Outcomes Following Pedestal Cup Reconstruction of (Impending) Pathological Fractures of the Acetabulum due to Metastatic Bone Disease

Management of periacetabular metastatic bone disease (MBD) is challenging, specifically if associated with bone loss or fracture. The aim of this study was to evaluate the complications and outcomes after undergoing peri-acetabular reconstruction using an 'ice-cream cone' pedestal cup endoprostheses for the most severe cases of (impending) pathological acetabular fractures. Fifty cases with severe periacetabular disease were identified. Acetabular defects were classified using the Metastatic Acetabular Classification (MAC). Pre- and post-operative mobility was assessed using the Eastern Cooperative Oncology Group (ECOG) Performance Status. Pain levels were assessed using a verbal rating scale. Surgical complications and patient survival were analysed; the Prognostic Immune Nutritional Index (PINI) was applied retrospectively to survival. There were 32 females and 18 males with a median age of 65 (41-88). Median post-operative follow-up was 16 months (IQR 5.5-28.5 months). Thirty-nine had complete, and 11, impending pathological fractures. The observed five-year survival was 19%, with a median survival of 16 months (IQR 5.8-42.5 months). Significantly worse survival was observed with PINI scores < 3.0 (p = 0.003). Excluding three perioperative deaths, 13 complications occurred in 12 patients: Implant failure in six patients (four aseptic loosening, one dislocation and one infection). At the final follow-up, mobility and pain levels were improved in 85% and 100%, respectively. Reconstruction of significant pelvic MBD with the 'ice-cream cone' reduces pain and improves mobility. Whilst the mortality rate is high, it remains a reasonable option for bed-bound, immobile patients. We advocate the use of an 'ice-cream cone' prosthesis for selected patients balancing the reported risks with the observed benefits.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13193-024-01917-x.

Micronutrient Status and Prediction of Disease Outcome in Adults With Inflammatory Bowel Disease Receiving Biologic Therapy

BACKGROUND AND AIMS

Micronutrient deficiencies are common in patients with inflammatory bowel disease (IBD), but whether they relate to disease outcomes remains unknown. This study assessed the micronutrient status of adults with IBD on treatment with biologic therapies and explored predictive relationships with disease outcomes.

METHODS

Seventeen micronutrients were measured in the blood of 216 adults with IBD on biologic therapy. Of these, 127 patients (58%) had Crohn's disease (CD), and the majority (70%) received treatment with infliximab. Patients were followed for 12 months and onset of adverse clinical outcomes (eg, requirement for treatment with corticosteroids, hospitalization, or surgical intervention) was recorded, and related to micronutrient status.

RESULTS

Among all patients, the most common deficiencies were for vitamin C (n = 35 of 212 [16.5%]), ferritin (n = 27 of 189 [14.3%]), folate (n = 24 of 171 [14.0%]), and zinc (n = 27 of 210 [12.9%]). During follow-up, 22 (10%) of the 216 patients developed 1 or more adverse clinical outcomes. Patients with CD and zinc deficiency were significantly more likely to require surgery (P = .002) or treatment with corticosteroids (P < .001). In contrast, patients with ulcerative colitis and selenium deficiency were significantly more likely to have a clinical flare of disease (P = .001), whereas those with CD were not. This relationship with selenium remained significant after adjustment for confounders.

CONCLUSIONS

A substantial proportion of adults with IBD present deficiencies for certain micronutrients, with selenium and zinc deficiency predicting adverse disease outcomes. For other micronutrients, deficiencies were less common and should not warrant routine screening. Intervention studies should explore the effect of micronutrient supplementation in modifying disease outcomes in IBD.

A28 TIME-RESTRICTED FEEDING REDUCES INFLAMMATORY BOWEL DISEASE AND IMPROVES EPITHELIUM COLON REGENERATION

Background

The circadian clock is a time keeping mechanism that drives daily rhythms in the body, including behavior and gastrointestinal digestion, inflammation, and metabolism. These daily rhythms are endogenous to cells, and they must adjust themselves to cyclic environmental cues like feeding schedules and light dark cycles. However, when the cyclical environment is chrono-disrupted (ex. shiftwork and jetlag), the temporal organization in the body is lost. Chrono-disruption is linked to an increase in the risk of Inflammatory Bowel Disease (IBD); studies in rodents shown that IBD is more severe in mice without a circadian clock and intestinal regeneration is compromised

Purpose

Recent studies have shown that time-restricted feeding (TRF, the provision of food at times of peak behavior activity – without caloric restriction), that aligns with circadian behavior improves daily organization in the body and health. Therefore, we hypothesized that time-restricted feeding would be an effective strategy to ameliorate IBD and improve regeneration in chrono-disrupted animals.

Method

To test this, we used the DSS induction of colitis in mutant mice without clock function (Bmal1^-/-) and controls with an intact clock (Bmal1^+/+) and compared ad libitum feeding vs. TRF conditions (food available from 7pm to 7am).

Result(s)

Our results show that TRF ameliorates IBD symptoms and protects against epithelium colon damage in animals without clock function. Our preliminary results suggest that TRF may function by increasing the expression of the anti-inflammatory signal PPARg in the colon. Currently, we are testing if the circadian clock controls the daily expression of PPARg in vivo and in vitro. To further test the effect of TRF during regeneration after colitis, we tested proliferation (Ki67) and regeneration in the colon. (Hopx). Our results show that TRF increases the number of Ki67 positive cells and the expression of fetal-like regenerative precursor Hopx in both animals with and without a functional clock.

Conclusion(s)

Together these data suggest that TRF enhances regeneration in the colon after colitis. Moving forward, we are testing transcriptional pathways that are activated during regeneration in animals under TRF. Our results show that time restricted feeding can ameliorate IBD and highlight the role of circadian rhythms in regeneration and intestinal stem cell biology.

Please acknowledge all funding agencies by checking the applicable boxes below

CIHR, Other

Please indicate your source of funding;

Crohn's and Colitis Canada

Disclosure of Interest

None Declared

Safety, immunogenicity, and reactogenicity of BNT162b2 and mRNA-1273 COVID-19 vaccines given as fourth-dose boosters following two doses of ChAdOx1 nCoV-19 or BNT162b2 and a third dose of BNT162b2 (COV-BOOST): a multicentre, blinded, phase 2, randomised trial

BACKGROUND

Some high-income countries have deployed fourth doses of COVID-19 vaccines, but the clinical need, effectiveness, timing, and dose of a fourth dose remain uncertain. We aimed to investigate the safety, reactogenicity, and immunogenicity of fourth-dose boosters against COVID-19.

METHODS

The COV-BOOST trial is a multicentre, blinded, phase 2, randomised controlled trial of seven COVID-19 vaccines given as third-dose boosters at 18 sites in the UK. This sub-study enrolled participants who had received BNT162b2 (Pfizer-BioNTech) as their third dose in COV-BOOST and randomly assigned them (1:1) to receive a fourth dose of either BNT162b2 (30 μg in 0·30 mL; full dose) or mRNA-1273 (Moderna; 50 μg in 0·25 mL; half dose) via intramuscular injection into the upper arm. The computer-generated randomisation list was created by the study statisticians with random block sizes of two or four. Participants and all study staff not delivering the vaccines were masked to treatment allocation. The coprimary outcomes were safety and reactogenicity, and immunogenicity (anti-spike protein IgG titres by ELISA and cellular immune response by ELISpot). We compared immunogenicity at 28 days after the third dose versus 14 days after the fourth dose and at day 0 versus day 14 relative to the fourth dose. Safety and reactogenicity were assessed in the per-protocol population, which comprised all participants who received a fourth-dose booster regardless of their SARS-CoV-2 serostatus. Immunogenicity was primarily analysed in a modified intention-to-treat population comprising seronegative participants who had received a fourth-dose booster and had available endpoint data. This trial is registered with ISRCTN, 73765130, and is ongoing.

FINDINGS

Between Jan 11 and Jan 25, 2022, 166 participants were screened, randomly assigned, and received either full-dose BNT162b2 (n=83) or half-dose mRNA-1273 (n=83) as a fourth dose. The median age of these participants was 70·1 years (IQR 51·6-77·5) and 86 (52%) of 166 participants were female and 80 (48%) were male. The median interval between the third and fourth doses was 208·5 days (IQR 203·3-214·8). Pain was the most common local solicited adverse event and fatigue was the most common systemic solicited adverse event after BNT162b2 or mRNA-1273 booster doses. None of three serious adverse events reported after a fourth dose with BNT162b2 were related to the study vaccine. In the BNT162b2 group, geometric mean anti-spike protein IgG concentration at day 28 after the third dose was 23 325 ELISA laboratory units (ELU)/mL (95% CI 20 030-27 162), which increased to 37 460 ELU/mL (31 996-43 857) at day 14 after the fourth dose, representing a significant fold change (geometric mean 1·59, 95% CI 1·41-1·78). There was a significant increase in geometric mean anti-spike protein IgG concentration from 28 days after the third dose (25 317 ELU/mL, 95% CI 20 996-30 528) to 14 days after a fourth dose of mRNA-1273 (54 936 ELU/mL, 46 826-64 452), with a geometric mean fold change of 2·19 (1·90-2·52). The fold changes in anti-spike protein IgG titres from before (day 0) to after (day 14) the fourth dose were 12·19 (95% CI 10·37-14·32) and 15·90 (12·92-19·58) in the BNT162b2 and mRNA-1273 groups, respectively. T-cell responses were also boosted after the fourth dose (eg, the fold changes for the wild-type variant from before to after the fourth dose were 7·32 [95% CI 3·24-16·54] in the BNT162b2 group and 6·22 [3·90-9·92] in the mRNA-1273 group).

INTERPRETATION

Fourth-dose COVID-19 mRNA booster vaccines are well tolerated and boost cellular and humoral immunity. Peak responses after the fourth dose were similar to, and possibly better than, peak responses after the third dose.

FUNDING

UK Vaccine Task Force and National Institute for Health Research.

STEM-14. THE WRAD COMPLEX REPRESENTS A THERAPEUTIC TARGET FOR CANCER STEM CELLS IN GLIOBLASTOMA

Glioblastoma (GBM) progression and resistance to conventional therapies is driven in part by cells within the tumor with stem cell properties including quiescence, self-renewal and drug efflux potential. It is thought that eliminating these cancer stem cells (CSCs) is a key component to successful clinical management of GBM. However, currently, few known molecular mechanisms driving CSCs can be exploited for therapeutic development. Core transcription factors such as SOX2, OLIG2, OCT4 and NANOG maintain the CSC state in GBM. Our laboratory recently uncovered a self-renewal signaling axis involving RBBP5 that is necessary and sufficient for CSC maintenance through driving expression of these core stem cell maintenance transcription factors. RBBP5 is a component of the WRAD complex, which promotes Lys4 methylation of histone H3 to positively regulate transcription. We hypothesized that targeting RBBP5 could be a means to disrupt epigenetic programs that maintain CSCs in stemness transcriptional states. We found that genetic and pharmacologic inhibition of the WRAD complex reduced CSC growth, self-renewal and tumor initiation potential. WRAD inhibitors partially dissembled the WRAD complex and reduced H3K4 trimethylation both globally and at the promoters of key stem cell maintenance transcription factors. Using a CSC reporter system, we demonstrated that WRAD complex inhibition decreased growth of SOX2/OCT4 expressing CSCs in a concentration-dependent manner as quantified by live imaging. Overall, our studies assess the function of the WRAD complex and the effect of WRAD complex inhibitors in preclinical models and specifically on the stem cell state for the first time in GBM. Studying the functions of the WRAD complex in CSCs may improve understanding of GBM pathogenesis and elucidate how CSCs survive despite aggressive chemotherapy and radiation. Our ongoing studies aim to develop brain penetrant inhibitors targeting the WRAD complex as an anti-CSC strategy that could potentially synergize with standard of care treatments.

Can patients with mild post-operative hyponatraemia following elective arthroplasty be discharged safely? A large-scale service evaluation suggests they can

BACKGROUND

Post-operative hyponatraemia is common following arthroplasty. Clinical hyponatraemia guidelines lack detail on when treatment is necessary, and there is a paucity of literature to guide best practice.

METHODS

Data were collected within retrospective service evaluations over two time periods in a single high throughput joint unit. The hospital's electronic database identified 1000 patients who were admitted electively between February 2012 and June 2013 and again between November 2018 and April 2019 for primary total hip, total knee or uni-compartmental knee arthroplasty. Hyponatraemia and non-hyponatraemia groups were compared. Logistic regression analysis was used to identify independent predictors of post-operative hyponatraemia, length of stay (LOS), re-attendance or re-admission to hospital.

RESULTS

Between 2012-2013 and 2018-2019, 32.1% and 25.7% of patients, respectively, developed post-operative hyponatraemia (serum sodium (s[Na]) ≤135 mmol/L). Those with post-operative hyponatraemia were significantly older, weighed less, were more comorbid and had lower pre-operative sodium. Multivariate analysis showed that increased age, knee surgery and lower pre-operative s[Na] independently predicted post-operative hyponatraemia. Post-operative hyponatraemia did not independently predict LOS, re-attendance or re-admission to hospital, within 90 days, in either cohort.

CONCLUSION

Post-operative hyponatraemia is common and may be a marker of pre-operative vulnerability. In these cohorts, it was not independently associated with LOS, re-attendance or re-admission to hospital. We suggest that otherwise well patients with mild hyponatraemia can be safely discharged earlier than is often the case and may not require extensive investigation. Further examination and research is required to develop a pre-operative approach to predict which patients will develop significant post-operative hyponatraemia.

Infliximab is associated with attenuated immunogenicity to BNT162b2 and ChAdOx1 nCoV-19 SARS-CoV-2 vaccines in patients with IBD

OBJECTIVE

Delayed second dose SARS-CoV-2 vaccination trades maximal effectiveness for a lower level of immunity across more of the population. We investigated whether patients with inflammatory bowel disease treated with infliximab have attenuated serological responses to a single dose of a SARS-CoV-2 vaccine.

DESIGN

Antibody responses and seroconversion rates in infliximab-treated patients (n=865) were compared with a cohort treated with vedolizumab (n=428), a gut-selective anti-integrin α4β7 monoclonal antibody. Our primary outcome was anti-SARS-CoV-2 spike (S) antibody concentrations, measured using the Elecsys anti-SARS-CoV-2 spike (S) antibody assay 3-10 weeks after vaccination, in patients without evidence of prior infection. Secondary outcomes were seroconversion rates (defined by a cut-off of 15 U/mL), and antibody responses following past infection or a second dose of the BNT162b2 vaccine.

RESULTS

Geometric mean (SD) anti-SARS-CoV-2 antibody concentrations were lower in patients treated with infliximab than vedolizumab, following BNT162b2 (6.0 U/mL (5.9) vs 28.8 U/mL (5.4) p<0.0001) and ChAdOx1 nCoV-19 (4.7 U/mL (4.9)) vs 13.8 U/mL (5.9) p<0.0001) vaccines. In our multivariable models, antibody concentrations were lower in infliximab-treated compared with vedolizumab-treated patients who received the BNT162b2 (fold change (FC) 0.29 (95% CI 0.21 to 0.40), p<0.0001) and ChAdOx1 nCoV-19 (FC 0.39 (95% CI 0.30 to 0.51), p<0.0001) vaccines. In both models, age ≥60 years, immunomodulator use, Crohn's disease and smoking were associated with lower, while non-white ethnicity was associated with higher, anti-SARS-CoV-2 antibody concentrations. Seroconversion rates after a single dose of either vaccine were higher in patients with prior SARS-CoV-2 infection and after two doses of BNT162b2 vaccine.

CONCLUSION

Infliximab is associated with attenuated immunogenicity to a single dose of the BNT162b2 and ChAdOx1 nCoV-19 SARS-CoV-2 vaccines. Vaccination after SARS-CoV-2 infection, or a second dose of vaccine, led to seroconversion in most patients. Delayed second dosing should be avoided in patients treated with infliximab.

TRIAL REGISTRATION NUMBER

ISRCTN45176516.

Anti-SARS-CoV-2 antibody responses are attenuated in patients with IBD treated with infliximab

OBJECTIVE

Antitumour necrosis factor (anti-TNF) drugs impair protective immunity following pneumococcal, influenza and viral hepatitis vaccination and increase the risk of serious respiratory infections. We sought to determine whether infliximab-treated patients with IBD have attenuated serological responses to SARS-CoV-2 infections.

DESIGN

Antibody responses in participants treated with infliximab were compared with a reference cohort treated with vedolizumab, a gut-selective anti-integrin α4β7 monoclonal antibody that is not associated with impaired vaccine responses or increased susceptibility to systemic infections. 6935 patients were recruited from 92 UK hospitals between 22 September and 23 December 2020.

RESULTS

Rates of symptomatic and proven SARS-CoV-2 infection were similar between groups. Seroprevalence was lower in infliximab-treated than vedolizumab-treated patients (3.4% (161/4685) vs 6.0% (134/2250), p<0.0001). Multivariable logistic regression analyses confirmed that infliximab (vs vedolizumab; OR 0.66 (95% CI 0.51 to 0.87), p=0.0027) and immunomodulator use (OR 0.70 (95% CI 0.53 to 0.92), p=0.012) were independently associated with lower seropositivity. In patients with confirmed SARS-CoV-2 infection, seroconversion was observed in fewer infliximab-treated than vedolizumab-treated patients (48% (39/81) vs 83% (30/36), p=0.00044) and the magnitude of anti-SARS-CoV-2 reactivity was lower (median 0.8 cut-off index (0.2-5.6) vs 37.0 (15.2-76.1), p<0.0001).

CONCLUSIONS

Infliximab is associated with attenuated serological responses to SARS-CoV-2 that were further blunted by immunomodulators used as concomitant therapy. Impaired serological responses to SARS-CoV-2 infection might have important implications for global public health policy and individual anti-TNF-treated patients. Serological testing and virus surveillance should be considered to detect suboptimal vaccine responses, persistent infection and viral evolution to inform public health policy.

TRIAL REGISTRATION NUMBER

ISRCTN45176516.

Disease monitoring of biologic treatment in IBD: early impact and future implications of COVID-19 pandemic

COVID-19 has dominated life in 2020 with, at the time of writing, over 4.9M global cases and >320 000 deaths. The impact has been most intensely felt in acute and critical care environments. However, with most UK elective work postponed, laboratory testing of faecal calprotectin halted due to potential risk of viral transmission and non-emergency endoscopies and surgeries cancelled, the secondary impact on chronic illnesses such as inflammatory bowel disease (IBD) is becoming apparent. Data from the Scottish Biologic Therapeutic Drug Monitoring (TDM) service shows a dramatic drop in TDM testing since the pandemic onset. April 2020 saw a 75.6% reduction in adalimumab testing and a 36.2% reduction in infliximab testing when compared with February 2020 data, a reduction coinciding with the widespread cancellation of outpatient and elective activity. It is feared that disruption to normal patterns of care and disease monitoring of biologic patients could increase the risk of disease flare and adverse clinical outcomes. Urgent changes in clinical practice have been instigated to mitigate the effects of the pandemic on routine clinical care. Further transformations are needed to maintain safe, effective, patient-centred IBD care in the future.

AB0309 MEASURING THE DIFFERENCE: COMPARISON OF MEASUREMENT OF FREE INFLIXIMAB ANTI-DRUG ANTIBODIES

Background:

Infliximab (IFX) was one of the first TNF alpha inhibitors to be licenced in inflammatory arthritis and is still commonly used today. Studies have shown that approximately 50% of primary IFX responders will suffer from secondary loss of response within the first 12 months of treatment (1). The development of Anti-Drug Antibodies (ADA’s) plays a significant role in this treatment failure (2).

Monitoring of ADA’s helps identify those patients who fail to respond to treatment due to low IFX trough levels. In this scenario the presence of ADA’s can aid decision-making regarding increasing IFX dosing or switching biologic therapy to optimise treatment. (3).

Objectives:

Despite their potential importance the detection of ADAs varies widely depending on the type of assays used. The aim of this study was to determine the qualitative concordance of three commercially available ELISA kits for measurement of free ADAs to IFX on the Grifols Triturus analyser.

Methods:

150 patient samples from patients with inflammatory conditions and low IFX trough drug levels (≤0.6µg/ml) were analysed for free ADAs using Promonitor, Lisa Tracker and IDKmonitor kits on the Grifols Triturus automated ELISA analyser.

Results:

Kappa coefficient (κ) analysis indicated a moderate agreement between the Promonitor and IDKmonitor assays (κ =0.484 (95% CI, 0.357 to 0.611)) and the IDKmonitor and Lisa Tracker assays (κ = 0.485 (95% CI, 0.348-0.621)) as well as substantial agreement between the Promonitor and Lisa Tracker assays (κ =0.768 (95% CI, 0.667-0.870)). Figure 1 shows the distribution of samples identified as free ADA positive by each kit.

Figure 1.

Distribution of samples identified as free ADA positive by Promonitor, Lisa Tracker, and IDKmonitor assays. Fifty samples were considered positive by all assays. Three samples were considered positive by Promonitor and Lisa Tracker, and eight samples were considered positive by Lisa Tracker and IDKmonitor. No samples were considered positive by Promonitor and IDKmonitor. One sample was considered positive by Promonitor only, seven samples were considered positive by Lisa Tracker only, and twenty-six samples were considered positive by IDKmonitor

Conclusion:

All kits appear amenable for utilisation in a high-throughput laboratory though a true quantitative comparison between these kits was precluded by the absence of any certified reference material for free ADAs to IFX.

Although broad qualitative agreement was found between the three kits, they should not be used interchangeably for patient management.

Further research is required to estimate the impact of free ADAs on efficiency of IFX treatment and patient management.

References:

[1]Quistrebert J, Hässler S, Bachelet D et al.Incidence and risk factors for adalimumab and infliximab anti-drug antibodies in rheumatoid arthritis: A European retrospective multicohort analysis. Seminars in Arthritis and Rheumatism Volume 48, Issue 6, June 2019, Pages 967-975 2.

[2]Moots RJ, Xavier RM, Mok CC, Rahman MU, Tsai W-C, Al-Maini MH, et al. (2017)The impact of anti-drug antibodies on drug concentrations and clinical outcomes in rheumatoid arthritis patients treated with adalimumab, etanercept, or infliximab: Results from a multinational, real-world clinical practice, non-interventional study. PLoS ONE 12(4): e0175207.https://doi.org/10.1371/journal.pone.0175207

[3]Smolen JS, Landewé R, Bijlsma J, et al.EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs:2016 update.Annals of the Rheumatic Diseases 2017;76:960-977.

Disclosure of Interests:

Rhona Hamilton: None declared, Stephanie Shields: None declared, Andrew McGucken: None declared, Jonathan MacDonald: None declared, Martin Perry Grant/research support from: Grifols, Abbvie, Sandoz unrestricted educational grant, Consultant of: Abbvie, Gilead, Celltrion Advisory Board, Speakers bureau: Sandoz, Allan Dunlop: None declared, Elaine Gribben: None declared, Peter Galloway: None declared

AB1186 THE NHS SCOTLAND THERAPEUTIC DRUG MONITORING SERVICE FOR BIOLOGIC MEDICINES: PRELIMINARY ANALYSIS OF UTILISATION AND CLINICAL RESULTS AT YEAR 1

Background:

Anti-tumour necrosis factor α (anti-TNFα) drugs infliximab (IFX) and adalimumab (ADL) are effective treatments for several rheumatic diseases. Therapeutic drug level and anti-drug antibody monitoring (TDM) has emerged as a useful tool for optimising drug effectiveness, by identifying individuals who may benefit from dose or treatment frequency adjustment, or have secondary drug failure due to immunogenicity.

Objectives:

Ensuring safe and effective use of biologic medicines has been identified as a key priority for NHS Scotland. Inequity and inconsistency of access to TDM across the nation was recognised as a barrier to delivering best practice and so a nationally commissioned TDM service was proposed in January 2018 to support clinical practice, providing universal access to TDM for services treating inflammatory diseases across Scotland. Data collection and analysis of results regarding usage and clinical impact of the service were identified as key outcome measures to assess service success and sustainability.

Methods:

A service webpage was developed to provide guidance on testing strategies and interpretation of TDM results (1). An automated search of clinical data and test results recorded within the clinical biochemistry electronic results management system was conducted to identify all TDM tests performed between 01/01/2018 and 31/12/2018. Descriptive analysis outcomes included the number of samples received, processed, overall testing population, service utilisation by Health Board, number and results of TDM tests performed per patient. TDM results were interpreted according to published guidance on the service webpage and comparison was made with previously published data (2).

Results:

3609 specimens were received for testing, from 13 of the 14 Scottish Health Boards. 3561 drug level (DL) tests were performed; 1786IFX, 1775 ADL. 2717 total antidrug anti-body (TABT) tests and 681 free antidrug anti-body tests (FABT) were performed according to service protocol. 2791 individuals had one or more TDM tests during the 12-month period, of whom 541 were tested twice or more (range 2-5).

Table 1.

IFX & ADL DL, TABT and FABT results by category as defined in service guidance (AU/ml = Arbitrary Units/ml)]

INFLIXIMABADALIMUMABDrug level by categorySupratherapeutic DL > 8mcg/ml546 (30.6%)708 (39.9%)Supratherapeutic DL > 10 mcg/mlTherapeutic DL ≥3<8.1mcg/ml738 (41.3%)636 (35.8%)Therapeutic DL ≥5<10.1 mcg/mlSub-therapeutic DL < 3mcg/ml502 (28.1%)431 (24.3%)Sub-therapeutic DL < 5 mcg/mlTABT by categoryNegative (<10 AU/ml)791 (54.2%)905 (71.9%)Negative (<10 AU/ml)Positive (>10 AU/ml)668 (45.8%)353 (28.1%)Positive (>10 AU/ml)FABT by categoryNegative (< 5AU/ml)376 (82.8%)176 (77.6%)Negative (<10 AU/ml)Positive (> 5 AU/ml)78 (17.2%)51 (22.4%)Positive (>10 AU/ml)

Conclusion:

TDM has been enthusiastically embraced. It is estimated that > 50% of individuals treated with IFX or ADL have been tested at least once in the first year. DL results were found to be similar to previously published data, as were rates of antibody positivity. The large volume of data generated by the service may provide additional evidence regarding the utility of TDM in predicting clinical response. Next steps are to conduct a comparative effectiveness analysis where proactive vs reactive TDM testing strategies will be compared, with the primary outcome measure being the proportions of patients with secondary loss of response.

References:

[1]Scottish Biologic therapeutic Drug Monitoring Servicehttps://www.nhsggc.org.uk/about-us/professional-support-sites/biochemistry/biological-therapy-monitoring/

[2]Jani, M. Et al (2015), Clinical Utility of Random Anti–Tumor Necrosis Factor Drug–Level Testing and Measurement of Antidrug Antibodies on the Long-Term Treatment Response in Rheumatoid Arthritis. Arthritis & Rheumatology, 67: 2011-2019. doi:10.1002/art.39169

Acknowledgments:

Biogen GmbH contributed partial funding for this research. Authors had full editorial control and approval of all content

Disclosure of Interests:

Jonathan MacDonald: None declared, Martin Perry Grant/research support from: Grifols, Abbvie, Sandoz unrestricted educational grant, Consultant of: Abbvie, Gilead, Celltrion Advisory Board, Speakers bureau: Sandoz, Peter Galloway: None declared, John-Paul Seenan: None declared, Alan Dunlop: None declared

Analysis of 61 exclusive enteral nutrition formulas used in the management of active Crohn's disease-new insights into dietary disease triggers

BACKGROUND

Exclusive enteral nutrition (EEN) is an effective treatment for Crohn's disease.

AIMS

To investigate the hypothesis that ingredients of EEN formulas are unlikely to initiate a disease flare and that their dietary elimination is not essential for disease amelioration.

METHODS

We performed compositional analysis of EEN formulas with evidence of efficacy in management of active Crohn's disease. Macronutrient content was compared against the dietary reference values (DRV), the UK National Diet and Nutrition Survey (NDNS) and intake of Crohn's disease children. Food additives were cross-referenced against the FAO/WHO database.

RESULTS

Sixty-one formulas were identified with variable composition (carbohydrates [22.8%-89.3%], protein [7.8%-30.1%], fat [0%-52.5%]). Maltodextrin, milk protein and vegetable/plant oils were the commonest macronutrient sources. Their n-6:n-3 fatty acid ratio varied from 0.25 to 46.5. 56 food additives were identified (median per formula: 11). All formulas were lactose-free, gluten-free, and 82% lacked fibre. The commonest food additives were emulsifiers, stabilisers, antioxidants, acidity regulators and thickeners. Food additives, implicated in Crohn's disease aetiology, were present in formulas (modified starches [100%], carrageenan [22%], carboxymethyl cellulose [13%] and polysorbate 80 [5%]). Remission rates did not differ between EEN formulas with and without those food additives. Analysis including only formulas from randomised controlled trials (RCTs) retained in the latest Cochrane meta-analysis produced similar findings. EEN formulas contained less energy from saturated fat than NDNS intake.

CONCLUSION

We have identified food ingredients which are present in EEN formulas that are effective in Crohn's disease and challenge perceptions that these ingredients might be harmful.

Bilateral fixation of a periprosthetic intertrochanteric hip fracture below Birmingham hip resurfacing

This case report involves a 59-year-old woman with a traumatic right intertrochanteric hip fracture below a previous Birmingham hip resurfacing (BHR). This woman had almost an identical fracture on the left hip 3 years before which was treated with a proximal femoral locking compression plate. Of note periprosthetic fractures following hip resurfacing are usually subcapital and treated with a revision or conservative management. We present an unusual surgical problem that has occurred twice in the same patient and has been treated effectively on both occasions using proximal femoral plating. To the best of our knowledge, there have been no other reports of bilateral periprosthetic fractures being treated in this way.

A fibre based triature interferometer for measuring rapidly evolving, ablatively driven plasma densities

We report on the first use of a fibre interferometer incorporating triature analysis for measuring rapidly evolving plasma densities of n(e) ∼ 10(13)/cm(3) and above, such as those produced by simple coaxial plasma guns. The resultant system is extremely portable, easy to field in experiments, relatively cheap to produce, and—with the exception of a small open area in which the plasma is sampled—safe in operation as all laser light is enclosed.

An evaluation of a collaborative bibliotherapy scheme delivered via a library service

This paper reports on the evaluation of a bibliotherapy scheme delivered via a local library service, in conjunction with General Practice (GP) practices, local social welfare agencies and through self-referral. The Read Yourself Well (RYW) scheme was based on principles established from other similar schemes and as a way of delivering support for adults experiencing mild to moderate mental health problems for whom clinical treatments are not appropriate. The intervention consisted of initial referral and evaluation by the scheme bibliotherapist, a one-hour session at the beginning and end of the intervention where a purpose-designed questionnaire and two mental health assessments were carried out (the General Health Questionnaire and the Clinical Outcomes in Routine Evaluation questionnaire). Contact and support from the bibliotherapist was provided during the intervention period. One hundred and fifty-seven participants were recruited to the evaluation of whom 114 provided full data. Statistical analyses of the mental health scores showed significant improvements post treatment, for, both male and female participants, for all three referral routes, and for participants who were previously library users, and those who joined the library service to participate in the RYW scheme. The results of this large sample evaluation support the proposal that library-based bibliotherapy can be effective in the treatment of mental health problems.

Regioselective C2-arylation of imidazo[4,5-b]pyridines

We show that N3-MEM-protected imidazo[4,5-b]pyridines undergo efficient C2-functionalisation via direct C-H arylation. Twenty-two substituted imidazo[4,5-b]pyridines are prepared and iterative, selective elaboration of functionalised imidazo[4,5-b]pyridines gives 2,7- and 2,6-disubstituted derivatives in good yields from common intermediates. Mechanistic observations are consistent with a concerted-metallation-deprotonation mechanism facilitated by coordination of copper(I)iodide to the imidazo[4,5-b]pyridine.

Self-harm and psychosocial characteristics of looked after and looked after and accommodated young people

Children and young people who are classed as "looked after" and "looked after and accommodated", have been identified as being especially at risk of self-harm, however there is little research that has assessed self-harm among these groups. This study investigates self-harm rates, distinguishing between cognitions and behaviours with non-suicidal and suicidal intent among the looked after and looked after and accommodated population of young people educated within mainstream institutions in West Central Scotland. Looked after young people who self-harmed were compared with looked after young people who had never self-harmed on reasons for living, self-critical style, common life problems and academic self-esteem. An anonymous self-report questionnaire was used to survey 102 looked after (LAC) and looked after and accommodated (LAAC) children and young people across 10 schools within 6 local authority regions in West Central Scotland that compared self-harmers (n = 32) with those who never self-harmed (n = 70). Thirty-two per cent of the looked after sample reported they had either thought about harming themselves or had actually engaged in self-harm behaviour. Self-harmers (including those who either thought about harming themselves and/or engaged in self-harm) differed from those who had never thought about harming themselves or engaged in self-harm behaviour, with significantly fewer reasons for living (RFL-A) and a more maladaptive self-critical style. The self-critical form of self-hate was found to be particularly important in predicting self-harm (thoughts and behaviours) among this sample of looked after and looked after and accommodated young people. Understanding the factors associated with self-harm and suicide risk is especially important given the already existing vulnerabilities to adverse outcomes associated with being looked after and looked after and accommodated. Strategies for the early identification of maladaptive behaviours among risk groups should take a wider approach beyond those already offered by health services. Utilising knowledge of behaviour and performance within additional key areas of young people's lives such as education could see a unique school-based intervention that can quickly and easily assess academic-related factors linked with self-harm and offer a strategy for early identification of at risk children and young people.

Coronary artery bypass grafting in a patient with hereditary hemorrhagic telangiectasia

Hereditary hemorrhagic telangiectasia (HHT, Osler-Weber-Rendu syndrome) is an autosomal dominant condition which usually presents with recurrent epistaxis, due to the presence of mucocutaneous telangiectasia, and circulatory arteriovenous malformations (pulmonary, hepatic, cerebral and spinal). We present a patient with HHT and coronary artery disease, who underwent coronary artery bypass grafting with a successful outcome.

Transverse sinus stenting for idiopathic intracranial hypertension: a review of 52 patients and of model predictions

BACKGROUND AND PURPOSE

Transverse sinus stenosis is common in patients with IIH. While the role of transverse sinus stenosis in IIH pathogenesis remains controversial, modeling studies suggest that stent placement within a transverse sinus stenosis with a significant pressure gradient should decrease cerebral venous pressure, improve CSF resorption in the venous system, and thereby reduce intracranial (CSF) pressure, improving the symptoms of IIH and reducing papilledema. We aimed to determine if IIH could be reliably treated by stent placement in transverse sinus stenosis.

MATERIALS AND METHODS

We reviewed the clinical, venographic, and intracranial pressure data before and after stent placement in transverse sinus stenosis in 52 of our own patients with IIH unresponsive to maximum acceptable medical treatment, treated since 2001 and followed between 2 months and 9 years.

RESULTS

Before stent placement, the mean superior sagittal sinus pressure was 34 mm Hg (462 mm H(2)0) with a mean transverse sinus stenosis gradient of 20 mm Hg. The mean lumbar CSF pressure before stent placement was 322 mm H(2)O. In all 52 patients, stent placement immediately eliminated the TSS pressure gradient, rapidly improved IIH symptoms, and abolished papilledema. In 6 patients, symptom relapse (headache) was associated with increased venous pressure and recurrent stenosis adjacent to the previous stent. In these cases, placement of another stent again removed the transverse sinus stenosis pressure gradient and improved symptoms. Of the 52 patients, 49 have been cured of all IIH symptoms.

CONCLUSIONS

These findings indicate a role for transverse sinus stent placement in the management of selected patients with IIH.

Quality of life in young people with cystic fibrosis: effects of hospitalization, age and gender, and differences in parent/child perceptions

BACKGROUND

The Cystic Fibrosis Questionnaire-Revised version (CFQ-R) was used to evaluate age/gender effects on quality of life (QOL) in Australian young people with cystic fibrosis (CF) who were inpatients/outpatients aged 6-18 years. Parent/child agreement was also examined.

METHOD

The CFQ-R was completed by 18 outpatients, and 15 inpatients at admission for an acute pulmonary exacerbation to a tertiary hospital, Brisbane, Australia, as well as by parents of those aged 6-13 years.

RESULTS

Inpatients scored significantly lower than outpatients for the CFQ-R domains 'emotional state', 'social', 'body image' and 'respiratory symptoms'. Young people aged 6-13 years scored significantly better than those aged 14-18 years for 'emotional state', 'body image' and 'treatment burden'. Women perceived less 'treatment burden' than did men. Young people aged 6-13 years perceived less 'treatment burden' than did their parents. A significant interaction occurred between child/parent report and gender for 'emotional state' and 'eating disturbances'.

CONCLUSION

The CFQ-R found differences between inpatients and outpatients and between younger and older paediatric patients with CF, and between parent and child perceptions of QOL.

Negative capsule endoscopy in patients with obscure GI bleeding predicts low rebleeding rates

BACKGROUND

Wireless capsule endoscopy (CE) is the investigation of choice in obscure GI bleeding (OGIB), with a high diagnostic yield when compared with other modalities. It enables specific treatment to be instigated in a significant proportion of cases, with the aim of reducing rebleeding rates. Little evidence is currently available on the clinical value of a negative study.

OBJECTIVE

To determine the long-term (>1 year) outcome in patients who underwent CE to investigate OGIB.

METHODS

Consecutive patients with OGIB referred for CE to a single center over an 18-month period were identified. Follow-up data were obtained by reviewing case notes and an internal CE database. Rates of rebleeding were established, and factors associated with rebleeding were assessed by means of univariate and multivariate analysis.

RESULTS

Forty-nine patients underwent CE for investigation of OGIB (obscure overt in 25 patients [51%]) between April 2005 and October 2006. Long-term data were available for 42 patients (86%), with a mean (+/- SD) follow-up of 17.3 +/- 6.2 months. Significant (P2) lesions were identified in 24 patients (57%). The overall rebleeding rate was 28%. There was a statistically significant difference in rebleeding between patients with a positive and patients with a negative study, 42% versus 11%, respectively, P < .01. Anticoagulant use was also associated with an increased risk of rebleeding.

CONCLUSION

A negative CE study in patients with OGIB is associated with a low rate of recurrent bleeding in the long term (11%). It is reasonable to take an expectant approach with these patients, thus avoiding the need for unnecessary additional investigations.

Addressing the challenges of renal anaemia: how nurses can make a difference

Nephrology nurses play a central and wide-ranging role in renal care. However, they have inadequate time to manage their responsibilities as patient volume increases due to earlier diagnosis and improved survival, and patient care becomes more complex. The challenge to achieve and maintain target haemoglobin levels with current agents compounds nursing workload. Early recognition and treatment of anaemia, a multidisciplinary approach and patient management algorithms can improve outcomes and nursing time utilisation. Innovative erythropoietic agents produce stable haemoglobin levels at extended administration intervals, offering time-savings. Such initiatives may allow nurses more time to focus on other aspects of patient care.