.2% did not map specifically to the human genome: 91.8% of these non-human reads could not be mapped to an individual microbial genome. Of the remaining 8.2% of non-human reads that mapped to a specific microbial genome (1.6% of total), 97.4% were classified as bacterial (1.5% of total), 0.71% as virus (0.011% of total), and 0.44% as fungal (0.0069% of total). Comparison of fungal RPM in the cervical and rectal microbiome revealed a significant decrease during treatment from baseline to week 5 (cervical, P = 0.0002; rectal, P = 0.0273). Distribution of bacterial reads exhibited similar trends as decreases were observed between baseline and week 5 for both cervical (P = 0.0116) and rectal (P = 0.0195) samples. Fungi to bacteria distribution ratios in the rectal microbiome revealed significant differences when comparing across all timepoints (P = 0.0041), baseline vs. week 1 (P = 0.0028), baseline vs. week 3 (P = 0.0389), and baseline vs. week 5 (P = 0.0113) with all three later timepoints higher relative to baseline.

CONCLUSION

The distributions of cervical and gut fungal reads and their relationship to the bacteriome shift during CRT. Further investigation into characterizing fungi and their relationship with other microbiota will be valuable to understanding its potential associations with cervical cancer and treatment response.

Proton Radiation Therapy for Stage IIA/IIB Testicular Seminoma

PURPOSE/OBJECTIVE(S)

Testicular seminoma affects young men and is associated with very favorable prognosis. The evolution in treatment paradigm has focused on minimizing acute and especially late toxicities. Following orchiectomy, while surveillance is favored in Stage I patients, radiotherapy (RT) is a standard treatment option for de novo or relapsed stage IIA or select non-bulky stage IIB disease. Despite low doses, standard RT fields to paraaortic and pelvic lymphatics using x-rays exposes a large volume of uninvolved normal tissue/viscera to excess dose. This young patient population is especially vulnerable to risks of late RT toxicities including secondary malignancy. Proton beam therapy (PBT) has dosimetric advantage over x-ray-based RT due to lack of exit dose, and comparative dosimetric/modeling studies show significant sparing of uninvolved abdominal/pelvic organs. However, there is scant reported clinical data at this time for PBT. We review our early institutional outcomes with PBT for testicular seminoma.

MATERIALS/METHODS

Single institution retrospective review from a tertiary care center of patients treated with PBT from 2013-2022 for testicular seminoma. Recurrence free (RFS) and overall survival (OS) were calculated from the completion of PBT. Toxicities were graded (Gr) using CTCAE v5.0.

RESULTS

Four patients underwent PBT, median age 39 (range 36-47). All were Stage I at diagnosis (pT1b n = 3; pT2 n = 1) and were treated for recurrent stage II disease (IIA n = 3; IIB n = 1) at a median of 34 months from orchiectomy (range 3 - 74 months). Nodal extent included 2 with multiple paraaortic nodes, 1 with solitary paraaortic node and 1 with solitary pelvic node. PBT was delivered with pencil-beam scanning, treating paraaortic + ipsilateral pelvic fields (20 Gy in 10 fractions), then sequential boost to involved nodes (10 -16 Gy in 5-8 fractions). Typically, PA or posterior oblique fields were used to minimize dose to out-of-field abdominal/pelvic viscera. Treatment was well tolerated with minimal acute toxicities: fatigue Gr 1 (n = 3), nausea Gr 1 (n = 3). No Gr 2 or higher acute toxicities or significant late toxicities were observed. At median follow up of 30 months (range 3 - 54), no recurrences were observed, and RFS and OS were 100%. Two patients are without evidence of disease > 4 years post-treatment.

CONCLUSION

In this case series, PBT for retroperitoneal and pelvic metastases in Stage IIA/IIB testicular seminoma was associated with oncologic efficacy with minimal toxicity. PBT reduces unnecessary dose to abdominal/pelvic organs compared to x-ray techniques, which is advantageous in young patients who have anticipated long-term survival. This is one of the few series reporting clinical outcomes of PBT in the management of seminoma. Randomized comparisons with x-ray approaches are impractical given the relatively low volume of patients receiving RT in modern seminoma management, so it is essential to report and track longitudinal outcomes across institutions to validate this approach.

Early Outcomes of MR-Guided SBRT for Patients with Recurrent Pancreatic Adenocarcinoma

PURPOSE/OBJECTIVE(S)

Local treatment options for patients with locally recurrent pancreatic adenocarcinoma (L-PAC) are limited, with expected median survival time (MST) of 8-11 months (mo) following recurrence. MRI-guided radiation therapy (MRgRT) provides the ability to dose escalate while sparing normal tissue. The literature for MR-guided Stereotactic Body Radiotherapy (MRgSBRT) for L-PAC is sparse. Here we report on the early outcomes of MRgSBRT in patients with L-PAC.

MATERIALS/METHODS

Patients with prior resection of pancreatic adenocarcinoma with post-operative chemotherapy as indicated followed by local recurrence of disease at prior surgical site and treated with MRgSBRT at a single tertiary referral center from 5-2021 to 8-2022 for L-PAC were identified from our prospective database. MRgSBRT was delivered to 40-50 Gy in 4-5 fractions with target and OAR delineation per institutional standards. Descriptive analysis of the patient, disease, and treatment characteristics were performed. Endpoints included local control, defined as absence of tumor progression per RECIST criteria, distant failure, overall survival (OS), and acute and chronic toxicities per Common Terminology Criteria for Adverse Events (CTCAE), version 5.

RESULTS

Eleven patients with L-PAC were identified with median follow-up of 10.7 mo (3.2 - 22.3). Ten of those underwent surgical resection at the treating radiation facility and one patient underwent preoperative radiation for 50.4 Gy in 28 fractions followed by surgical resection at an outside hospital. MRgRT was delivered a median of 18.8 mo (3.5 - 48.0) following resection. There were 5 females and 6 males, with a median age of 72 years (52-83) and median KPS of 80 (60-100). OS rates following initial diagnosis at 12, 18 and 24 mo were 100%, 82%, and 61%, respectively, with an MST of 25.3 mo (12.4-53.1). OS rates following recurrence at 6 and 12 mo were 82% and 52%, respectively, with an MST of 10.7 mo (3.2 - 21.9). One patient experienced local failure at 7.8 mo, and 9 patients experienced distant failure at a median of 3.4 mo (0.3 - 21.9) following MRgSBRT. Five patients experienced distant failure less than 3 mo following radiation. Grade 1 or 2 acute GI toxicity was noted in 45% of patients and chronic GI toxicity, in 18% of patients. No Grade≥3 AEs were noted.

CONCLUSION

MRgSBRT for recurrent pancreatic adenocarcinoma demonstrates good local control with acceptable acute and chronic toxicity as well as reasonable overall survival. Distant failure remains a substantial problem with a significant number of patients demonstrating metastases immediately following radiation, suggesting the presence of micro-metastatic disease prior to local therapy. Adequate patient selection for MRgSBRT, and proper integration of systemic therapy in this patient population remains a topic of discussion that requires further exploration.

Association of Bacterial Composition and Diversity in the Cervical Tumor Microbiome with HPV Genotype in a Large, International Patient Cohort

PURPOSE/OBJECTIVE(S)

Tumor bacterial composition is strongly associated with response to cancer therapy, and is impacted by environment, including geography. Human papillomavirus (HPV) genotypic diversity composition and load are dynamic during pelvic radiation (RT) and correlate with differential responses to RT in cervical cancer patients. In this multi-institutional, collaborative study, we aimed to explore associations between bacterial composition, HPV serotypes, and geographical distribution in an international patient population.

MATERIALS/METHODS

Cervical swabs were collected from 287 patients diagnosed with cervical cancer/ dysplasia in four locations: Houston, USA (TX; N = 94), Ethiopia (ETH; N = 85), Puerto Rico (PR; N = 71), and Botswana (BOT; N = 37). Swabs were collected prior to treatment and were subjected to 16S V4 rRNA gene sequencing and HPV genotyping. We compared HPV types and geography via Chi-squared test. We analyzed bacterial composition, alpha diversity (ANOVA), and beta diversity (principal coordinates analysis [PCoA] with PERMANOVA) for HPV type and geography. We used Linear Discriminant Effect Size (LEfSe) analysis to distinguish taxa associated with HPV types.

RESULTS

Overall, the global bacterial composition for patients with cancer or dysplasia did not significantly vary by location. However, the proportion of patients with each HPV type varied by location (p<0.01); HPV16 was most frequent in TX (54%), BOT (70%) and ETH (61%), while HPV18 was most frequent in PR (62%). The proportion of patients with HPV low-risk/negative tumors was highest in ETH (25%) compared to other sites (2% - 14%). Patients with HPV 16 had significantly higher bacterial alpha diversity across locations (all p<0.01). The bacterial composition also differed by HPV type across locations (p = 0.01). On LEfSe, bacterial genera enriched in HPV 16 samples were Bacteroides, Clostridium, and Prevotella. Non-HPV16 tumors were enriched in species of Lactobacillus and Gardnerella and HPV 18 and high-risk type tumors were enriched in Escherichia.

CONCLUSION

In thislarge, international cohort of cervical cancer and dysplasia patients, bacterial composition was more closely associated with cervical HPV genotype than with geography. This finding has implications for the development of biomarkers and interventions aimed at improving chemotherapy and radiation response through manipulation of the microbiome.

Navigating Countertransference in Inpatient Settings: Optimizing Interventions for Patients with Borderline Personality Disorder and Repeated Acute Hospitalizations

Over the years, the psychiatric inpatient treatment paradigm has shifted to more brief stays focused on acute stabilization and psychopharmacologic-focused interventions, rather than individual psychotherapeutic engagement. Unfortunately, this has allowed patients with complex interpersonal dynamics, particularly borderline personality disorder, to slip through the cracks of effective treatment. This can contribute to repeated inpatient admissions, where both patients and clinicians feel trapped in a maladaptive, unhelpful cycle. In this article, we examine the evolution of inpatient treatment with de-emphasized psychotherapy practices, review the particular dynamics that patients with borderline personality disorder may evoke within an interdisciplinary treatment team, and provide a framework of clinically based vignettes for scenarios that may arise within inpatient treatment of this patient population. With attention to countertransference patterns and common pitfalls of communication, we offer alternative approaches and conversations with the hopes of improving outcomes and alliances in a new landscape of psychiatric practice.

Beliefs and counseling practices among dermatologists regarding sexual and other adverse effects of finasteride

Finasteride may cause low libido and erectile dysfunction and the product label of finasteride also includes post-marketing reactions of sexual dysfunction that continued after discontinuation of treatment, as well as male infertility and depression. The aim of this study was to evaluate the beliefs and counseling practices among dermatologists regarding adverse effects of finasteride. Anonymous paper surveys were personally distributed to 122 attendees at two annual major dermatology meetings. The participation rate was 82% with 47% women and 77% residents of the United States. 51% of respondents believed that finasteride could cause sexual side effects and 18% believed that it could cause persistent sexual side effects. Fewer than a quarter believed that finasteride could cause depression or lower sperm counts. When initiating finasteride, 69% of respondents counseled at least half of their patients about potential sexual side effects with 52% for persistent sexual side effects and 30% for depression. This study identifies the need for greater awareness of the potential adverse effects of finasteride and identifies opportunities for improvement in counseling practices that reflect finasteride's product labeling.

[Primary α-fetoprotein positive hepatoid adenocarcinoma of the lung: a case report]

This paper reports the data of a patient who was admitted to hospital for "cough with blood in sputum for 6 months" and diagnosed with α-fetoprotein(AFP) positive primary hepatoid adenocarcinoma of the lung. The patient was an 83-year-old male with a history of smoking for more than 60 years. Tumor indicators of patients were: AFP>3 000 ng/ml, carcinoembryonic antigen(CEA) 31.5 ng/ml, CA724 46.90 U/ml, Cyfra21-1 10.20 ng/ml, NSE 18.50 ng/ml, and the pathological findings of percutaneous lung biopsy showed that poorly differentiated cancer with significant necrosis. Combined with the results of immunohistochemistry and clinical laboratory examination, it is considered as metastatic hepatocellular carcinoma. PET-CT showed that FDG metabolism of multiple lymph nodes in the right lower lung, part of the pleura and mediastinum was increased, and the FDG metabolism in the liver or other systems/tissues was normal. Based on these results, it was diagnosed as AFP positive primary hepatoid adenocarcinoma of the lung, and the tumor stage was T4N3M1a(IVA). Through the data of the patient and the existing literature and reviews, we can get the tumor characteristics, diagnosis, treatment and prognosis of HAL, and improve the level of diagnosis and treatment of HAL by clinicians.

Drugs targeting epithelial-to-mesenchymal transition molecules for treatment of lichen planopilaris

Primary Cicatricial or scarring alopecia (PCA) is a diverse group of hair disorders that cause permanent destruction of the pilosebaceous unit, resulting in disappearance of the follicular ostia. Lichen Planopilaris (LPP) is a subtype of primary lymphocytic cicatricial alopecia and there urgent need to identify novel molecules that successfully target specific pathogenic pathways in LPP to inhibit and reverse disease progression. Recent studies into LPP pathogenesis have discovered that follicular stem cells undergo epithelial-to-mesenchymal transition (EMT). We sought to identify drugs that target molecules involved in EMT to repurpose these drugs for treatment of LPP. We identified 8 molecules and 15 drugs that target these EMT molecules. Only 4 of these drugs, pioglitazone, tofacitinib, barcitinib, and apremilast, have been reported in individual cases or case series of patients with LPP, and controlled studies are missing. We describe each drug and mechanism of action target EMT in detail in this review article. Although studies have demonstrated the efficacy of EMT inhibitors in anti-cancer therapy, there are no studies using EMT-attenuating drugs for the treatment of LPP. The treatment molecules discussed provide a new platform for clinical studies and controlled trials in LPP.

A8 REPEATED SUBMERGENCE OF AIR-LIQUID INTERFACE COLONOID CULTURES IMPAIRS INFLAMMATORY AND REGENERATIVE RESPONSES

Background

Damage in the intestinal epithelium is repaired via de-differentiation of mature intestinal epithelial cells to a stem-like state. Indeed, literature has primarily focused on acute forms of intestinal damage, but there is a lack of models to study how intestinal stem cells function after chronic injury, such as in inflammatory bowel disease (IBD). A previous report found that growth of mouse intestinal organoids in air-liquid interface (ALI) follows by submergence caused differentiation and reversible injury, but this has not been demonstrated in human cells or with repeated cycles of injury. Understanding how chronic damage alters human intestinal stem cell fate and function is imperative to developing novel therapies that repair the epithelium in people with IBD

Aims

To develop a robust in vitro model to differentiate and damage human intestinal epithelial cells, with or without the addition of bacterial flagellin to mimic pathogen exposure.

Methods

Human colonoid monolayers were seeded on Transwell inserts for 10 days until fully confluent and then differentiated by removing the apical media to create ALI growth conditions for 7 days. To induce damage, media was added to the apical side of the Transwell, with or without the addition of flagellin in the basolateral compartment. Following submergence induced damage, the apical media was removed and collected for chemokine analysis, and the cells were grown back in ALI for 3 days to recover them from injury. This cycle was repeated 5 times to induce chronic damage. Cells were collected for qPCR analysis, immunofluorescence imaging, RNA sequencing and DNA methylation analysis

Results

Repeated rounds of damage impaired the ability of intestinal epithelial cells (IECs) to respond to TLR stimulation (a decrease in basolateral IL-8 with each round), likely due to a decrease in TLR signaling pathways, as demonstrated by GSEA and qPCR. Chronic submergence damage led to an increase in differentiation of cells expressing MUC2, SLC26a3 and CHGA, and a decrease in stemness as shown by qPCR for BMI1, HOPX, and LGR5. After several rounds of damage, colonoid monolayers were unable to regrow as monolayers after passaging, likely due to a decrease in YAP signaling. We also identified mRNA expression and DNA methylation changes in genes associated with IBD and colon cancer.

Conclusions

We have developed a novel chronic damage model of recurrent IEC injury, which possibly mimics pathologies seen in people with inflammatory bowel disease. This model can be used to understand how chronic damage alters the ability of IECs to respond to pathogens and regenerate to repair and protect the epithelium from further damage.

Funding Agencies

CCC

Visualization of Fast Ion Phase-Space Flow Driven by Alfvén Instabilities

Fast ion phase-space flow, driven by Alfvén eigenmodes (AEs), is measured by an imaging neutral particle analyzer in the DIII-D tokamak. The flow firstly appears near the minimum safety factor at the injection energy of neutral beams, and then moves radially inward and outward by gaining and losing energy, respectively. The flow trajectories in phase space align well with the intersection lines of the constant magnetic moment surfaces and constant E-(ω/n)P_{ζ} surfaces, where E, P_{ζ} are the energy and canonical toroidal momentum of ions; ω and n are angular frequencies and toroidal mode numbers of AEs. It is found that the flow is so destructive that the thermalization of fast ions is no longer observed in regions of strong interaction. The measured phase-space flow is consistent with nonlinear hybrid kinetic-magnetohydrodynamics simulation. Calculations of the relatively narrow phase-space islands reveal that fast ions must transition between different flow trajectories to experience large-scale phase-space transport.

Health-related quality of life in patients with recurrent pericarditis: results from RHAPSODY, a phase 3 study of rilonacept

Background

Recurrent pericarditis (RP) patients report that painful, debilitating flares negatively impact their health-related quality of life (HRQoL). RHAPSODY, the Phase 3 trial of rilonacept (IL-1α/IL-1β cytokine trap), included a daily pain diary and patient-reported outcome SF-36v2 to measure HRQoL throughout the trial.

Purpose

The purpose of this research is to evaluate the effect of rilonacept on HRQoL in relation to changes in pain for RP patients who have a recurrence.

Methods

RHAPSODY enrolled 86 patients with acute symptomatic RP to receive weekly rilonacept for a 12-week run-in (RI) period and randomized 61 patients (1:1) to receive placebo (n=31) or continue rilonacept (n=30) for the event-driven randomized-withdrawal (RW) period. Patients on placebo who experienced a qualifying recurrence during RW (return of pericarditis pain and increase in C-reactive protein) were rescued with bailout rilonacept. Patients reported daily pericarditis pain electronically, using a 0–10 numeric rating scale (NRS), and completed the SF-36v2 at study visits prior to clinician interaction. Scores from RI Baseline (BL), RI Week 12 (RW BL), Recurrence visit, and RW up to Week 24 (or end of study; EOS) were evaluated for patients who experienced recurrence in RW. Analyses exclude one patient randomized to placebo who had a recurrence after Week 24 of the RW period.

Results

Analyses focused on the 22 of 30 patients (73%) in the placebo group who experienced a recurrence before Week 24 of RW (median time from RW BL to recurrence: 8.6 weeks). During RI, daily pain scores decreased while on rilonacept (Cohen's effect size [ES] d=−2.0), and SF-36v2 scores improved, with scores at RI BL (Fig. 1 red line) below the general population average of 50 and near or above average at RI Week 12 (Fig. 1 blue line); ES were all large (d&gt;0.8), ranging from 0.917 (Mental Component Summary) to 2.021 (Bodily Pain). At recurrence, pain scores increased (d=6.5; Fig. 2) and SF-36v2 scores were below the population average (Fig. 1 orange line), with largest reductions between RI Week 12 (RW BL) and recurrence for Bodily Pain (−13.4) and Physical Component Summary (−10.6). Following rilonacept bailout, average pain decreased (d=−2.1; Fig. 2), and by RW Week 24/EOS, SF-36v2 scores returned to similar levels as at the end of the RI period (Fig. 1 green line).

Conclusion

Impaired RI BL SF-36v2 scores indicate negative impact of RP on HRQOL in RP patients. While receiving rilonacept, HRQoL scores improved to near or above population averages, in conjunction with patient-reported pain. After discontinuing rilonacept during RW, HRQoL scores worsened at recurrence and improved upon receipt of bail-out rilonacept, similar to pain. These results provide support for the broader benefit of rilonacept treatment beyond pain, when administered on top of conventional therapies and as mono-therapy, providing evidence of its potential to improve HRQoL in this patient population.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): Kiniksa Pharmaceuticals, Ltd.

RESONANCE Registry: rationale and design of the retrospective and prospective longitudinal, observational registry in pediatric and adult patients with recurrent pericarditis

Background

Annually in the United States (US), an estimated 80–90,000 patients are diagnosed with acute pericarditis and 15–30% experience recurrent pericarditis (RP), resulting in increased morbidity and reduced health-related quality of life (HRQoL). Treatment options include non-steroidal anti-inflammatory drugs (NSAIDs) and colchicine. Corticosteroids (CS) are often added to the treatment plan in RP despite CS-associated adverse events and inherent potentiation of recurrence with long-term treatment. A recent Phase 3 clinical trial RHAPSODY (NCT03737110) demonstrated efficacy and safety of rilonacept, an interleukin-1 α and β cytokine trap, in patients with RP. RHAPSODY data helped support FDA approval of the first therapy for RP. With the emergence of this targeted therapy, there is increased interest to learn more about this disease with the goal to better inform treatment and management decisions and improve long-term outcomes.

Purpose

RESONANCE Registry aims to evaluate the natural history of RP by collecting retrospective and prospective, longitudinal physician- and patient-reported outcomes data in real-world clinical practice across the US.

Methods

RP patients with active disease (recurrence within 3 years) will have both retrospective and prospective data collected (Figure 1) for as long as their RP is managed up to 5 years. For patients with inactive disease (no recurrence within 3 years), data collection will be retrospective (Figure 2). Up to 500 patients in the US are planned for enrollment at pediatric and adult medical centers, with the potential for expansion to European sites. Additionally, patients will be recruited through a novel, internet-based technology platform and screened for eligibility at a “decentralized” trial site. The registry will include variables obtained from health records, including baseline characteristics and medical history, as well as patient reported outcome (PRO) measures collected every 3 months. The RESONANCE protocol is designed to include a broad population of pediatric and adult patients, regardless of etiology or treatment course, including patients treated with rilonacept. Data will be analyzed to understand disease heterogeneity, variability in treatment and management, and impact on HRQoL. The protocol and Case Report Forms (CRFs) were developed in collaboration with physicians, patients, and patient advocates.

Conclusions

Registries utilize real-world data to fill knowledge gaps in the management of less common diseases such as RP. The RESONANCE Registry is the first RP registry designed to collect data across a broad range of patients regardless of treatment. The registry will also serve as a connection point for physicians to further educate and empower patients with information about their disease. In addition, PRO data may enable greater insights into the understanding of the burden of RP from the patient's perspective.

Funding Acknowledgement

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

Role of QRS amplitude, fractionation and duration in predicting clinical response to anti-inflammatory treatment in cardiac sarcoidosis

Background

Low QRS amplitude (QRSa), QRS fractionation (QRSf) and longer QRS duration (QRSd) are markers of myocardial fibrosis and inflammation in non-ischemic cardiomyopathy (NICM).

Objective

To determine if reduction of inflammation with treatment of cardiac sarcoidosis (CS) may reverse these 12 lead ECG parameter changes.

Methods

21 patients (pts) with CS and VT ablation with a positive baseline positron emission tomographic (PET 1) scan were studied. All pts received prednisone ≥40 mg for 4 to 8 weeks followed by a taper and maintenance with methotrexate ± low-dose prednisone, &lt;10 mg/day, until clinically stable and resolution of inflammation on PET 2 one year after initial. In addition, pts with low LV ejection fraction (13/21) received guideline directed medical therapy for heart failure. Pts at 1yr with positive PET2 (9) were compared to those with negative PET2 (12). Baseline and 1yr 12-lead ECGs were analyzed for QRSd, ≥2QRSf contiguous leads and QRSa in the limb leads.

Results

Pts in PET2(+) vs PET2(−) groups has similar gender (men 89% vs 100%, p=0.42), age (57±8 vs 56±10 years, p=0.8) and LV ejection fraction (41±11 vs 46±11, p=0.31). Baseline 12-lead ECGs showed similar QRSd, ≥2QRSf contiguous leads and QRSa for PET2(+) vs PET2(−); P all &gt;0.15 (Table 1). At 1 yr there was a lower prevalence of ≥2QRSf contiguous leads and strong trend for shorter QRS duration and larger QRSa in lead DI if PET2(−) vs PET2(+). 4 pts demonstrated loss of QRSf 2 contiguous leads and/or increase in QRSa in DI by at least 0.15 mV from baseline if PET2(−) and none if PET2(+).

Conclusions

In pts with CS and VT, reversal of inflammation may result in a greater QRSa and reduction in QRSf. An increase in QRSa in lead 1 by &gt;0.15mV and/or loss of QRSf identifies a clear positive response to treatment and negative PET at 1 year.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Richard T and Angela Clark Innovation Fund in Cardiovascular Medicine, the Mark S Marchlinski EP Research and Education Fund and the Winkelman Family Fund in Cardiovascular Innovation. Table 1

Adapting active case-finding for TB during the COVID-19 pandemic in Yogyakarta, Indonesia

The COVID-19 pandemic and response measures, including lockdowns and the reorientation of health services, have disrupted essential health services for other diseases, including TB, HIV and malaria. For TB, reductions in case detection due to the COVID-19 pandemic are projected to result in increased TB transmission, morbidity and mortality. Active case-finding (ACF) for TB using community-based approaches is a potential strategy to offset reductions in TB detection by obviating the need for patients to seek care at a health facility. A number of approaches can be used to conduct TB ACF safely and screen designated target populations while managing the risks of SARS-CoV-2 transmission for staff, individuals and the community. We present a framework of options for and experience of adapting TB ACF services in response to the challenges of COVID-19 in our programme in Yogyakarta, Indonesia. Key changes have included revised prioritisation of target populations focusing on household contacts, reducing case-finding throughput, implementation of additional infection control measures and precautions, and integration of COVID-19 screening among those being screened for TB. Our approach could inform other programmes seeking to adapt TB ACF services to mitigate the negative impact of COVID-19 on TB case detection.

[Dasatinib combined with multi-agent chemotherapy regimen in newly diagnosed Philadelphia chromosome-positive acute lymphoblastic leukemia: a prospective study from a single center]

目的

评价达沙替尼联合多药化疗方案在Ph染色体阳性急性淋巴细胞白血病（Ph⁺ ALL）患者中的疗效及安全性。

方法

前瞻性、单臂、开放的临床研究。2016年1月至2018年4月中国医学科学院血液病医院收治的30例初诊成人Ph⁺ ALL患者入组。采用多药化疗方案，标准诱导化疗为期4周，自诱导化疗第8天开始口服达沙替尼（商品名依尼舒，正大天晴药业集团股份有限公司产品）100 mg/d，持续应用至整体治疗结束。有条件和意愿进行移植者，可进行异基因造血干细胞移植或自体造血干细胞移植。

结果

所有30例患者在诱导治疗4周后均达到血液学完全缓解（HCR），累积完全分子学反应（MCR）率为70.0％（21/30）。中位随访时间为37.8（32.0～46.6）个月。3年总生存（OS）率为68.1％，3年无血液学复发生存（HRFS）率为61.6％。63.3％的患者在治疗3个月时达到主要分子学反应（MMR）（其中有43.3％患者达到MCR）。6个月时60.0％的患者达到MCR，达到MCR的患者具有更好的OS（P＝0.004）、HRFS（P＝0.049）和EFS（P＝0.001）。15例（50.0％）患者在第1次HCR期内进行移植，移植组患者HRFS（P＝0.030）和EFS（P＝0.010）优于化疗组。

结论

达沙替尼联合多药化疗方案治疗初诊Ph⁺ALL安全有效。

临床试验注册

ClinicalTrials.gov，NCT02523976。

How Jupiter's unusual magnetospheric topology structures its aurora

Jupiter's bright persistent polar aurora and Earth's dark polar region indicate that the planets' magnetospheric topologies are very different. High-resolution global simulations show that the reconnection rate at the interface between the interplanetary and jovian magnetic fields is too slow to generate a magnetically open, Earth-like polar cap on the time scale of planetary rotation, resulting in only a small crescent-shaped region of magnetic flux interconnected with the interplanetary magnetic field. Most of the jovian polar cap is threaded by helical magnetic flux that closes within the planetary interior, extends into the outer magnetosphere, and piles up near its dawnside flank where fast differential plasma rotation pulls the field lines sunward. This unusual magnetic topology provides new insights into Jupiter's distinctive auroral morphology.

The imaging fast ion D-alpha diagnostic (IFIDA) on DIII-D

An Imaging Fast Ion D-alpha (IFIDA) diagnostic, characterized by a high optical spatial resolution of ≤2 mm for accurate validation of energetic particle (EP) transport models, has been developed on DIII-D. The diagnostic provides a 2D image in the radial-poloidal plane of the FIDA signal generated by EP emission after charge exchange with an injected neutral beam. A narrow passband filter integrates the FIDA signal in the spectral region of 650-652 nm (blue-shifted FIDA tail), which is mostly generated by co-passing EPs of energies E ≃ 40-80 keV. A beam modulation technique is employed to estimate the active component of the signal, which is then used to compute EP profiles and gradients with a higher accuracy than the standard spectroscopic FIDA diagnostic. The current diagnostic time resolution is ≃3 ms. In this work, the IFIDA diagnostic design is explained and data are compared with the spectroscopic FIDA diagnostic, which shares the same viewing geometry, to assess the improvements in EP profile reconstruction.

[Investigation and clinical analysis of a family with germline CEBPA mutations in acute myeloid leukemia]

目的

探讨伴CEBPA基因突变的家族性急性髓系白血病（AML）的临床特征、病因及转归，提高对家族性白血病的认识。

方法

调查一个伴CEBPA基因突变AML家系患者的发病年龄、临床特征、转归及预后并绘制家系谱。对先证者采集骨髓及口腔黏膜细胞，与先证者有血缘关系的亲属，采集外周血，通过基因测序技术检测基因突变。

结果

该家系共有10人诊断为AML，其中男4例，女6例，中位年龄9（3～48）岁。10例患者中，6例死亡，其中4例未进行治疗，1例患者化疗后生存3年复发死亡，1例采取中药及支持治疗生存2年后死亡。4例患者生存，1例接受化疗患者生存达15年，3例患者接受化疗联合造血干细胞移植，至随访截止，生存时间分别为6、9、28个月。对先证者及8名与先证者有血缘关系的亲属进行基因测序，发现5例存在胚系CEBPA TAD p.G36Afs*124突变，其中4例确诊为AML，1例随访至今未发病。

结论

伴CEBPA基因突变的家族性AML多在儿童及青壮年期发病，具有完全或接近完全的外显率，通过积极治疗，大多预后良好。

Immunization against gonadotropin-releasing factor (GnRF) in market gilts: Effect on growth and carcass parameters, and impact of immunization timing

Reproductive cycling in fattening gilts can be associated with undesirable effects, such as estrus-related aggressive behavior, reduced feed intake and, in production systems where gilts are co-housed with entire males, unwanted pregnancy. Immunization against Gonadotrophin Releasing Factor (IM) can temporarily suppress ovarian activity, including related negative consequences on animal welfare and productivity. Feed intake has been shown to be higher after IM, resulting in both increased growth and increased carcass fat. A series of studies was conducted to confirm these effects on production and look at their dynamics over time. Three trials were performed to a similar design, each involving 240 gilts divided into 4 experimental groups at 12 weeks of age. One group remained untreated while the others had the two dose, IM course completed 8, 6 or 4 weeks before harvest, which was on a single day at 24, 25 or 26 weeks of age depending on the study. Feed intake was measured daily and bodyweight weekly, allowing growth parameters to be calculated on a weekly basis and for specific longer periods. Carcass weight, backfat depth and lean meat percentage were recorded at harvest. No effects were observed before the second application of the immunological product (V2) and completion of the IM course. Starting in the second week after V2 all IM groups showed a marked and consistent increase in Average Daily Feed Intake (ADFI), typically peaking at over 120% of the control group 3 to 4 weeks after V2 and then slowly declining, but still remaining elevated at 8 weeks. Weekly Average Daily Gain (ADG) showed a similar pattern but with a faster decline, resulting in the initially favorable impact on feed efficiency becoming less favorable as the V2 to harvest interval (V2H) progressed. Carcass weights were higher in IM gilts and backfat depths were greater, with the effects increasing with increasing V2H. Correspondingly, carcass lean meat percentage tended to decrease, although the higher carcass weights meant that the absolute weight of lean meat remained similar or higher. Carcass yield was generally unaffected by IM, but some between-group differences were statistically significant, and it is possible that different factors predominated at different times after V2, creating a complex relationship with V2H duration. The optimum IM protocol will depend on local conditions and production objectives but, as a generalization and assuming ad libitum feeding, a shorter V2H will favor efficient growth, while a longer duration will maximize carcass changes, such as increased fat coverage. It is suggested that the growth performance changes seen after IM in gilts might be viewed as a process of adjustment to a heavier and fatter target body type.

Documented Reasons of Cancellation and Rescheduling of Telehealth Appointments During the Pandemic

Background and Objective: The COVID-19 pandemic increased the use of telehealth around the world. The aim is to minimize health care service disruption as well as reducing COVID-19 exposure. However, one of the major operational concerns is cancellations and rescheduling (C/Rs). C/Rs may create additional burden and cost to the patient, provider, and the health system. Our aim is to understand the reasons for C/Rs of the telehealth session after the scheduled start time. Materials and Methods: We reviewed electronic health records (EHRs) to identify the C/R reasons for behavioral health and speech language pathology departments. Documented C/Rs in the medical charts were identified from EHR by using a keyword-based and Natural Language Processing (NLP)-supported EHR search engine. From the search results, we randomly selected 200 notes and conducted a thematic analysis. Results: We identified four themes explaining C/R reasons. Most frequent theme was "technicality" (47, 36%), followed by "engagement" (34, 25%), "scheduling" (31, 24%), and "unspecified" (20, 15%). The findings showed that technical reasons are the leading cause of C/Rs, constituting 36% of the cases (95% confidence interval [CI]: 29-43%). Notably, "engagement" constituted a sizeable 25% (95% CI: 19-31%) of C/Rs, as a result of the inability to engage a patient to complete the telehealth session. Conclusions: The study shows that engagement is one of the new challenges to the pediatric telehealth visits. Future studies of new engagement models are needed for the success of telehealth. Our findings will help fill the literature gaps and may help with enhancing the digital experience for both caregivers and providers, reducing wasted time and resources due to preventable C/Rs, improving clinical operation efficiency, and treatment adherence.

Clinical characteristics and health-related quality of life of patients with recurrent pericarditis in the United States: findings from a patient survey

Background

Recurrent pericarditis (RP) is characterized by recurrence of symptoms of pericarditis after the original episode has ceased for 4–6 weeks. Though RP is associated with significant morbidity, there is little information regarding the impact of RP on patients' health-related quality of life (HRQOL).

Purpose

To describe clinical characteristics of and HRQOL burden in patients with RP in the United States.

Methods

An IRB-approved web-based survey was conducted among patients ≥18 years old with RP who experienced ≥1 recurrence during the prior 12 months. Respondents were recruited from the RHAPSODY clinical trial recruitment database. Patients who met the survey inclusion criteria were asked to provide information on their demographic/clinical characteristics, treatments for RP, and to complete an 11-point pericarditis pain numerical rating scale, the Patient Global Impression of Pericarditis Severity scale, the Patient-Reported Outcomes Measurement Information System® (PROMIS®) Global Health and Sleep Disturbance scales, and questions about the impact of RP on daily life.

Results

Of the 83 respondents with RP included in the study, 25% responded while experiencing a recurrence. Most respondents were Caucasian (76%) and 55% were female, with mean (standard deviation [SD]) age of 49.3 (13.7) years. Patients frequently reported history of hypertension (39%), anxiety (37%), and depression (34%); 16% and 15% of patients reported having pre-existing autoimmune disease and diabetes, respectively. About half (49%) of patients reported ≥3 recurrences in the prior year, and 40% visited the ER and 25% were hospitalized for their most recent recurrence. Among patients not actively experiencing a recurrence, 37% reported that the duration of their prior episode lasted ≥8 days. Medications most frequently used for RP and pain in the prior year included non-steroidal anti-inflammatory drugs (82%), colchicine (63%), and corticosteroids (29%). Commonly reported symptoms included chest pain (93%), shortness of breath (66%), weakness/fatigue (64%), and heart palpitations (52%). Two-thirds of patients rated the severity of symptoms during the most recent RP episode as moderately severe to very severe, and 48% reported “quite a bit” or “very much” fear of pericarditis recurrence. The mean (SD) value for worst pericarditis pain (0–10 scale) during the recent recurrence was 6.1 (2.3), with 48% reporting severe pain (≥7 on the scale). Patients had substantially worse mean [SD] T scores for PROMIS physical health (37.6 [8.6]), mental health (42.8 [9.9]), and sleep disturbance (60.6 [8.3]) than the general population (50 [10]).

Conclusions

RP is a burden on the daily lives of patients, resulting in severe pain and impaired quality-of-life including poor physical and mental health, sleep disturbance, and fear of recurrence. This study demonstrates the unmet need for therapies that can rapidly resolve symptoms and prevent recurrences.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Kiniksa Pharmaceuticals Corp.

Stability and performance of the EnSite Precision cardiac mapping system for electrophysiology mapping and ablation procedures: results from the EnSite Precision observational study

Background

The EnSite Precision™ Cardiac Mapping System is a catheter navigation and mapping system capable of displaying the three-dimensional (3D) position of conventional and sensor enabled electrophysiology catheters, as well as displaying cardiac electrical activity as waveform traces and dynamic 3-D maps of cardiac chambers.

Objective

The EnSite Precision™ Observational Study was designed to quantify and characterize the use of the EnSite Precision™ Cardiac Mapping System for mapping and ablation of cardiac arrhythmias in a real-world environment and to evaluate procedural and subsequent clinical outcomes.

Methods

1065 patients were enrolled at 38 centers in the U.S. and Canada between 2017–2018. Eligible subjects were adults undergoing a cardiac electrophysiology mapping and radiofrequency ablation procedures using the EnSite Precision™ System.

Results

Of 989 patients who completed the protocol, a geometry was created in 936 (94.7%). Most initial maps were created using Automap (n=545, 67.0%) or a combination of Automap and manually mapping (n=151, 18.6%). Median time to create an initial map was 9.0 min (IQR 5.0–15.0), with a median number of used mapping points per minute of 92.7 (IQR 30.0–192.0). During ablation, AutoMark was used in 817 (82.6%) of procedures. The most frequent metrics for lesion color were Impedance Drop or Impedance Drop Percent (45.5% combined), time (23.9%) and average force (14.2%). At Canadian sites where LSI was an option, it was used as the color metric in 87 (45.8%) of cases (10.6% overall). The EnSite System was stable throughout 79.7% (n=788 of 989) of procedures. Factors affecting stability were respiratory change (n=88 of 989, 8.9%), patient movement (n=73, 7.4%), CS Positional Reference dislodgement (n=32, 3.2%), and cardioversion (n=19, 1.9%). Conscious sedation was used in 189 (19.1%) of patients. Acute success was reached based on the pre-defined endpoints for the procedure in 97.4% (n=963) of cases.

Conclusion

In a real-world study analysis, the EnSite Precision™ mapping system was associated with a high prevalence of acute procedural success, low mapping times, and high system stability.

Funding Acknowledgement

Type of funding source: None

Long non-coding RNA MIAT promotes non-small cell lung cancer progression by sponging miR-1246

OBJECTIVE

Recently, long non-coding ribonucleic acids (lncRNAs) have attracted more attention for their roles in tumor progression. The aim of this study was to investigate the exact role of lncRNA MIAT in the progression of non-small cell lung cancer (NSCLC) and to explore the possible underlying mechanism.

PATIENTS AND METHODS

MIAT expression in NSCLC tissue samples was detected by quantitative Real Time-Polymerase Chain Reaction (qRT-PCR). The association between the expression of MIAT and the prognosis of NSCLC patients were explored. Furthermore, the wound healing assay and the transwell assay were conducted in vitro. In addition, the luciferase assay and the RNA immunoprecipitation assay (RIP) were used to elucidate the underlying mechanism.

RESULTS

The MIAT expression in NSCLC tissues was significantly higher than that of the corresponding normal tissues. Meanwhile, the MIAT expression was associated with the overall survival time of NSCLC patients. The migration and invasion of cells were significantly promoted after MIAT was over-expressed in vitro. Meanwhile, the cell migration and cell invasion were obviously remarkedly inhibited after MIAT knock-down in vitro. Bioinformatics analysis predicted that microRNA-1246 (miR-1246) was as a novel target for MIAT. The expression of miR-1246 was significantly down-regulated or up-regulated after the overexpression or down-expression of MIAT, respectively. Further mechanism assays showed that miR-1246 was a direct target of MIAT in NSCLC.

CONCLUSIONS

MIAT enhanced the NSCLC cell migration and invasion via targeting miR-1246, which might be a potential biomarker in NSCLC.

[Rituximab combined with short-course and intensive regimen for Burkitt leukemia: efficacy and safety analysis]

目的

探讨利妥昔单抗联合短疗程、高强度方案治疗成人Burkitt白血病患者的疗效和安全性。

方法

收集2006年1月30日至2018年9月12日中国医学科学院血液病医院收治的11例Burkitt白血病患者病例资料，分析统计患者的临床特征、完全缓解（CR）率、总生存率、无复发生存率及不良事件。

结果

11例患者中位年龄34（15~54）岁，其中男6例，女5例。发病时中位WBC 12.28（2.21~48.46）×10⁹/L，HGB 113（74~147）g/L，PLT 35（13~172）×10⁹/L，乳酸脱氢酶2 721（803~17 370）U/L，外周血中位原始细胞比例0.40（0.03~0.76），骨髓中位原始细胞比例0.840（0.295~0.945）。10例患者接受利妥昔单抗联合短疗程、高强度化疗，其中2例患者巩固化疗后行自体造血干细胞移植。所有治疗患者1个疗程CR率为100%，4年总生存率为90%，4年无复发生存率为90%。所有治疗患者中，只有1例患者在诱导化疗中出现肿瘤溶解综合征，经血液透析等治疗后肾功能恢复。无治疗相关性死亡病例。

结论

利妥昔单抗联合短疗程、高强度方案治疗成人Burkitt白血病疗效及安全性均较为理想。

AB0347 INCREASING TO OPTIMAL METHOTREXATE DOSE MIGHT BE A BETTER TRADITIONAL DMARD STRATEGY IN RA TREATMENTS: A RANDOMIZED CASE-CONTROL TRIAL OF HAKKA PEOPLE IN SOUTHERN CHINA

Background:

The optimal methotrexate (MTX) dose is defined as 0.3mg/kg/week or ≥ 20mg/week at 6 months. [1] Considering average weight of Chinese, [2] the optimal MTX should be >15mg/w. However, not more than 30% in 25191 RA cases ever had MTX treatment in CREDIT (Chinese Registry of Rheumatoid arthritis). [3] The biggest concern is side effects of MTX. Our study is to investigate whether increasing MTX would get better results accompanied with more side effects to Chinese people.

Objectives:

Hakka people have the purest genes of the majority people-Han in China. It is planned to recruit 160 RA patients in Meizhou, where is a gathering place of Hakka people.

Methods:

The RA volunteers had no relief with 10 mg/w oral dose of MTX with/without other 1-2 inadequate dose of DMARDs for at least 3 months. They were randomly divided into 1:1 groups*. The experimental group would be treated with original DMARDs and incremental MTX (gradually increased to the optimal oral dose (0.3 mg/k/w) in the first 12 weeks and folic acid (the dose adjusted on demand with range from 5 mg/w to 5mg tid). While the control group would be treated with original MTX dose(10mg/w) but incremental original DMARDs(gradually increased to the maximum dose in the first 12 weeks). The two groups would keep the treatment at 12thweek last to the 36thweek, and the efficacy and safety indexes would be evaluated during the whole study.

Results:

1)We planned to recruit 160 RA patients in our study. 46 Hakka RA patients were enrolled in the study so far. 2 of 46 finished the 24thweek visit and 24 finished the 36thweek visit. The average age is 54.2± 9.3 years old, the average weight is 59.1±11.1kg, and the female to male ratio is 41:5.

2)The average Folic acid dose is 14.4±9.5mg/w in the experimental group at the 12thweek.

3)The morning stiffness time, PGA, PhGA, HAQ, DAS28 were better in experimental group after 12 weeks though slightly worse during 0-12 weeks. 100%(12) patients in experimental group, while 66.67%(8/12) in control group reach ACR20.

4) Only 1 case(5.9%,1/23)had adverse event while 6 cases (26%,6/23) occurred adverse events. All events were mild level. 1 case (4.2%,1/23) in control group withdrew from the study because the disease was getting worse during 0-24 weeks.

Conclusion:

Hakka patients in China might have better outcomes due to increasing MTX to the 0.3mg/kg/w dose than increasing the other DMARDs. Therefore, We recommended the Chinses patients choose MTX as first incremental DMARD. The appropriate dose of Folic acid plus with the optimal dose of MTX in our study is higher than previous studies (such as 13.0±4.8mg/w reported by Gaujoux-Viala, 2018[1]). We recommended Chinese patients take 15mg/w folic acid to prevent MTX side effects in view of lower folic acid level in Chinese population.[3]

References:

[1]Gaujoux-Viala C, Rincheval N, Dougados M, et al. Optimal methotrexate dose is associated with better clinical outcomes than non-optimal dose in daily practice: results from the ESPOIR early arthritis cohort. Ann Rheum Dis. 2017 Dec;76(12):2054-2060.

[2]Nan Jiang, Mengtao Li, Yanhong Wang, et al. Baseline characteristics and treatments among patients with rheumatoid arthritis: the CREDIT study in China, 2016-2018. Ann Rheum Dis. 2019 Jun; 78 (Suppl 2) 1404-1405.

[3]He Y, Pan A, Hu FB,et al. Folic acid supplementation, birth defects, and adverse pregnancy outcomes in Chinese women: a population-based mega-cohort study, Lancet, 2016 Oct,Volume 388, Number 1, pp. S91-S91-(1)

Disclosure of Interests:

None declared