OP0173 INCIDENCE OF COVID-19 INFECTION AND HOSPITALISATION ACCORDING TO VACCINATION STATUS AND DMARD TREATMENT IN PATIENTS WITH RHEUMATOID ARTHRITIS: A NATIONWIDE MATCHED COHORT STUDY FROM DENMARK

Background

Patients with rheumatoid arthritis (RA) may have impaired immunogenicity to COVID-19 vaccines.

Objectives

To investigate the incidence of COVID-19 infection and hospitalisation in unvaccinated and vaccinated patients with RA compared with matched individuals; and secondarily in patients with RA according to DMARD treatment.

Methods

Danish nationwide matched cohort study from January to October 2021. Patients with RA were identified in DANBIO and matched 1:20 with individuals from the general population on age, sex, and vaccination status (month and exact type of vaccination). Primary and secondary outcomes were COVID-19 hospitalisation (Danish National Patient Register) and positive SARS-CoV2 PCR test (Danish COVID-19 Surveillance Register), respectively. Stratified by vaccination status, incidence rates (IRs) per 1000 person years (PY) and comorbidity-adjusted hazard ratios (aHRs) in cause-specific Cox models were calculated with 95% confidence intervals. Using the Aalen-Johansen estimator, the cumulative incidence of COVID-19 hospitalisations was visualised according to RA and vaccine exposure status.

Results

Regardless of vaccination status, patients with RA had increased incidence of COVID-19 hospitalisation compared to matched individuals (Table 1). However, the absolute risk was 0.20% for unvaccinated patients at 60 days and 0.08% for comparators, whereas it remained below 0.05% at 180 days of follow-up in both groups when fully vaccinated (Figure 1). Increased SARS-CoV2 infection rates were seen only among unvaccinated patients with RA (Table 1). Unadjusted analyses showed increased incidence of COVID-19 hospitalisation among rituximab-treated compared with conventional DMARD treated: unvaccinated HR 4.71 (1.98 to 11.18) and vaccinated HR 11.69 (2.07 to 66.06). However, the proportions of patients with previous cancer and treated with prednisolone were higher among the rituximab treated.

Table 1.UnvaccinatedPartially vaccinatedFully vaccinatedRAControlsRAControlsRAControlsN28 447568 94027 154542 61026 217523 826Women, %71.371.371.271.271.071.0Age in years, median [IQR]67.7 [34.2 to 88.3]67.8 [34.2 to 88.4]68.4 [36.4 to 88.6]68.4 (36.5 to 88.6)68.9 [40.9 to 88.7]68.9 (41.0 to 88.7)Methotrexate /55.5 /0.5 /55.4 /1.2 /55.7 /1.3 /Sulfasalazine /14.2 /0.1 /13.7 /0.3 /13.5 /0.3 /Hydroxychloroquine /10.4 /0.1 /10.3 /0.0 /10.3 /0.0 /Other csDMARD,11.0 /0.2 /10.7 /0.3 /10.6 /0.3 /Prednisolone,all in %12.52.012.20.512.20.5TNFi /16.9 /0.1 /17.2 /2.9 /17.1 /3.1 /abatacept /1.5 /0.0 /1.5 /0.5 /1.5 /0.5 /tocilizumab /3.0 /0.0 /3.0 /0.0 /2.9 /0.0 /rituximab, all in %2.20.12.10.12.10.1COVID-19 hospitalisationN65727119511131Median [IQR] days of follow-up102 [62 to 137]115 [88 to 146]28 [22 to 35]30 (21 to 39)150 [111 to 189]150 (111 to 189)Rate per 1000 PY10.4 (8.0 to 13.4)4.7 (4.3 to 5.1)5.5 (3.0 to 10.0)2.2 (1.8 to 2.7)0.9 (0.5 to 1.6)0.5 (0.4 to 0.6)Adjusted HRa1.88 (1.44 to 2.46)1 (Ref.)2.47 (1.25 to 4.89)1 (Ref.)1.94 (1.03 to 3.66)1 (Ref.)SARS-CoV2 infectionRate per 1000 PY37.8 (33.6 to 42.6)33.9 (33.1 to 34.8)27 (20.7 to 35.1)28.5 (27 to 30.2)11.3 (9.2 to 13.9)10.4 (9.9 to 10.9)Adjusted HRa1.22 (1.09 to 1.57)1 (Ref.)0.87 (0.95 to 1.74)1 (Ref.)1.09 (0.92 to 1.14)1 (Ref.)

IQR, Interquartile range. a Adjusted for cancer history, cardiovascular disease, diabetes mellitus, chronic kidney disease, and chronic lung disease.

Figure 1.

Cumulative incidence of COVID-19 hospitalisation (%) as a function of follow-up time (days) for (A) unvaccinated, (B) partially vaccinated and (C) fully vaccinated patients and comparators.

Conclusion

The incidence of COVID-19 hospitalisation was increased for both unvaccinated and vaccinated patients with RA compared with controls. Importantly, the parallel decreasing risk for patients with RA suggests a comparable relative benefit of vaccination. Less favourable outcomes among rituximab-treated warrant that this drug should be considered with extra care.

Acknowledgements

The authors wish to acknowledge The Danish Departments of Clinical Microbiology and Statens Serum Institut for carrying out laboratory analysis, registration, and release of the national SARS-CoV-2 surveillance data use in the present study. Further, the authors wish to thank all the Danish departments of rheumatology for reporting to the DANBIO register.

Disclosure of Interests

René Cordtz: None declared, Salome Kristensen: None declared, Rasmus Westermann: None declared, Kirsten Duch: None declared, Fiona Pearce Grant/research support from: Pearce reports a grant from Vifor Pharma outside the submitted work., Jesper Lindhardsen: None declared, Christian Torp-Pedersen Grant/research support from: Torp-Pedersen reports grants from Bayer and Novo Nordisk outside the submitted work., Mikkel Porsborg Andersen: None declared, Lene Dreyer Speakers bureau: Dreyer has received speakers bureau from Eli Lilly and Galderma., Grant/research support from: Dreyer has received research grant/support from BMS.

POS1412 IDENTIFYING HIGH-COST DRUGS FOR RARE RHEUMATIC DISEASES IN ROUTINELY COLLECTED NHS DATA. RESULTS FROM A PILOT STUDY OF RITUXIMAB USE IN VASCULITIS USING DATA FROM THE NATIONAL DISEASE REGISTRATION SERVICE AND THE REGISTRATION OF COMPLEX RARE DISEASES-EXEMPLARS IN RHEUMATOLOGY (RECORDER) PROJECT

Background:

Understanding real-world usage of high-cost drugs is crucial to support planning, adoption of innovation and reduce unwarranted variation in treatment. Hospital Episode Statistics (HES) contain diagnoses (coded by ICD-10) and procedures/treatments (coded by OPCS) for all daycase or inpatient care in England. However, OPCS codes are not specific for individual drugs, for example X921 (cytokine inhibitors band 1) includes rituximab (RTX) and 15 other drugs.

Objectives:

We aimed to validate the accurate identification of patients treated with RTX for ANCA-associated vasculitis (AAV) using HES data.

Methods:

We used data from the National Congenital Anomaly and Rare Disease Registration Service (NCARDRS) at Public Health England and their legal permissions (CAG 10-02(d)/2015). We extracted records from HES of all patients treated at two hospitals during financial year 2018/19 who ever had a coded diagnosis of granulomatosis with polyangiitis (GPA, M313), eosinophilic granulomatosis with polyangiitis (EGPA, M301), microscopic polyangiitis (MPA, M317), polyarteritis nodosa (PAN, M300) or arteritis unspecified (I776). Where people had multiple diagnoses of vasculitis, the most specific was considered their diagnosis. Enabled by data sharing agreements, we reviewed hospital records of those patients to validate diagnoses and whether X921 reliably identified RTX. We report the positive predictive value and sensitivity of the coding for X921 and GPA/EGPA/MPA for identifying people with AAV who are treated with RTX.

Results:

At Trust 1 records ever coded with GPA/EGPA/MPA identified 74 people, 69 of whom had AAV confirmed in their medical notes. Among these 74 patients there were 59 episodes coded with X921 procedure codes, of which 56 correctly identified a RTX infusion given for AAV. A total of 64 RTX infusions were given to people with AAV – 3 missed infusions were X921 procedures in patients who had coded diagnoses of PAN or I776 but never GPA/EGPA/MPA and 5 infusions were not coded as X921.

The same analysis at Trust 2 identified 46 people, 44 of whom had AAV confirmed in their medical notes. Among patients identified with AAV there were 17 episodes coded as X921, of which 15 correctly identified a RTX infusion. A total of 23 infusions were given to people with AAV: 4 infusions were X921 procedures in patients who had coded diagnoses of PAN or I776 but never GPA/EGPA/MPA, and 4 infusions were not coded as X921.

Table 1.

Summary of Positive Predictive Values (PPV) applying our algorithm to identify AAV diagnoses and RTX use

Trust 1Trust 2CombinedDiagnosis of AAV and coded as AAV6944113AAV coded7446120Diagnosis of AAV under any code7355128PPV AAV ascertainment (95% CI)93.2% (84.9-97.8)95.7% (85.2-99.5)94.2% (88.4-97.6)Sensitivity of AAV ascertainment (95% CI)94.5% (86.8-98.5)80.0% (67.0-89.6)88.3% (81.4-93.3)RTX given in people coded as AAV561571RTX coded in people coded as AAV591776RTX given for AAV under any diagnostic or procedure code642387PPV RTX ascertainment (95% CI)94.9% (85.9-98.9)88.2% (63.6-98.5)93.4% (85.3-97.8)Sensitivity of RTX ascertainment (95% CI)87.5% (76.8-94.4)65.2% (42.7-83.6)81.6% (71.9-89.1)

Conclusion:

HES data identified patients treated with RTX for AAV with a PPV of 93.4% (85.3-97.8) and sensitivity of 81.6% (71.9-89.1). This demonstrates the utility of national data to identify people receiving RTX for AAV. The RECORDER project, within the National Disease Registration Service plans to conduct real-world studies of the high-cost drug RTX, given for AAV, across the whole of England, and assess whether geography, demographics or socioeconomic factors influence frequency of prescription of this, and potentially other, high-cost drugs in line with the NHS long term plan.

References:

[1]Ward-Platt M, Stevens S, Miller N. I18 The national congenital anomaly and rare disease registration service (NCARDRS): The first year

Acknowledgements:

I have no acknowledgements to declare.

Disclosure of Interests:

Cattleya Godsave: None declared, Mithun Chakravorty: None declared, Megan Rutter: None declared, Peter Lanyon Grant/research support from: P.C.L. is a recipients of a grant from Vifor Pharma. Vifor Pharma had no influence on the design, conduct or interpretation of this study., Jeanette Aston: None declared, Mary Bythell: None declared, Sarah Stevens: None declared, Fiona Pearce Grant/research support from: I have received a research grant from Vifor Pharma

Comparative assessment of live cyprinid and salmonid movement networks in England and Wales

Disease poses a significant threat to aquaculture. While there are a number of factors contributing to pathogen transmission risk, movement of live fish is considered the most important. Understanding live fish movement patterns for different aquaculture sectors is therefore crucial to predicting disease occurrence and necessary for the development of effective, risk-based biosecurity, surveillance and containment policies. However, despite this, our understanding of live movement patterns of key aquaculture species, namely salmonids and cyprinids, within England and Wales remains limited. In this study, networks reflecting live fish movements associated with the cyprinid and salmonid sectors in England and Wales were constructed. The structure, composition and key attributes of each network were examined and compared to provide insight into the nature of trading patterns and connectedness, as well as highlight sites at a high risk of spreading disease. Connectivity at both site and catchment level was considered to facilitate understanding at different resolutions, providing further insight into disease outbreaks, with industry wide implications. The study highlighted that connectivity through live fish movements was extensive for both industries. The salmonid and cyprinid networks comprised 2533 and 3645 nodes, with a network density of 5.81 × 10^-4 and 4.2 × 10^-4, respectively. The maximum network reach of 2392 in the salmonid network was higher, both in absolute terms and as a proportion of the overall network, compared to maximum network reach of 2085 in the cyprinid network. However, in contrast, the number of sites in the cyprinid network with a network reach greater than one was 513, compared to 171 in the salmonid network. Patterns of connectivity indicated potential for more frequent yet smaller scale disease outbreaks in the cyprinid industry and less frequent but larger scale outbreaks in the salmonid industry. Further, high connectivity between river catchments within both networks was shown, posing challenges for zoning at the catchment level for the purpose of disease management. In addition to providing insight into pathogen transmission and epidemic potential within the salmonid and cyprinid networks, the study highlights the utility of network analysis, and the value of accessible, accurate live fish movement data in this context. The application of outputs from this study, and network analysis methodology, to inform future disease surveillance and control policies, both within England and Wales and more broadly, is discussed.

Correlation of rheoencephalogram and intracranial pressure: results of a rat study

Measuring brain electrical impedance (rheoencephalography-REG) is a potential technique for noninvasive, continuous neuro-monitoring. Typically, intracranial pressure (ICP), an invasive monitoring modality, is used in brain monitoring. Our hypothesis was that both modalities would reflect cerebrovascular reactivity. In the present study we compared results of REG to results of ICP measurement. Rats were used under anesthesia ([Formula: see text]; 36 control and 59 vinpocetine infusions). REG was measured by two bipolar REG amplifiers; time constants (Tc) were 3 and 0.3 s. The vinpocetine injection caused a transient decrease in systemic arterial pressure (SAP) and a simultaneous increase in ICP and REG pulse amplitude. SAP decrease was 25%  ±  14%; ICP was 28%  ±  16%; REG pulse amplitude increase was 209%  ±  17% (Tc 3) and 107%  ±  68% (Tc 0.3). ICP increase correlated with REG pulse amplitude increase. Area under the receiver operating characteristic curve was 0.9481 for ICP-REG time constants 3 and 0.9335 for ICP-REG time constants 0.3; both with [Formula: see text]. The fact that both REG and ICP reflect cerebrovascular reactivity indicates the usefulness of REG as a potential technique for noninvasive, continuous neuro-monitoring. The Tc of REG amplifier requires optimization for continuous monitoring of pressure reactivity index.

Lupus nephritis: a 15-year multi-centre experience in the UK

OBJECTIVES

Our aim was to audit the outcome of lupus nephritis (LN) at three East Midlands centres.

METHODS

We undertook a retrospective review of all biopsy-proven LN types III-V 1995-2010.

RESULTS

In total, 61 patients with LN were identified, with a median follow-up of 68 months. LN was present at the time of systemic lupus erythematosus (SLE) diagnosis in 20 patients. The median time from SLE diagnosis to the first LN episode was 5.3 years. Some 35 patients received IV cyclophosphamide and 17 received mycophenolate mofetil (MMF) as induction therapy; 81.8% of those treated with cyclophosphamide and 81.3% with MMF had at least 'improved' according to the ACR-response criteria 6 months from induction; 33.3% and 37.5%, respectively, had a 'complete' response. MMF and azathioprine were the most frequently used maintenance therapy. We found that 32.8% experienced a flare after a mean post-induction time of 3.5 years, irrespective of the maintenance therapy used, and 43.8% of partial responders flared compared with 4.8% of complete responders. End-stage renal failure developed in 8.2%.

CONCLUSIONS

Overall, outcomes (response, flare-rate, end-stage renal failure) were comparable with European clinical studies. Partial responders are more likely to flare compared with complete responders. The results highlight that LN can occur, and flare, after many years of SLE, emphasizing the importance of continued vigilance for LN in all patients.

Clinical evaluation of the Life Support for Trauma and Transport (LSTAT) platform

INTRODUCTION

The Life Support for Trauma and Transport (LSTAT trade mark ) is a self-contained, stretcher-based miniature intensive care unit designed by the United States Army to provide care for critically injured patients during transport and in remote settings where resources are limited. The LSTAT contains conventional medical equipment that has been integrated into one platform and reduced in size to fit within the dimensional envelope of a North Atlantic Treaty Organization (NATO) stretcher. This study evaluated the clinical utility of the LSTAT in simulated and real clinical environments. Our hypothesis was that the LSTAT would be equivalent to conventional equipment in detecting and treating life-threatening problems.

METHODS

Thirty-one anesthesiologists and recovery room nurses compared the LSTAT with conventional monitors while managing four simulated critical events. The time required to reach a diagnosis and treatment was recorded for each simulation. Subsequently, 10 consenting adult patients were placed on the LSTAT after surgery for postoperative care in the recovery room. Questionnaires about aspects of LSTAT functionality were completed by nine nurses who cared for the patients placed on the LSTAT.

RESULTS

In all of the simulations, there was no clinically significant difference in the time to diagnosis or treatment between the LSTAT and conventional equipment. All clinicians reported that they were able to manage the simulated patients properly with the LSTAT. Nursing staff reported that the LSTAT provided adequate equipment to care for the patients monitored during recovery from surgery and were able to detect critical changes in vital signs in a timely manner.

DISCUSSION

Preliminary evaluation of the LSTAT in simulated and postoperative environments demonstrated that the LSTAT provided appropriate equipment to detect and manage critical events in patient care. Further work in assessing LSTAT functionality in a higher-acuity environment is warranted.

Subcutaneous tissue oxygen pressure: a reliable index of peripheral perfusion in humans after injury

The usual initial life-threatening effect of injury is hypovolemic shock. In the hierarchical physiologic response to hypovolemia, perfusion of peripheral tissues is sacrificed early and restored late. But the usual hemodynamic and metabolic measurements of blood pressure, urine output, and base deficit are not reliable indices of peripheral perfusion. Although the Clark electrode can quantitate tissue oxygen pressure and thereby serve as an index of perfusion, its use is compromised by several technical deficiencies. Recently, an optical method (optode) using fluorescent technology has been developed for measurement of oxygen tension in subcutaneous tissue (P sgO2). Our studies compared this device with the Clark electrode in the laboratory and tested its value in both animal and clinical studies of hypovolemic shock. The results of these several studies demonstrated that: (1) the new oximeter tracked a rapid fall or rapid rise of oxygen tension between room air (150 mm Hg) and 0 mm Hg ( a glucose oxidase/catalase solution) as well as the Clark electrode without encountering its technical problems; (2) with an acute hemorrhage to 20% of base line, the PsgO2 was found to decline rapidly in parallel with the decline of mean arterial pressure (MAP). Although the MAP rapidly returned to normal after immediate complete return of all shed blood, the PsgO2 did not reach normal levels for at least 2 hours, suggesting persistent peripheral vasoconstriction. (3) Studies in progress suggest that between 35 and 78% of trauma patients (n = 18) adequately resuscitated for hypovolemia b customary criteria have a decreased level of PsgO2 for as long as 60 hours after resuscitation for injury. If care is taken to prevent other causes of catecholamine induced vasoconstriction such as pain, fear, cold, and arterial hypoxia, these several results suggest that a certain number of injured patients are inadequately resuscitated despite the return to normal of conventional hemodynamic measurements. The serial analysis of PsgO2 may assist in managing patients and promote better understanding of the responses to injury.

Metabolic and functional cardiac impairment after reperfusion with persantine

The effect of dipyridamole (DYP) on postischemic myocardial function and metabolism was studied using the isolated rabbit heart model. Twenty-one isolated rabbit heart preparations were divided into two groups: KH (control N = 10) were reperfused after 24 min normothermic hyperkalemic arrest with modified Krebs-Henseleit buffer (KH) while DYP (N = 11) were reperfused with KH and 5 X 10(-6) M DYP. Hearts were analyzed for myocardial function (DP, developed pressure, +dp/dt, -dp/dt) and metabolic function (ATP, CrP, ADP, AMP, purines, and lactate levels). Data analysis revealed significant reperfusion depression in DYP myocardial function compared with KH (P less than 0.05): DP (42 +/- 6 vs 89 +/- 7 mm Hg), +dp/dt (390 +/- 21.6 vs 1227 +/- 48.4), and -dp/dt (280 +/- 20.1 vs 677 +/- 19.8). Comparison of DYP to KH metabolic parameters was also significantly different (P less than 0.05): ATP (5.8 +/- 0.7 vs 9.5 +/- 1.4), ADP (2.1 +/- 0.2 vs 3.2 +/- 0.6), CrP (9.6 +/- 0.3 vs 17.2 +/- 1.3). Tissue purines (adenosine and inosine) were significantly elevated (P less than 0.01) in the DYP group, while coronary sinus purines and lactate loss were similar. Thus, the data suggest that DYP, present during postischemic reperfusion, depresses myocardial function by inhibiting adenosine phosphorylation, thereby decreasing the generation of high-energy phosphates without increased substrate loss or ischemia.

Impaired responsiveness of homosexual men with HIV antibodies to plasma derived hepatitis B vaccine

Thirty five homosexual men (17 positive for antibody to the human immunodeficiency virus (HIV) and 18 consistently negative) were vaccinated against hepatitis B virus infection. Eight of the 17 seropositive patients failed to develop detectable hepatitis B surface antibody within three months of the third injection compared with only one of the 18 seronegative patients (p less than 0.01). HIV infection is prevalent in the developed world in groups at risk for hepatitis B infection and in certain Third World countries where widespread vaccination programmes exist. This study shows the impact that coincident HIV infection may have on an otherwise efficacious vaccine. The efficacy of this and other vaccines in patients infected with HIV needs to be studied urgently.

Prevalence of antibodies to human immunodeficiency virus, gonorrhoea rates, and changed sexual behaviour in homosexual men in London

The prevalence of antibody against human immunodeficiency virus (anti-HIV), which rose among British homosexual/bisexual men attending a London sexually-transmitted-disease clinic from 3.7% (4/107) in March, 1982, to 21% (26/124) in July, 1984, was 18.1% (17/94) in April/May 1985, 24.5% (61/249) in January, 1986, and 25.3% (25/99) in November/December, 1986. This slower rise in anti-HIV prevalence coincided with a fall in the annual gonorrhoea rate from 15.3% in 1982 to 5.1% in the first half of 1986 in the same male homosexual clinic population. Over the same period a reduction in the number of sexual partners and a change to safer sexual practices has been documented among homosexual and bisexual men taking part in a prospective study of the natural history of HIV infection. These data support the value of continuing preventive efforts to control viral spread in the absence of an effective vaccine or therapy.