Perceived barriers and solutions by generalist physicians to work towards timely young-onset dementia diagnosis

Objectives: Timely diagnosis of young-onset dementia (YOD) is an important prerequisite to initiate appropriate support. However, YOD diagnosis is often late. We aimed to explore the perspectives of referring general practitioners and occupational physicians, to better understand their barriers to YOD diagnosis and reveal potential solutions to facilitate timely diagnosis.Methods: We conducted 16 semi-structured qualitative interviews with general practitioners and occupational physicians in the Netherlands. Inductive thematic analysis was applied to the transcripts with a team including researchers from various (clinical) backgrounds.Results: Thematic analysis revealed three themes related to: (1) disease characteristics that hinder YOD recognition, being the low incidence and the fact that they mimic other prevalent conditions like burn-out and depression; (2) physicians' attitudes that delay YOD diagnosis, as fear of mis-diagnosis and therapeutic nihilism; and (3) proposed solutions to navigate the challenging YOD diagnostic trajectory including monitoring people with depression and burn-out to consider YOD when recovery stagnates, and more effective interprofessional collaboration.Conclusion: In this study, referring physicians confirmed barriers known to YOD diagnosis and suggested potential solutions to improve YOD diagnosis. Future prospective studies in people with a primary diagnosis of depression or burn-out may show whether these interventions are potentially effective.

Residual ctDNA after treatment predicts early relapse in patients with early-stage non-small cell lung cancer

BACKGROUND

Identification of residual disease in patients with localized non-small cell lung cancer (NSCLC) following treatment with curative intent holds promise to identify patients at risk of relapse. New methods can detect circulating tumour DNA (ctDNA) in plasma to fractional concentrations as low as a few parts per million, and clinical evidence is required to inform their use.

PATIENTS AND METHODS

We analyzed 363 serial plasma samples from 88 patients with early-stage NSCLC (48.9%/28.4%/22.7% at stage I/II/III), predominantly adenocarcinomas (62.5%), treated with curative intent by surgery (n = 61), surgery and adjuvant chemotherapy/radiotherapy (n = 8), or chemoradiotherapy (n = 19). Tumour exome sequencing identified somatic mutations and plasma was analyzed using patient-specific RaDaR™ assays with up to 48 amplicons targeting tumour-specific variants unique to each patient.

RESULTS

ctDNA was detected before treatment in 24%, 77% and 87% of patients with stage I, II and III disease, respectively, and in 26% of all longitudinal samples. The median tumour fraction detected was 0.042%, with 63% of samples <0.1% and 36% of samples <0.01%. ctDNA detection had clinical specificity >98.5% and preceded clinical detection of recurrence of the primary tumour by a median of 212.5 days. ctDNA was detected after treatment in 18/28 (64.3%) of patients who had clinical recurrence of their primary tumour. Detection within the landmark timepoint 2 weeks to 4 months after treatment end occurred in 17% of patients, and was associated with shorter recurrence-free survival [hazard ratio (HR): 14.8, P <0.00001] and overall survival (HR: 5.48, P <0.0003). ctDNA was detected 1-3 days after surgery in 25% of patients yet was not associated with disease recurrence. Detection before treatment was associated with shorter overall survival and recurrence-free survival (HR: 2.97 and 3.14, P values 0.01 and 0.003, respectively).

CONCLUSIONS

ctDNA detection after initial treatment of patients with early-stage NSCLC using sensitive patient-specific assays has potential to identify patients who may benefit from further therapeutic intervention.

First Direct Detection Constraints on Planck-Scale Mass Dark Matter with Multiple-Scatter Signatures Using the DEAP-3600 Detector

Dark matter with Planck-scale mass (≃10^{19}  GeV/c^{2}) arises in well-motivated theories and could be produced by several cosmological mechanisms. A search for multiscatter signals from supermassive dark matter was performed with a blind analysis of data collected over a 813 d live time with DEAP-3600, a 3.3 t single-phase liquid argon-based detector at SNOLAB. No candidate signals were observed, leading to the first direct detection constraints on Planck-scale mass dark matter. Leading limits constrain dark matter masses between 8.3×10^{6} and 1.2×10^{19}  GeV/c^{2}, and ^{40}Ar-scattering cross sections between 1.0×10^{-23} and 2.4×10^{-18}  cm^{2}. These results are interpreted as constraints on composite dark matter models with two different nucleon-to-nuclear cross section scalings.

Pulse-shape discrimination against low-energy Ar-39 beta decays in liquid argon with 4.5 tonne-years of DEAP-3600 data

The DEAP-3600 detector searches for the scintillation signal from dark matter particles scattering on a 3.3 tonne liquid argon target. The largest background comes from 39 Ar beta decays and is suppressed using pulse-shape discrimination (PSD). We use two types of PSD estimator: the prompt-fraction, which considers the fraction of the scintillation signal in a narrow and a wide time window around the event peak, and the log-likelihood-ratio, which compares the observed photon arrival times to a signal and a background model. We furthermore use two algorithms to determine the number of photons detected at a given time: (1) simply dividing the charge of each PMT pulse by the mean single-photoelectron charge, and (2) a likelihood analysis that considers the probability to detect a certain number of photons at a given time, based on a model for the scintillation pulse shape and for afterpulsing in the light detectors. The prompt-fraction performs approximately as well as the log-likelihood-ratio PSD algorithm if the photon detection times are not biased by detector effects. We explain this result using a model for the information carried by scintillation photons as a function of the time when they are detected.

A lifetime of challenges: real-life decision outcomes in early- and late-onset suicide attempters

Background

People who have attempted suicide display suboptimal decision-making in the lab. Yet, it remains unclear whether these difficulties tie in with other detrimental outcomes in their lives besides suicidal behavior. We hypothesize that this is more likely the case for individuals who first attempted suicide earlier than later in life.

Methods

A cross-sectional case-control study of 310 adults aged ≥ 50 years (mean: 63.9), compared early- and late-onset attempters (first attempt < 55 vs. ≥ 55 years of age) to suicide ideators, non-suicidal depressed controls and non-psychiatric healthy controls. Participants reported potentially avoidable negative decision outcomes across their lifetime, using the Decision Outcome Inventory (DOI). We employed multi-level modeling to examine group differences overall, and in three factor-analytically derived domains labeled Acting Out, Lack of Future Planning, and Hassles.

Results

Psychopathology predicted worse decision outcomes overall, and in the more serious Acting Out and Lack of Future Planning domains, but not in Hassles. Early-onset attempters experienced more negative outcomes than other groups overall, in Lack of Future Planning, and particularly in Acting Out. Late-onset attempters were similar to depressed controls and experienced fewer Acting out outcomes than ideators.

Limitations

The cross-sectional design precluded prospective prediction of attempts. The assessment of negative outcomes may have lacked precision due to recall bias.

Conclusions

Whereas early-onset suicidal behavior is likely the manifestation of long-lasting decision-making deficits in several serious aspects of life, late-onset cases appear to function similarly to non-suicidal depressed adults, suggesting that their attempt originates from a more isolated crisis.

749 Delivering Safe and Timely Cancer Care During COVID 19. Lessons and Successes from The Transition Period

Introduction

Delivering timely cancer care during the COVID-19 pandemic was a major challenge. We analysed our success in addressing this.

Method

A key factor was the proximity of a private hospital (GN) to the primary trust. GN acted as a ‘clean site’. From 6th April 2020, two robots and dedicated staff were relocated to day surgery theatres with direct access to GN. Procedures and post-operative recovery happened in GN. National surgical guidelines were followed related to Covid-19. All theatre staff were swabbed weekly. Patients were risk stratified prior to admittance.

Results

We reviewed operations performed and cancer pathway data from March to June 2020 and compared it to data collected from August to November 2019. From March until June 2020 we performed 369 cancer operations; 120 robotic, 138 endoscopic and 7 open cases. From August to November 2019 we performed 407 cancer operations; 116 robotic, 175 endoscopic and 7 open cases. No elective patient developed symptomatic COVID-19 secondary to admission.

Conclusions

This study demonstrates that with rapid development of separate ‘clean’ and ‘COVID’ sites, we successfully delivered a comparable, safe and effective cancer service. As we potentially face a second wave we share our success to see if these changes can be replicated elsewhere.

P80 Meeting urological cancer targets during Covid-19

Introduction & Objectives

The pandemic caused by Covid-19 has caused significant strain on healthcare professionals across the globe.

Without downplaying the devastating effects of the virus itself, the collateral damage – specifically in cancer targets – has only compounded an already difficult time in medicine. Therefore, it was of the utmost importance that we: strived to continue to meet our cancer targets, and we analysed our success in addressing this.

Materials & Methods

A key factor was the proximity of a private Nuffield hospital (GN) to the primary trust. GN acted as a ‘clean site’. From 6th April 2020, 2 Xi Da Vinci robots and dedicated staff were relocated to day surgery theatres with direct: access to GN. Endoscopic procedures occurred in GN theatres. Post-operative recovery happened in GN. National guidelines were followed including COVID-19 symptom screening, isolation and preoperative nasopharyngeal swabs. All theatre staff were swabbed weekly and worked solely at GN. Patients were risk stratified prior to admittance. Cancer features and patient risk factors for COVID-19 were taken into account. Standard enhanced recovery principles were applied throughout the patient’s journey. In theatre, we worked to ensure minimal staff numbers for safe practice were present. We reviewed operations performed, alongside cancer (prostate & bladder) pathway data from March to June 2020. For comparison identical data from August to November 2019 was collected.

Results

There were a total of 369 cancer operations performed at our Trust from March until June 2020. In comparison, 407 cancer operations were performed in the 4 months from August until November 2019. For both timeframes, a: variety of robotic, endoscopic and open surgeries were carried, with similar numbers seen in each.

In total, we received 80 referrals for possible prostate malignancies from March – June 2020, and 150 from August – November 2019. Days to MRI was slightly better in March to June, but we did not find a statistical difference. We: found a statistically significant decrease in the number of days it took for a patient to go from referral to diagnosis.

Furthermore, we also improved on the proportion of patients who had their diagnosis told to them within 28 days, from 74% to 87%.

In total, we received 134 referrals for possible bladder malignancies from March – June 2020, and 81 from August – November 2019. We improved on days to OPA for patients and time to flexible cystoscopy, with both results carrying statistical significance. We were able to reduce time to OPA from 8 to 6 days, and time to flexible cystoscopy from 26 to 12 days.

Conclusions

This study demonstrates that with rapid development of separate ‘clean’ and ‘COVID’ sites, we successfully delivered a comparable, safe and effective cancer service. As we potentially face a second wave we share our success to see if these changes can be replicated elsewhere.

Neurofibromatosis type 2 discordance in monozygous twins

Neurofibromatosis type 2 (NF2) is an autosomal dominant condition caused by pathogenic variants in the NF2 gene. The pathogenic variant is either inherited or obtained by de novo mutation, characterised by the presence of schwannomas, meningiomas and ependymomas. Here we report the presence of NF2 in one twin, with bilateral vestibular schwannomas and a pathogenic variant of the NF2 gene identified in both tumour and lymphocytes, while his monozygous brother remains asymptomatic. Imaging of the unaffected twin showed no tumour load and genetic testing via Sanger sequencing and Amplification Refractory Mutation System assay demonstrated low levels of expression of the NF2 variant in lymphocytes. Further testing on non-haemopoietic tissue showed little expression or absence of the pathogenic variant. Given there is no family history and the low level of the variant, we assume the pathogenic variant is a de novo mutation during embryogenesis. De novo mutations have been described as occurring at three possible time points in the creation of monozygous twins with different genetic make-up; prior to the twinning event, as a cause of the event, or after the twinning event. Of these options, we hypothesise that the discordance in the expression of the NF2 variant between these twins is likely due to a mutational event that occurred as a result of either of the latter two possibilities, between which we cannot determine. The pathogenic variant in lymphocytes was likely transferred between the twins through a shared blood supply in utero, and the non-haemopoietic samples that showed low levels of expression, were likely due to the presence of lymphocytic cells. Therefore, we have a discordance between monozygous twins at the NF2 gene.

Microelimination or Not? The Changing Epidemiology of Human Immunodeficiency Virus-Hepatitis C Virus Coinfection in France 2012–2018

Background

The arrival of highly effective, well-tolerated, direct-acting antiviral agents (DAA) led to a dramatic decrease in hepatitis C virus (HCV) prevalence. Human immunodeficiency virus (HIV)-HCV–coinfected patients are deemed a priority population for HCV elimination, while a rise in recently acquired HCV infections in men who have sex with men (MSM) has been described. We describe the variations in HIV-HCV epidemiology in the French Dat’AIDS cohort.

Methods

This was a retrospective analysis of a prospective cohort of persons living with HIV (PLWH) from 2012 to 2018. We determined HCV prevalence, HCV incidence, proportion of viremic patients, treatment uptake, and mortality rate in the full cohort and by HIV risk factors.

Results

From 2012 to 2018, 50 861 PLWH with a known HCV status were followed up. During the period, HCV prevalence decreased from 15.4% to 13.5%. HCV prevalence among new HIV cases increased from 1.9% to 3.5% in MSM but remained stable in other groups. Recently acquired HCV incidence increased from 0.36/100 person-years to 1.25/100 person-years in MSM. The proportion of viremic patients decreased from 67.0% to 8.9%. MSM became the first group of viremic patients in 2018 (37.9%). Recently acquired hepatitis represented 59.2% of viremic MSM in 2018. DAA treatment uptake increased from 11.4% to 61.5%. More treatments were initiated in MSM in 2018 (41.2%) than in intravenous drug users (35.6%). In MSM, treatment at the acute phase represented 30.0% of treatments in 2018.

Conclusions

A major shift in HCV epidemiology was observed in PLWH in France from 2012 to 2018, leading to a unique situation in which the major group of HCV transmission in 2018 was MSM.

Clinical Trials Registration. NCT02898987.

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

AB1185 BUDGET IMPACT ANALYSIS OF INTRODUCING SUBCUTANEOUS INFLIXIMAB CT-P13 SC FROM THE UK PAYER PERSPECTIVE

Background:

CT-P13 subcutaneous (SC) is the first and only SC version of infliximab developed by Celltrion Healthcare and currently approved by the European Medicines Agency (EMA) for the treatment of rheumatoid arthritis (RA). Infliximab has been only available in intravenous (IV) formulation and thus this new mode of administration will allow patients to self-inject at homes. Self-injection will reduce number of outpatient visits and expected to decrease IV administration cost significantly. This research describes the economic impact of introducing infliximab SC from the UK payer perspective.

Objectives:

The budget impact analysis (BIA) was conducted to assess the financial impact of the adoption of infliximab SC. The BIA calculates the costs of treatment (drug acquisition cost and administration) for patients with RA as first-line treatments, and compares the cost in a scenario without infliximab SC vs a scenario with infliximab SC to estimate the budget impact over the 5 year period.

Methods:

A prevalence-based BIM was developed incorporating epidemiological data, administration cost data from the literature and market share data from IQVIA. The analysis compared a market scenario where a proportion of patients were treated with infliximab SC (‘World With’ infliximab SC) to an alternative market scenario where infliximab SC were not available and all patients were treated with IV (‘World Without’ infliximab SC). The model assumed that the clinical outcomes are same between infliximab SC and infliximab IV, and patients entering the model were all naïve and remained in the treatment for 5 years. In the ‘World With’ scenario, patients receiving infliximab IV switched to SC administration at 30% in Year 1, 45% in Year 2, and remained 60% from Year 3 to 5. The drug cost of infliximab SC is assumed to be the same as that of comparator treatments. Administration cost per infliximab IV infusion was estimated to be ₤382 and ₤3.32 per SC administration.

Results:

Compared to the “World Without” infliximab SC, the introduction of subcutaneous infliximab resulted in cost savings of ₤39.6 million in UK over a 5-year period, equating to 4,466 additional patients to be treated with infliximab SC in base case scenario.

Sensitivity analysis includes dose-escalation up to 5mg/kg to reflect the real-world setting. In that scenario, the saving increases to ₤279.6 million over a 5-year period, equating to 30,839 additional patients to be treated with infliximab SC.

Conclusion:

Utilization of subcutaneous infliximab may lead to substantial cost savings for UK payers. Self-injection will significantly reduce the burden on healthcare delivery allowing resource to be spent elsewhere. Sensitivity analysis concluded that treatment with increased IV dose will result in higher savings from switching patients to subcutaneous infliximab.

References:

[1]European Medicines Agency. Remsima SC authorization details.https://www.ema.europa.eu/en/documents/product-information/remsima-epar-product-information_en.pdf

[2]Carpenter, L., et al. (2014). Patients with Moderate Disease Activity in the First 5 Years of Rheumatoid Arthritis Still Progress Radiographically Despite Conventional Disease Modifying Therapy.: 2135.Arthritis & Rheumatology,66.

[3]The NICE British National Formulary (BNF).https://bnf.nice.org.uk/medicinal-forms/

[4]Tetteh, E. K., & Morris, S. (2014). Evaluating the administration costs of biologic drugs: development of a cost algorithm. Health economics review, 4(1), 26.

[5]National Institute for Health and Care Excellence. (2016). Adalimumab, etanercept, infliximab, certolizumab pegol, golimumab, tocilizumab and abatacept for rheumatoid arthritis not previously treated with DMARDs or after conventional DMARDs only have failed.

Disclosure of Interests:

Martin Perry Grant/research support from: Grifols, Abbvie, Sandoz unrestricted educational grant, Consultant of: Abbvie, Gilead, Celltrion Advisory Board, Speakers bureau: Sandoz, Minyoung Jang Employee of: HEOR & Market access specialist in Celltrion Healthcare

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

The potential value of blood monitoring of biologic drugs used in the treatment of rheumatoid arthritis

The advent of biological therapies has been a major therapeutic advance in rheumatology. Many patients now enjoy improved quality of life through better disease control. The number of therapies continues to grow both within drug class (including biosimilar drugs) and via new mechanisms. For the first time, nonbiological drugs such as small-molecule inhibitors (Janus kinase inhibitors) have shown clinical equivalence. However, clinical unmet need remains with up to a third of patients commenced on a biologic therapy having minimal or no response: (a) Generally, the first biologic used secures the best response, with likelihood of remission falling thereafter with successive therapies; (b) the success of strategy trials using biological therapies can be difficult to replicate in clinical practice due to a combination of patient factors and service limitations. Accordingly, ensuring optimization of initial treatment is an important consideration before switching to alternatives. Therapeutic drug monitoring (TDM) is the measurement of serum levels of a biologic drug with the aim of improving patient care. It is usually combined with detection of any antidrug antibodies that could neutralize the effect of the therapy. This technology has the potential to be a form of 'personalized medicine' by individualizing therapy, in particular, dosing and likelihood of sustained treatment response. It requires a clear relationship between drug dose, blood concentration and therapeutic effect. This paper will outline the technology behind TDM and unpack what we can learn from our colleagues in gastroenterology, where the adoption of TDM is at a more advanced stage than in rheumatology. It will explore and set out a number of clinical scenarios where rheumatologists might find TDM helpful in day-to-day practice. Finally, an outline is given of international developments, including regulatory body appraisals and guideline development.

Effects of Finishing Diet and Packaging on Longissimus Dorsi Color

ObjectivesMeat color is extremely influential in purchasing decisions as consumers associate a bright-red color with freshness. The type of finishing diet can influence beef color. Previous studies have shown that grass-finished cattle have darker muscle color than grain-finished cattle. With the use of modified atmospheric packaging (MAP), beef purveyors are able to vary the gas compositions within a package and enhance beef color. However, limited studies have determined the effects of modified atmospheric packaging on grass-finished beef color. The objective of this study was to determine how finishing diet and packaging type affects the color of the longissimus dorsi (LD) muscle.Materials and MethodsDuring the stocker period, all of the cattle were on a forage diet. Cattle were then randomly assigned to either a conventional grain-based diet or an alfalfa pasture diet for finishing. Both conventionally and pasture-finished cattle were fed for 91 d. Cattle were slaughtered on the same day at a commercial beef processing facility under normal conditions and chilled for approximately 30 h. After grading, one strip loin from each carcass was collected and transported to Oklahoma State University. At 11 d postmortem, one steak (n = 60) from each strip loin was vacuum packaged and randomly assigned to display. Those steaks were then randomly assigned to PVC, HiOx-MAP (80% oxygen and 20% carbon dioxide), or CO-MAP (0.4% carbon monoxide, 69.5% nitrogen, and 30% carbon dioxide) packaging and were displayed under retail conditions for 5 d. Muscle darkening (MD), muscle color (MC), and surface discoloration (SD) were all analyzed by a trained panel (n = 6). MD was evaluated only on d 0 and MC and SD were scored once every 24 h for 0, 1, 2, 3, and 4 d. Lipid oxidation was measured by thiobarbituric acid reactive substances (TBARS) assay on d 4. Data were analyzed using the Mixed Procedure of SAS.ResultsThere was a significant display day by finishing diet by packaging interaction (P < 0.05) for muscle color and surface discoloration. There was also a significant finishing diet by packaging interaction (P < 0.05) for muscle darkening. Steaks packaged in HiOx-MAP remained the most stable in color and the brightest cherry-red colored throughout display time (P < 0.05) compared with other packaging types. PVC was the most discolored (P < 0.05) on d 3 and 4 when compared to HiOx-MAP and CO-MAP with the grain-finished PVC packaged steaks showing the most discoloration on d 4. Pasture-finished steaks packaged in CO-MAP displayed the darkest colored muscle (P < 0.05) on d 0. Steaks packaged in PVC had a higher amount of lipid oxidation (P < 0.05) compared with other packaging types.ConclusionThese results indicate that HiOx-MAP more effectively maintains the desired beef color of bright cherry-red for pasture-finished beef. The results also indicate that the use of appropriate packaging type can minimize the losses due to discoloration of steaks from either grain or grass-finished beef.

Traumatic orbital third nerve palsy

We present a case series of three patients who developed acute traumatic orbital third nerve palsies. To our knowledge, reported cases have mainly been localised to the intracranial course of the nerve and often associated with visual impairment. Those in which the orbit is the site of injury are rare. Our case series highlights the importance of careful preoperative assessment of patients with orbital trauma (particularly when there is a coexisting fracture) and the need to assess ocular movements and pupillary reactions to distinguish between a neurogenic and soft tissue injury. Early diagnosis is helpful in deciding on the timing of the operation and enables patients to be given appropriate counselling to make sure that their expectations are realistic.

Do orbital floor plates adequately protect against serious secondary injury?

Reconstruction of the orbital floor is common in cases of trauma and a variety of alloplastic materials, including titanium, can be used. However, we know of no reports about what happens to these materials if there is a second injury to the surgical site. This pilot study on six human cadavers (12 orbits) was therefore designed to investigate the possible outcomes should this occur. A "blowout fracture" was created in each orbit, which was then repaired using a preformed titanium implant. In two orbits, two implants were placed without fixation. The remaining implants were secured to the anterior orbital floor with a single screw, which was placed laterally or medially. A second impact sufficient to fracture the zygomaticomaxillary complex was then applied and its effect on the implants noted.

Ambient Cured Fly Ash Geopolymer Coatings for Concrete

The reinforced concrete structures that support transport, energy and urban networks in developed countries are over half a century old, and are facing widespread deterioration. Geopolymers are an affordable class of materials that have promising applications in concrete structure coating, rehabilitation and sensing, due to their high chloride, sulphate, fire and freeze-thaw resistances and electrolytic conductivity. Work to date has, however, mainly focused on geopolymers that require curing at elevated temperatures, and this limits their ease of use in the field, particularly in cooler climates. Here, we outline a design process for fabricating ambient-cured fly ash geopolymer coatings for concrete substrates. Our technique is distinct from previous work as it requires no additional manufacturing steps or additives, both of which can bear significant costs. Our coatings were tested at varying humidities, and the impacts of mixing and application methods on coating integrity were compared using a combination of calorimetry, x-ray diffraction and image-processing techniques. This work could allow geopolymer coatings to become a more ubiquitous technique for updating ageing concrete infrastructure so that it can meet modern expectations of safety, and shifting requirements due to climate change.

Tests of a full-scale ITER toroidal interferometer and polarimeter (TIP) prototype on the DIII-D tokamak (invited)

A full-scale ITER toroidal interferometer and polarimeter (TIP) prototype, including an active feedback alignment system, has been installed and tested on the DIII-D tokamak. In the TIP prototype, a two-color interferometry measurement of line-integrated density is carried out at 10.59 μm and 5.22 μm using a CO₂ and quantum cascade laser, respectively, while a separate polarimetry measurement of the plasma-induced Faraday effect is made at 10.59 μm. The TIP prototype is equipped with a piezo tip/tilt stage active feedback alignment system that minimizes noise in the measurement and keeps the diagnostic aligned throughout DIII-D discharges. The measured phase resolution for the polarimeter and interferometer is 0.05° (100 Hz bandwidth) and 1.9° (1 kHz bandwidth), respectively. The corresponding line-integrated density resolution for the vibration-compensated interferometer is δnL = 1.5 × 10¹⁸ m^-2, and the magnetic field-weighted line-integrated density from the polarimeter is δnBL = 1.5 × 10¹⁹ Tm^-2. Both interferometer and polarimeter measurements during DIII-D discharges compare well with the expectations based on calculations using Thomson scattering measured density profiles and magnetic equilibrium reconstructions. Additionally, larger bandwidth interferometer measurements show that the diagnostic is a sensitive monitor of core density fluctuations with demonstrated measurements of Alfvén eigenmodes and tearing modes.

A heterodyne dispersion interferometer for wide bandwidth density measurements on DIII-D

In order to improve both the density and particularly the temporal resolution beyond previous dispersion interferometers (DIs), a heterodyne technique based on an acousto-optic (AO) cell has been added to the DI. A 40 MHz drive frequency for the AO cell allows density fluctuation measurements into the MHz range. A CO₂ laser-based heterodyne DI (HDI) installed on DIII-D has demonstrated that the HDI is capable of tracking the density evolution throughout DIII-D discharges, including disruption events and other rapid transient phenomena. The data also show good agreement with independent density measurements obtained with the existing DIII-D two-color interferometer. The HDI line-integrated density resolution sampled over a 1 s interval is ∼9 × 10¹⁷ m^-2. Density fluctuations induced by MHD instabilities are also successfully measured by the HDI.

Abstract 3877: MPL-5821, a macrophage targeted ESMTM p38 MAPK inhibitor, inhibits the production of TLR agonist induced IL-10 whilst sparing T-cell functionality

Compensatory release of immunosuppressive cytokines, such as IL-10, by macrophages present in the tumor microenvironment has been implicated as a mechanism for adaptive resistance to a number of immunotherapies. Our drug discovery effort utilises Esterase Motif TechnologyTM (ESMTM) which selectively targets myelomonocytic cells sparing the concomitant lymphocyte anti-tumor immune response. TLR agonists are known to be stimulators of the immune response, a key component of which is the production of myeloid cell IL-12p70. However, their therapeutic potential has been limited by their accompanying induction of IL-10 and other factors. MPL-5821 is an ESMTM p38 MAPK inhibitor which not only inhibits IL-10 but also enhances LPS stimulated IL-12p70 and in contrast to conventional p38 MAPK inhibitors provides enhancement of lymphocyte IFNγ production.

The present studies contrast MPL-5821 with multiple non-targeted agents, including inhibitors of HDAC, JAK, PI3K, MEK and CSF-1R, in human PBMC assays. These demonstrated the benefit of ESMTM-targeting as applied to p38 MAP kinase inhibition to not only inhibit TLR agonist induced immunosuppression but also enhance IFNγ due to its sparing of the myeloid-lymphocyte axis. None of the other modalities were able to achieve the effects observed for MPL-5821.

Having established the unique ability of MPL-5281 to inhibit LPS induced IL-10 production whilst still maintaining lymphocyte IFNγ production, we extended our studies to human cancer ex vivo models. We chose to evaluate MPL-5821 in combination with TLR agonists in ex vivo assays using tissue and ascites derived from ovarian and cervical cancer patients. A single cell suspension was prepared from cervical cancer tumor draining lymph nodes and incubated with MPL-5821 +/- the TLR 7/8 agonist R848 for 24 and 48 hours. MPL-5821 potently inhibited the R848 induced IL-10 production as measured by Cytometric Bead Array and in contrast to a conventional p38 MAP inhibitor LY2228820 also enhanced IFNγ production.

We studied MPL-5821 in cell suspensions prepared from human ovarian tumor and ascites. For the tumor sample, a single cell homogenate was prepared by mechanical and enzymatic digestion and for the ascites the cells were isolated by centrifugation. The cell populations were then analysed by flow cytometry and the cell preparation cultured for 72 hours with anti-CD3 or TLR agonist in the presence of test compound. Cytokine production was measured after 72 hours by ELISA or Luminex bead array. MPL-5821 again showed potent inhibition of TLR agonist induced IL-10 with concomitant enhancement of IFNγ production. We conclude that application of ESMTM technology to macrophage selective delivery of p38 MAPK inhibitors has the potential to inhibit TLR agonist induction of IL-10, which is implicated in limiting the performance of TLR agonists in the clinic.

Citation Format: David Moffat, Martin Perry, A. Marijne Heeren, Tanja D. de Gruijl, Justyna Rzepecka, Lucia Janicova, Anastasia Nika, Darryl Turner, Clare Doris, Claire Tebbutt, Kathryn Chapman, Gary Newton, Stephen Anderton. MPL-5821, a macrophage targeted ESMTM p38 MAPK inhibitor, inhibits the production of TLR agonist induced IL-10 whilst sparing T-cell functionality [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 3877.

Zoonotic Transfer of Clostridium difficile Harboring Antimicrobial Resistance between Farm Animals and Humans

The emergence of Clostridium difficile as a significant human diarrheal pathogen is associated with the production of highly transmissible spores and the acquisition of antimicrobial resistance genes (ARGs) and virulence factors. Unlike the hospital-associated C. difficile RT027 lineage, the community-associated C. difficile RT078 lineage is isolated from both humans and farm animals; however, the geographical population structure and transmission networks remain unknown. Here, we applied whole-genome phylogenetic analysis of 248 C. difficile RT078 strains from 22 countries. Our results demonstrate limited geographical clustering for C. difficile RT078 and extensive coclustering of human and animal strains, thereby revealing a highly linked intercontinental transmission network between humans and animals. Comparative whole-genome analysis reveals indistinguishable accessory genomes between human and animal strains and a variety of antimicrobial resistance genes in the pangenome of C. difficile RT078. Thus, bidirectional spread of C. difficile RT078 between farm animals and humans may represent an unappreciated route disseminating antimicrobial resistance genes between humans and animals. These results highlight the importance of the "One Health" concept to monitor infectious disease emergence and the dissemination of antimicrobial resistance genes.

Raynaud's of the Tongue

We describe a 40-year-old lady who presents with a painful white tongue on exposure to the cold. The differential diagnosis and investigations are outlined with a discussion about this unusual presentation of a common problem.

Asynchronously Calibrated Quantitative Bone Densitometry

Conventional quantitative computed tomography (QCT) uses a phantom scanned simultaneously with the anatomical region of interest. A newly developed method called asynchronous QCT does not require a phantom to be present during the patient scan. This allows the inclusion of computer tomography scans performed without any calibration standard in a different clinical context than bone densitometry, for example, in a screening context. In the present study, the asynchronous and the conventional quantitative computed tomographies were compared. Specifically, short-term precision, a phantom-induced bias, methodical equivalence of the asynchronous and the conventional methods, and interobserver variability were investigated. Ten phantom scans served for investigation of short-term precision. A prospective dataset of 43 study participants (44-80 years, mean 63.8 ± 8.6 years) was acquired over 3 clinical sites. Trabecular regions of the spine as well as cortical and trabecular regions of the hip (femoral neck, trochanter, intertrochanter, and shaft) were analyzed with respect to the presence or absence of a phantom and with regard to the synchronous and asynchronous calibration methods. Regarding precision, all variations of the mean areal and volumetric densities were lower for the asynchronous method than for the conventional method. The presence of the phantom resulted in a bias of 2.3 mg/cm³, and the choice of the asynchronously or synchronously calibrated analysis resulted in a bias of 3.7 mg/cm³ at the spine. Both were statistically, but not clinically, significant. The total hip was statistically, but not clinically, significantly different by 0.008 g/cm². The bone density values between the 2 techniques correlated highly with one another at all regions investigated. Interobserver variability between 2 trained observers showed a difference of 0.2 mg/cm³ (spine) and differences less or equal to 0.009 g/cm² (hip), which again was regarded as clinically nonsignificant. In summary, the asynchronously calibrated QCT provides results comparable to the established synchronously calibrated QCT.

Bench testing of a heterodyne CO2 laser dispersion interferometer for high temporal resolution plasma density measurements

A heterodyne detection scheme is combined with a 10.59 μm CO₂ laser dispersion interferometer for the first time to allow large bandwidth measurements in the 10-100 MHz range. The approach employed utilizes a 40 MHz acousto-optic cell operating on the frequency doubled CO₂ beam which is obtained using a high 2nd harmonic conversion efficiency orientation patterned gallium arsenide crystal. The measured standard deviation of the line integrated electron density equivalent phase resolution obtained with digital phase demodulation technique, is 4 × 10¹⁷ m^-2. Air flow was found to significantly affect the baseline of the phase signal, which an optical table cover was able to reduce considerably. The heterodyne dispersion interferometer (DI) approach is found to be robustly insensitive to motion, with measured phase shifts below baseline drifts even in the presence of several centimeters of retroreflector induced path length variations. Plasma induced dispersion was simulated with a wedged ZnSe plate and the measured DI phase shifts are consistent with expectations.

Promoting Linkage to Foreign Transnational in a ‘Tiger’ State: Singapore and the Local Industry Upgrading Programme

Singapore is a key destination for high-technology foreign direct investment in the Asia Pacific, particularly in the areas of disk drives and semiconductors, but increasingly in terms of knowledge-based services. Since the 1980s the government has made strenuous efforts to harness the innovative capacity of foreign transnational corporations through a series of policy initiatives aimed at facilitating a variety of forms of technology transfer to locally owned firms. This paper critically evaluates the impacts of these policy initiatives, and more specifically the Local Industry Upgrading Programme (LIUP), through case studies of the electronics and software sectors. The analysis suggests that supplier upgrading has been limited in the electronics sector, but that horizontal partnership arrangements, as evidenced by the software sector LIUP, may have more beneficial impacts.

Emergency management for orbital compartment syndrome-is decompression mandatory?

Current guidelines for the urgent management of patients with orbital compartment syndrome include immediate lateral canthotomy and cantholysis, followed by surgical decompression. Medical treatment is also advocated to 'buy time' while preparing the patient for theatre. This consists of high-dose steroids, mannitol, and acetazolamide diuretics to reduce swelling and orbital pressure. It is generally recognized that late or delayed intervention is associated with poor outcomes including blindness. With early presentation, given the potential risk to sight, there is generally a low threshold for treating suspected cases. However, whether or not to treat late cases is more controversial, partly because clinicians could face accusations of medical negligence if they do nothing. The case of a patient who sustained an orbital trauma to his only seeing eye, which resulted in acute proptosis and loss of vision, is presented here. He received no treatment at all for what appeared to be an orbital compartment syndrome secondary to retrobulbar haemorrhage, but surprisingly made a full recovery of vision within 48h. In contrast to the current literature in favour of urgent treatment, this case would appear to cast some doubt over the concept of 'always' treating orbital compartment syndrome and our understanding of the condition.