Alpha-1 antitrypsin limits neutrophil extracellular trap disruption of airway epithelial barrier function

Neutrophil extracellular traps contribute to lung injury in cystic fibrosis and asthma, but the mechanisms are poorly understood. We sought to understand the impact of human NETs on barrier function in primary human bronchial epithelial and a human airway epithelial cell line. We demonstrate that NETs disrupt airway epithelial barrier function by decreasing transepithelial electrical resistance and increasing paracellular flux, partially by NET-induced airway cell apoptosis. NETs selectively impact the expression of tight junction genes claudins 4, 8 and 11. Bronchial epithelia exposed to NETs demonstrate visible gaps in E-cadherin staining, a decrease in full-length E-cadherin protein and the appearance of cleaved E-cadherin peptides. Pretreatment of NETs with alpha-1 antitrypsin (A1AT) inhibits NET serine protease activity, limits E-cadherin cleavage, decreases bronchial cell apoptosis and preserves epithelial integrity. In conclusion, NETs disrupt human airway epithelial barrier function through bronchial cell death and degradation of E-cadherin, which are limited by exogenous A1AT.

POS1411 ARTIFICIAL INTELLIGENCE FOR IDENTIFYING NEW DISEASE CLUSTERS IN PATIENTS WITH PSORIATIC ARTHRITIS/PSORIASIS: A PROOF-OF-CONCEPT STUDY

Background

Psoriatic arthritis (PsA)/Psoriasis (PsO) patients present with multiple long-term conditions (MLTCs), and more than half of PsA patients have ≥1 LTC, which have an impact on the quality of life. We used the Clinical Practice Research Datalink (CPRD) in the UK to determine multimorbidity in patients with PsA/PsO. CPRD is a database of routinely collected UK patient data that can be used to examine multimorbidity over the life course of the disease. A understanding of clusters and timing may allow the development of tailored programmes for surveillance and early interventions to reduce MLTcs in PSA/PO.

Objectives

The overall objective of our study was to use CPRD to identify and interpret new and frequently-occurring disease clusters in the PsA/PsO population.

Methods

We identified PsA/PsO patients from the CPRD GOLD for the UK from 2009 to 2018 with at least one year of follow up but excluded patients in practices that had migrated to Aurum, a different electronic health record system held by CPRD. All patients were matched to controls at a 1: 4 ratio by age, sex, practice. We analysed 40 common MLTCs outlined by Barnett et al. to identify and interpret multimorbidity clusters. Multimorbidity clusters were identified using the network bi-clustering. Our methodology can be divided into three steps- (a) Separate the “case” and the “control” population, (b) Create a patient-condition matrix for each of “case” and “control” population and (c) From the patient-condition matrix in each case use a the Euclidean distance criterion to compute a similarity matrix of all the possible conditions among those patients.

Results

We identified 67,827 incident or prevalent PsA/PsO patients aged 20 years and above who were matched to 271,308 controls by age, sex and practice (Table 1). The median number of long-term conditions (LTCs) was higher in the cases than in the controls.

Table 1.CharacteristicCASE, N = 67,827CONTROL, N = 271,308Age Group, n (%)<206,491 (9.6%)27,897 (10%)20-5442,357 (62.4%)169,008(62.3%)55 and above19,148 (28.2%)74,403 (27.4%)Ethnicity, n (%)White28,200 (41.6%)93,485 (34.5%)Black, S.Asian and other956 (1.4%)3,735 (1.4%)Unknown38,671 (57%)174,088(64.2%)Sex, n (%)F35,431 (52%)141,724 (52%)BMI category, n (%)20 to <2511,183 (16.5%)43,240 (15.9%)25 to <3013,565 (20%)45,783 (16.9%)30 to <357,584 (11.2%)22,690 (8.4%)35 to 403,048 (4.5%)8,172 (3.0%)Alcohol status, n (%)Non-drinker/ Ex-drinker8,649/2,159 (15.9%)33,983/7,579 (15.3%)Drinker/Heavy drinker47,316/3,030 (74.2%)180,888/8,831 (69.9%)Smoking status, n (%)Ex-smoker/Non-smoker14,137/29,289 (64%)48,110/142,295 (70.2%)Smoker24,018 (35%)71,779 (26%)Long term condition, Median (IQR)1.00 (0.00, 3.00)1.00 (0.00, 2.00)

We present the results obtained via spectral clustering on the similarity matrix obtained in each “case” and “control” population via Euclidean distance. There are 40 LTCs which are represented via two clusters in the “case” and the “control” population network (Figure 1). The LTCs in the same cluster are strongly connected within themselves compared to those in the other cluster. The noticeable part was clustering of diabetes, hypertension and chronic heart diseases in one group, especially in the “case” population over the “control” population. Interestingly depression, dementia and chronic heart diseases were in the same group in the clustering results for both the “case” and the “control” population. There are a central group of diseases (HYP, DEM, DIV, CHD etc.) in Figure 1, which seems to be connected with both sets of clusters. As mentioned earlier, diabetes has connections with these central groups of diseases, and it tends to be more pronounced in the “case” population.

Figure 1.

Conclusion

MLTCs including diabetes, hypertension, chronic kidney disease and heart disease occurred together more commonly in patients with PsA/PsO than those without PsA/PsO.

The future goal is to identify frequently occurring clusters of MLTCs in the immune-mediated inflammatory disease population.

Disclosure of Interests

Prasad Nishtala: None declared, Neil McHugh: None declared, William Tillett Speakers bureau: Abbvie, Amgen, Celgene, Eli-Lilly, Janssen, MSD, Novartis, Pfizer and UCB, Consultant of: Abbvie, Amgen, Celgene, Eli-Lilly, Janssen, MSD, Novartis, Pfizer and UCB, Grant/research support from: Abbvie, Celgene, Eli-Lilly, Janssen, and UCB, Sarah Skeoch: None declared, Jenny Humphreys: None declared, John Pauling: None declared, Olga Isupova: None declared, Anita McGROGAN: None declared, Julia Snowball: None declared, Sandipan Roy: None declared

Safety of direct oral anticoagulants (DOACs) vs. warfarin for people aged ≥ 75 years with atrial fibrillation: a cohort study

Introduction

Warfarin significantly reduces the risk of stroke in people with atrial fibrillation (AF), but historically has been underused in older people due to complicated dosage regimens. DOACs offer an attractive alternative to warfarin and were shown to be non-inferior in randomised controlled trials, however older people were underrepresented in these trials and there have been few studies investigating outcomes specifically in this high risk group (1).

Aim

To compare the risk of major, non-major, gastrointestinal, and intracranial bleeding between warfarin and DOACs in people aged ≥ 75 years with AF.

Methods

A cohort of patients aged ≥ 75 years with a diagnosis of AF was extracted from the Clinical Practice Research Datalink (CPRD). Patients could enter the study on the date of their first prescription for warfarin or a DOAC between 1/1/2013 and 27/12/2017. Patients were censored on the date of the outcome, death, or leaving the general practice. Switching between anticoagulants and unexposed periods were measured using prescription mapping. Crude and adjusted hazard rates of the risk of bleeding were calculated using a Cox proportional hazards model with oral anticoagulant prescribing as a time varying covariate.

Results

The cohort included 10,149 patients in the warfarin group and 10,237 in the DOAC group. The groups had similar characteristics and the average age was 81 in the warfarin group and 82 in the DOAC group. The table summarises the results. Whilst major and non-major bleeding was similar between all DOACs and warfarin, rivaroxaban was associated with higher risk and apixaban lower risk when analysed separately. Risk of gastrointestinal bleeding was higher with all DOACs and rivaroxaban than warfarin but apixaban was not significantly different. Few intracranial events occurred (n=131).

Conclusion

The results indicate that DOACs as a group are not significantly different to warfarin, however when analysed separately, apixaban may be safer. While the study relies on prescription data and hence it is not known if patients were taking the medications, the large cohort studied is representative of older people who are prescribed these medications in UK primary care.

Reference

(1) Mitchell A, Watson MC, Welsh T, McGrogan A. Effectiveness and safety of direct oral anticoagulants versus vitamin K antagonists for people aged 75 years and over with atrial fibrillation: A systematic review and meta-analyses of observational studies. Journal of Clinical Medicine. 2019; 8 (554).

SAT0399 RISK OF OSTEOARTHRITIS IN AN INCIDENT COHORT OF PEOPLE WITH PSORIATIC ARTHRITIS: A POPULATION-BASED COHORT STUDY

Background:

Psoriatic arthritis (PsA) is a chronic inflammatory arthritis that causes pain, stiffness and swelling around the joints. PsA is reported to affect between 10 and 40% of individuals with psoriasis1and in the majority of patients presents after, or synchronously with, psoriasis onset.2Osteoarthritis (OA) is a common form of non-inflammatory arthritis related to joint degeneration and typically commences late in the fifth decade. PsA and OA have long been considered two distinct arthropathies, however they do have some overlapping features and symptoms and in certain circumstances it can be difficult to differentiate between them, particularly in the small joints of the hands or spine.3

Objectives:

To determine the risk of a diagnosis of osteoarthritis in psoriatic arthritis patients compared to patients with psoriasis and a general population cohort.

Methods:

Incident PsA patients aged 18-89 years at diagnosis were identified from the UK Clinical Practice Research Datalink between 1998 and 2014. All PsA patients were matched to a cohort of patients with psoriasis and a general population cohort (with no psoriasis or PsA) at a 1:4 ratio based on index date, year of birth, sex and general practice. The baseline prevalence of OA of any site was calculated as a percentage for each study cohort and then those prevalent cases were excluded from the numerators and denominators of the incident calculations. The incidence of OA was calculated and relative risks (RRadj), adjusting for body mass index (BMI), were calculated using conditional Poisson regression.

Results:

In total, 6,783 incident PsA patients were identified. The baseline prevalence of OA ranged from 22.1% (CI9521.1-23.1) in the PsA cohort to 12.6% (CI9512.2-13.0) and 11.0% (CI9510.6-11.3) in the psoriasis and general population cohorts respectively. The incidence of OA was significantly higher in the PsA cohort compared to the psoriasis and general population cohorts after adjusting for BMI (RRadj1.68 CI951.46-1.93 and RRadj1.86 CI951.62-2.14 respectively) (Tables 1 and 2).

Conclusion:

An increased risk of OA was observed in patients with PsA compared to patients with psoriasis alone and those in the general population. Further work is needed to determine whether this reflects a true increase in OA risk or misdiagnosed PsA and the extent to which it can be explained by differences in the opportunity for OA diagnosis between cohorts.

Table 1.

Incidence of osteoarthritis in the PsA, psoriasis and general population cohorts

CasesMedian age (years) at diagnosis (IQR)Person yearsIncidence rate per10,000 person yearsCI95Any OAϮGeneral population137459 (51 - 66)125,798109.2(103.5 - 115.0)Psoriasis143259 (53 - 67)122,279117.1(111.0 - 123.2)PsA46459 (51 - 66)28,574162.4(147.6 - 177.2)

Ϯincluding spondylosis

References:

[1]Ogdie A, Weiss P. Rheum Dis Clin North Am. 2015;41(4):545-568.

[2]Tillett Wet al.Rheumatol. 2017;56(12):2109-2113.

[3]McGonagle Det al. Rheumatology. 2015;54(1):29-38.

Table 2.

Risk of osteoarthritis in patients with PsA compared with patients in the general population and patients with psoriasis

PsA compared with a general population cohortPsA compared with a psoriasis cohortUnadjustedAdjusted†UnadjustedAdjusted†RRCI95PRRCI95PRRCI95PRRCI95POA1.871.67-2.10<0.00011.861.62-2.14<0.00011.681.50-1.88<0.00011.681.46-1.93<0.0001

†adjusted for BMI taken as the closest entry within 3 years of the index date

Acknowledgments:

This report is independent research funded by the National Institute for Health Research, Programme Grants for Applied Research [Early detection to improve outcome in patients with undiagnosed PsA (‘PROMPT’), RP-PG-1212-20007]. The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care.

Disclosure of Interests:

None declared

Sensitivity of the UK Clinical Practice Research Datalink to Detect Neurodevelopmental Effects of Medicine Exposure in Utero: Comparative Analysis of an Antiepileptic Drug-Exposed Cohort

Introduction

Electronic healthcare data have several advantages over prospective observational studies, but the sensitivity of data on neurodevelopmental outcomes and its comparability with data generated through other methodologies is unknown.

Objectives

The objectives of this study were to determine whether data from the UK Clinical Practice Research Datalink (CPRD) produces similar risk estimates to a prospective cohort study in relation to the risk of neurodevelopmental disorders (NDDs) following prenatal antiepileptic drug (AED) exposure.

Methods

A cohort of mother–child pairs of women with epilepsy (WWE) was identified in the CPRD and matched to a cohort without epilepsy. The study period ran from 1 January 2000 to 31 March 2007 and children were required to be in the CPRD at age 6 years. AED exposure during pregnancy was determined from prescription data and children with an NDD diagnosis by 6 years were identified from Read clinical codes. The prevalence and risk of NDDs was calculated for mother–child pairs in WWE stratified by AED regimen and for those without epilepsy. Comparisons were made with the results of the prospective Liverpool and Manchester Neurodevelopment Group study which completed assessment on 201 WWE and 214 without epilepsy at age 6 years.

Results

In the CPRD, 1018 mother–child pairs to WWE and 6048 to women without epilepsy were identified. The CPRD identified a lower prevalence of NDDs than the prospective study. In both studies, NDDs were more frequently reported in children of WWE than women without epilepsy, although the CPRD risk estimate was lower (2.16 vs. 0.96%, p < 0.001 and 7.46 vs. 1.87%, p = 0.0128). NDD prevalence differed across AED regimens but the CPRD data did not replicate the significantly higher risk of NDDs following in utero monotherapy valproate exposure (adjusted odds ratio [OR_adj] 2.02, 95% confidence interval [CI] 0.52–7.86) observed in the prospective study (OR_adj 6.05, 95% CI 1.65–24.53).

Conclusion

It was possible to identify NDDs in the CPRD; however, the CPRD appears to under-record these outcomes. Larger studies are required to investigate further.

Electronic supplementary material

The online version of this article (doi:10.1007/s40264-017-0506-5) contains supplementary material, which is available to authorized users.

Pregnancy losses in women with Type 1 or Type 2 diabetes in the UK: an investigation using primary care records

AIM

This study aims to investigate pregnancy losses in women with Type 1 or Type 2 diabetes and compare this with the general population.

METHODS

Pregnancies ending between 1993 and 2006 in those with Type 1 or Type 2 diabetes were identified on the General Practice Research Database. Pregnancy losses were identified from medical records and the cohort described by their characteristics and prescribing for diabetes.

RESULTS

Of 2001 pregnancies identified in women with Type 1 diabetes, 678 ended in a pregnancy loss: 19.6% were spontaneous, 9.6% were induced and 4.3% were losses for unknown reasons. In women with Type 2 diabetes, there were 240 losses in 669 pregnancies: 21.1% were spontaneous, 10.3% induced and 4.0% were losses for unknown reasons. The proportion of spontaneous losses in women with diabetes was higher than in the general population (13.2%). Women with Type 1 diabetes treated with human and analogue insulins were 60% more likely to have a delivery than a loss (odds ratio 1.6, 95% CI 1.18-2.18) compared with human insulin treatment alone, although numbers were small.

CONCLUSION

We found that the proportions of spontaneous losses in women with Type 1 or Type 2 diabetes were similar at approximately 20%, which is higher than in the general population and also higher than previous studies have reported. While much emphasis has been placed on pre-conception care for women with Type 1 diabetes, the same is now needed for those with Type 2 diabetes, given the similarity in outcomes and increasing prevalence of this condition.

The impact of media coverage of the Flexible Sigmoidoscopy Trial on English colorectal screening uptake

Objective

To assess the impact of media coverage of the UK Flexible Sigmoidoscopy Trial on colorectal screening uptake in England.

Setting

In April 2010, publication of the UK Flexible Sigmoidoscopy (FS) Trial results generated considerable media interest in both FS and colorectal cancer (CRC) generally.

Methods

We used routinely collected data from the south of England (excluding London) to analyse return of faecal occult blood test (FOBt) kits within 28 days of the invitation (early uptake) among 60–69 year olds, before (T1, n = 31,229), around the time of (T2, n = 39,571), and one month after (T3, n = 33,430) the FS publicity.

Results

FOBt uptake over the whole period was 58.2%, with 38.4% of the kits returned within 28 days (early uptake). Across the three time periods, early uptake was 35.8% at T1, 39.4% at T2, and 39.7% at T3. Multivariate regression controlling for age, gender and socioeconomic status confirmed that uptake was higher if people received the FOBt kit around the time of the media coverage (T2: odds ratio [OR] = 1.17, 95% CI = 1.13–1.20), or one month after (T3: OR = 1.18, 95% CI = 1.15–1.22) than before (T1). Sub-group analyses demonstrated that the impact was stronger among previous non-responders than among first-time invitees or previous responders (P < 0.001).

Conclusion

Media coverage of the FS Trial appeared to have a small but positive impact on FOBt screening uptake, especially among people who had previously abstained from screening.

Telomere length shortening is associated with disease evolution in chronic myelogenous leukemia

We studied telomere length in the peripheral blood leukocyte samples of a large group of patients with chronic myelogenous leukemia (CML) by Southern blot hybridization using the (TTAGGG)4 probe. The average telomere length expressed as the peak telomere repeat array (TRA) of the peripheral blood samples obtained from a group of 34 healthy age-matched controls ranged between 7.6 and 10.0 kb and the mean peak TRA was 8.7 kb. Forty-one patients in the chronic phase of CML were studied; 32/41 (78%) showed telomere reduction (<7.6 kb) relative to age-matched controls and the mean peak TRA was 6.4 kb (range 4.0-10.6 kb). Serial samples were analysed from 12 patients at both chronic phase and during disease progression. The leukocyte DNA of all 12 patients in accelerated phase and/or blast crisis showed telomere reduction relative to age-matched controls and the mean peak TRA was 4.1 kb (range 3.0-5.4 kb). The peak TRA in the accelerated or blast phase was reduced compared with the corresponding paired sample in the chronic phase in all cases studied. These data show that a marked reduction in telomere length is associated with disease progression in CML.

Psychosocial care in oncology nursing: a study of social knowledge

A combination of focus group and individual interviews aimed to examine psychosocial aspects of nursing within a social context and social knowledge held by two teams of ward-based oncology nurses. Five core categories of knowledge emerged: knowledge of how to care, knowledge of the patient, knowledge of the ward, knowledge of nurses coping, and knowledge of involvement. Involvement or emotional closeness was seen as a necessary, inevitable and potentially stressful feature of psychosocial care. The authors conclude that interpersonal and professional aspects of nursing must be balanced in order to provide effective psychosocial care.

Asking nurses about advocating for patients: 'reactive' and 'proactive' accounts

The concepts of the nurse as patient advocate is not new, and the evolution of this role is briefly traced in this paper as a background to presenting the findings from a small-scale qualitative study. However, whilst there is much written there is a lack of empirical work describing nurses' understandings and experiences of advocacy and what there is often derives from the USA and centres on specialized groups such as mental health, paediatric or intensive care patients or those with a learning disability. This study sought to explore understandings of the concept in a group of 15 adult nurses from general medical and surgical wards. Audiotaped semi-structured interviews were used for data collection. Data were analysed using a method appropriate for qualitative studies. Categories were generated and are presented here supported by direct participant quotes derived from the interview transcripts. These include the importance of the therapeutic relationship as the key to advocacy, nurse and patient shared common humanity, the cultural environment of care in which advocacy occurs and descriptions of 'reactive' and 'proactive' levels of advocacy.

Illuminating dissertation supervision through reflection

This paper describes a small research study designed to explore the role of the dissertation supervisor and to examine the potential of using reflection as a tool for learning and for enhancing professional educational practice. The authors met to discuss and reflect upon the processes of supervision and the role of the supervisor throughout the period of supervising three dissertation students. Each author maintained individual reflective written accounts of supervisory meetings with students. These accounts and the transcribed tape-recordings of the group meetings provided two sets of data which were analysed using qualitative techniques. From the data analysis the authors were able to identify various phases in dissertation supervision--partnership; setting the learning contract; signposting; ownership of the dissertation; letting go; the rush at the end; maintaining the balance--and also contextual issues of humanness; time; and energy, which were needed to sustain the supervisory processes. The role of the dissertation supervisor was illuminated and the potential of using reflection as a tool for developing professional educational practice was realized. The importance of constructive support while engaged in processes of reflection cannot be underestimated.