OMERACT 2023 Systemic Lupus Erythematosus Special Interest Group: Winnowing and Binning Preliminary Candidate Domains for the Core Outcome Set

BACKGROUND

The Outcome Measures in Rheumatology (OMERACT) Systemic Lupus Erythematosus (SLE) Working Group held a Special Interest Group (SIG) at the OMERACT 2023 conference in Colorado Springs where SLE collaborators reviewed domain sub-themes generated through qualitative research and literature review.

OBJECTIVE

The objective of the SIG and the subsequent meetings of the SLE Working Group was to begin the winnowing and binning of candidate domain sub-themes into a preliminary list of candidate domains that will proceed to the consensus Delphi exercise for the SLE COS.

METHODS

Four breakout groups at the SLE SIG in Colorado Springs winnowed and binned 132 domain sub-themes into candidate domains, which was continued with a series of virtual meetings by an advisory group of SLE patient research partners (PRPs), members of the OMERACT SLE Working Group Steering Committee, and other collaborators.

RESULTS

The 132 domain sub-themes were reduced to a preliminary list of 20 candidate domains based on their clinical and research relevance for clinical trials and research studies.

CONCLUSION

A meaningful and substantial winnowing and binning of candidate domains for the SLE COS was achieved resulting in a preliminary list of 20 candidate domains.

Outcome data from 15 years of cystic fibrosis newborn screening in a large UK region

BACKGROUND

The West Midlands Newborn Bloodspot Screening Laboratory is one of 16 in the UK and serves two tertiary paediatric cystic fibrosis (CF) centres (Staffordshire Children's Hospital at Royal Stoke and Birmingham Children's Hospital). CF newborn bloodspot screening (NBS) in this region started in November 2006 prior to the UK national roll-out in 2007. It uses an immunoreactive trypsinogen (IRT)/DNA/IRT protocol. We report the outcomes from 15 years of CF screening.

METHODS

The West Midlands CF NBS outcomes from 1 November 2006 to 31 October 2021 were reviewed. Clinical data were also obtained for babies referred to the CF centres as 'CF suspected'.

RESULTS

1 075 161 babies were screened, with 402 referred as 'CF suspected' and 205 identified as CF carriers. Of the 'CF suspected' babies, 268 were diagnosed with CF, 33 with CF screen positive, inconclusive diagnosis (CFSPID) and 17 as a CF carrier. Any CF-related diagnosis was excluded in 67. Outcome data were not available for 17, of whom 14 had died. Eighteen children with a negative CF NBS have subsequently been diagnosed with CF, 10 had meconium ileus and 8 were true 'affected not detected', presenting with respiratory symptoms or failure to thrive. This gives the West Midlands a CF birth prevalence of 1 in 4012 live births and the NBS protocol a sensitivity of 97.1% and a positive predictive value of 66.7%.

CONCLUSIONS

This large regional data set has excellent case ascertainment and demonstrates successful performance of the CF NBS protocol, with low numbers identified as CFSPID or CF carriers.

Adverse health outcomes among people who inject drugs who engaged in recent sex work: findings from a national survey

OBJECTIVES

This study explores trends in sex work among people who inject drugs (PWID) by gender and the relationship between sex work and adverse health outcomes including overdose, injection-site, and blood-borne virus (BBV) infections.

STUDY DESIGN

The Unlinked Anonymous Monitoring Survey of PWID is an annual cross-sectional survey that monitors BBV prevalence and behaviours, including transactional sex, among PWID recruited through specialist services in England, Wales, and Northern Ireland.

METHODS

Trends in sex work among PWID (2011-2021) were described. Data were analysed to assess differences between PWID who engaged in sex work in the past year (sex workers [SWs]) and those who did not (non-SWs) by gender (Pearson Chi2 tests) (2018-2021). Associations between sex work in the past year and adverse health outcomes were investigated using logistic regression.

RESULTS

Between 2011 and 2021, sex work among PWID remained stable, with 31% of women and 6.3% of men who inject, reporting having ever engaged in sex work, and 14% of women and 2.2% of men engaging in sex work in the past year. Between 2018 and 2021, SWs had greater odds of reporting symptoms of an injection-site infection (adjusted odds ratio (aOR): 1.68 [95% confidence interval {CI}: 1.31-2.16], P < 0.001) and reporting overdose (aOR: 2.21 [CI: 1.74-2.80], P < 0.001) than non-SWs had in the past year. Among men, SWs had 243% greater odds of having HIV than non-SWs (aOR: 3.43 [CI: 1.03-11.33], P = 0.043).

CONCLUSIONS

Our findings highlight disproportionate vulnerability and intersection of overlapping risk factors experienced by PWID SWs and a need for tailored interventions which are inclusive and low-threshold.

A rapid review of antenatal hepatitis C virus testing in the United Kingdom

BACKGROUND

The United Kingdom (UK) has committed to the World Health Organization's viral hepatitis elimination targets. New case finding strategies, such as antenatal testing, may be needed to achieve these targets. We conducted a rapid review to understand hepatitis C-specific antibody (anti-HCV) and HCV RNA test positivity in antenatal settings in the United Kingdom to inform guidance.

METHODS

Articles and conference abstracts published between January 2000 and June 2022 reporting anti-HCV testing in antenatal settings were identified through PubMed and Web of Science searches. Results were synthesised using a narrative approach.

RESULTS

The search identified 2,011 publications; 10 studies were included in the final synthesis. Seven studies used anonymous testing methods and three studies used universal opt-out testing. Anti-HCV test positivity ranged from 0.1 to 0.99%, with a median value of 0.38%. Five studies reported HCV RNA positivity, which ranged from 0.1 to 0.57% of the testing population, with a median value of 0.22%. One study reported cost effectiveness of HCV and found it to be cost effective at £9,139 per quality adjusted life years.

CONCLUSION

The relative contribution of universal opt-out antenatal testing for HCV should be reconsidered, as antenatal testing could play an important role in new case-finding and aid achieving elimination targets.

Cutaneous lymphangitis carcinomatosa: a unique presentation of a rare disease

A 75-year-old man with a three-year history of metastatic lung adenocarcinoma was diagnosed with cutaneous lymphangitic carcinomatosa of unique morphology. He was admitted to our hospital for right neck swelling, erythema, and failure to thrive. Skin examination demonstrated an indurated, thickened, firm, hyperpigmented plaque extending from the right neck and chest to the right ear, cheek, and eyelids. Skin biopsy demonstrated poorly differentiated adenocarcinoma, morphologically consistent with metastasis from the patient's known pulmonary adenocarcinoma and showed dermal invasion, perineural invasion, and involvement of dermal lymphatics. The diagnosis was an atypical presentation of cutaneous lymphangitis carcinomatosa from metastatic lung adenocarcinoma. This case presentation affirms that cutaneous lymphangitis carcinomatosa has a variety of atypical presentations, so physicians must maintain a high index of suspicion when evaluating cutaneous lesions in patients with known or suspected internal malignancy.

Monoclonal antibody and protein therapeutic formulations for subcutaneous delivery: high-concentration, low-volume vs. low-concentration, high-volume

Biologic drugs are used to treat a variety of cancers and chronic diseases. While most of these treatments are administered intravenously by trained healthcare professionals, a noticeable trend has emerged favoring subcutaneous (SC) administration. SC administration of biologics poses several challenges. Biologic drugs often require higher doses for optimal efficacy, surpassing the low volume capacity of traditional SC delivery methods like autoinjectors. Consequently, high concentrations of active ingredients are needed, creating time-consuming formulation obstacles. Alternatives to traditional SC delivery systems are therefore needed to support higher-volume biologic formulations and to reduce development time and other risks associated with high-concentration biologic formulations. Here, we outline key considerations for SC biologic drug formulations and delivery and explore a paradigm shift: the flexibility afforded by low-to-moderate-concentration drugs in high-volume formulations as an alternative to the traditionally difficult approach of high-concentration, low-volume SC formulation delivery.

Inner southern magnetosphere observation of Mercury via SERENA ion sensors in BepiColombo mission

Mercury's southern inner magnetosphere is an unexplored region as it was not observed by earlier space missions. In October 2021, BepiColombo mission has passed through this region during its first Mercury flyby. Here, we describe the observations of SERENA ion sensors nearby and inside Mercury's magnetosphere. An intermittent high-energy signal, possibly due to an interplanetary magnetic flux rope, has been observed downstream Mercury, together with low energy solar wind. Low energy ions, possibly due to satellite outgassing, were detected outside the magnetosphere. The dayside magnetopause and bow-shock crossing were much closer to the planet than expected, signature of a highly eroded magnetosphere. Different ion populations have been observed inside the magnetosphere, like low latitude boundary layer at magnetopause inbound and partial ring current at dawn close to the planet. These observations are important for understanding the weak magnetosphere behavior so close to the Sun, revealing details never reached before.

Globe dislocation and optic nerve avulsion following all-terrain vehicle accidents

Purpose

Observations

Conclusions and Importance

Parker Solar Probe Observations of Solar Wind Energetic Proton Beams Produced by Magnetic Reconnection in the Near-Sun Heliospheric Current Sheet

We report observations of reconnection exhausts in the Heliospheric Current Sheet (HCS) during Parker Solar Probe Encounters 08 and 07, at 16 R _s and 20 R _s , respectively. Heliospheric current sheet (HCS) reconnection accelerated protons to almost twice the solar wind speed and increased the proton core energy by a factor of ∼3, due to the Alfvén speed being comparable to the solar wind flow speed at these near-Sun distances. Furthermore, protons were energized to super-thermal energies. During E08, energized protons were found to have leaked out of the exhaust along separatrix field lines, appearing as field-aligned energetic proton beams in a broad region outside the HCS. Concurrent dropouts of strahl electrons, indicating disconnection from the Sun, provide further evidence for the HCS being the source of the beams. Around the HCS in E07, there were also proton beams but without electron strahl dropouts, indicating that their origin was not the local HCS reconnection exhaust.

In vitro efficacy of relebactam versus avibactam against Mycobacterium abscessus complex

Infections resulting from Mycobacterium abscessus are increasing in prevalence worldwide, with the greatest risk posed to patients with underlying respiratory conditions. Treatment for infections is difficult due to wide ranging intrinsic antimicrobial resistance, which is compounded by the existence of a range of subspecies within the M. abscessus complex, each with varying additional antimicrobial resistance profiles. Previously, the use of β-lactam/β-lactamase inhibitors within a combination therapy has been proposed as an effective treatment option for pulmonary M. abscessus infections. Here, we assess the in vitro efficacy of two non-β-lactam based inhibitors, relebactam and avibactam, as agents against M. abscessus with their respective partner drugs imipenem and ceftazidime, as well as in triplicate combinations with additional β-lactam antibiotics against the M. abscessus complex. We have shown that the commercially available ratio of imipenem to relebactam is the appropriate ratio for bactericidal activity against M. abscessus, whereas the ratio between ceftazidime and avibactam is redundant, due to inactivity of ceftazidime to inhibit the bacteria. We have identified that the use of imipenem and meropenem alongside either relebactam or avibactam yield low minimum inhibitory concentrations (MIC) and minimum bactericidal concentrations (MBC) for each M. abscessus subspecies, which are within the therapeutically achievable concentration ranges within the epithelial lining fluid of the lungs. We propose the implementation of imipenem with relebactam in place of stand-alone imipenem into the current treatment regime, alongside meropenem, as a future front-line treatment option for M. abscessus complex infections.

Feasibility, preliminary efficacy, and accessibility of a twitter-based social support group vs Fitbit only to decrease sedentary behavior in women

BACKGROUND

Health behavior change interventions delivered by social media allow for real-time, dynamic interaction, peer social support, and experimenter-provided content.

AIMS

We tested the feasibility, acceptability, and preliminary efficacy of a novel Twitter-based walking break intervention with daily behavior change strategies and prompts for social support, combined with a Fitbit, vs. Fitbit alone.

METHODS

In a 2-group pilot, 45 sedentary women from a heart clinic were randomized to Twitter + Fitbit activity tracker (Tweet4Wellness, n = 23) or Fitbit-only (control, n = 22). All received a Fitbit and 13 weeks of tailored weekly step goals. Tweet4Wellness consisted of a private Twitter support group, with daily automated behavior change "tweets" informed by behavior change theory, and encouragement to communicate within the group. Feasibility outcomes included recruitment and enrollment numbers, implementation challenges, and number and type of help requests from participants throughout the study period. Preliminary efficacy outcomes provided by Fitbit data were sedentary minutes, number of hours with >250 steps, maximum sitting bout, weighted sedentary median bout length, total steps, intensity minutes (>3.0 METS), and ratio of time spent sitting-to-moving. Acceptability outcomes included level of Twitter participation within Tweet4Wellness, and Likert scale plus open-ended survey questions on enjoyment and perceived effectiveness of intervention components. Survey data on acceptability of the features of the intervention were collected at 13 weeks (end-of-treatment [EOT]) and 22 weeks (follow-up).

RESULTS

The study was feasible, with addressable implementation challenges. Tweet4Wellness participants changed significantly from baseline to EOT relative to control participants on number of active hours p = .018, total steps p = .028, and ratio of sitting-to-moving, p = .014. Only sitting-to-moving was significant at follow-up (p = .047). Among Tweet4Wellness participants, each tweet sent during treatment was associated with a 0.11 increase in active hours per day (p = .04) and a 292-step increase per day (p < .001). Tweet4Wellness participants averaged 54.8 (SD = 35.4) tweets, totaling 1304 tweets, and reported liking the accountability and peer support provided by the intervention.

CONCLUSION

A Twitter-delivered intervention for promoting physical activity among inactive women from a heart clinic was feasible, acceptable, and demonstrated preliminary efficacy in increasing daily active hours, daily total steps, and the ratio of sitting-to-moving from pre to post for the intervention compared with the control. Lessons learned from this pilot suggest that the next study should expand the recruitment pool, refine the intervention to increase group engagement, and select active hours, total steps, and ratio of sitting-to-movement as primary sedentary behavior measures.

SERENA: Particle Instrument Suite for Determining the Sun-Mercury Interaction from BepiColombo

The ESA-JAXA BepiColombo mission to Mercury will provide simultaneous measurements from two spacecraft, offering an unprecedented opportunity to investigate magnetospheric and exospheric particle dynamics at Mercury as well as their interactions with solar wind, solar radiation, and interplanetary dust. The particle instrument suite SERENA (Search for Exospheric Refilling and Emitted Natural Abundances) is flying in space on-board the BepiColombo Mercury Planetary Orbiter (MPO) and is the only instrument for ion and neutral particle detection aboard the MPO. It comprises four independent sensors: ELENA for neutral particle flow detection, Strofio for neutral gas detection, PICAM for planetary ions observations, and MIPA, mostly for solar wind ion measurements. SERENA is managed by a System Control Unit located inside the ELENA box. In the present paper the scientific goals of this suite are described, and then the four units are detailed, as well as their major features and calibration results. Finally, the SERENA operational activities are shown during the orbital path around Mercury, with also some reference to the activities planned during the long cruise phase.

Pneumothorax following serratus anterior plane block

Serratus anterior plane blocks may provide analgesia for rib fractures, thoracic surgery and breast surgery. There remains uncertainty regarding the location of injection, be it superficial or deep to the serratus anterior muscle. We describe the case of a 63-year-old ASA physical status 3 woman undergoing a wire-guided wide local excision of a right breast lump. A modified right serratus anterior plane block was performed under ultrasound guidance, injecting 20 ml of bupivacaine 0.25% deep to the serratus anterior muscle. No immediate complications were noted. Intra-operatively the patient developed arterial desaturation associated with high airway pressures. A subsequent chest radiograph in the post-anaesthetic care unit demonstrated a large right-sided pneumothorax which was treated with immediate needle decompression and chest drain insertion. This is the first case of pneumothorax reported from this approach to serratus anterior plane blockade and serves as a reminder of a potential serious complication.

Efficacy of cryotherapy as first line therapy in patients with Barrett's neoplasia: a systematic review and pooled analysis

Cryotherapy has been used as salvage therapy; however, its efficacy as first line treatment in patients with Barrett's esophagus (BE) neoplasia has not been well studied. The aim of this paper was to perform a systematic review to look at the efficacy of cryotherapy as the primary treatment of BE. An electronic database search was performed (PubMed, Embase, Cochrane, and Google Scholar) to search for studies with cryotherapy as the initial primary modality of ablation in patients with BE neoplasia. Studies that included patients with other prior forms of therapy were excluded. The primary outcomes were the pooled rates of complete eradication of intestinal metaplasia (CE-IM) and CE of neoplasia (CE-N). Secondary outcomes were recurrence rates of neoplasia and intestinal metaplasia (IM) and adverse events. The statistical software OpenMetaAnalyst was used for analysis with pooled estimates reported as proportions (%) with 95% confidence intervals (CI) with heterogeneity (I2) among studies. The search revealed 6 eligible studies with a total of 282 patients (91.5% male, average age 65.3 years) with 459 person years of follow-up. 69.35% [95% CI (52.1%-86.5%)] of patients achieved CE-IM and 97.9% (95% CI: 95.5%-100%) had CE-N. 7.3% of patients had persistent dysplasia with 4% progressing to cancer. The recurrence rate of neoplasia was 10.4 and that of IM was 19.1 per 100 patient years of follow-up. The overall rate of stricture formation was 4.9%. There are scarce data on the use of cryotherapy as the primary modality for the treatment of BE dysplasia. The published data demonstrate efficacy rates of 69% and 98% for complete eradication of metaplasia and neoplasia, respectively. These results need to be assessed in prospective, comparative trials with other forms of therapy.

Integrating HIV, syphilis, malaria and anaemia point-of-care testing (POCT) for antenatal care at dispensaries in western Kenya: discrete-event simulation modelling of operational impact

BACKGROUND

Despite WHO advocating for an integrated approach to antenatal care (ANC), testing coverage for conditions other than HIV remains low and women are referred to distant laboratories for testing. Using point-of-care tests (POCTs) at peripheral dispensaries could improve access to testing and timely treatment. However, the effect of providing additional services on nurse workload and client wait times are unknown. We use discrete-event simulation (DES) modelling to understand the effect of providing four point-of-care tests for ANC on nurse utilization and wait times for women seeking maternal and child health (MCH) services.

METHODS

We collected detailed time-motion data over 20 days from one high volume dispensary in western Kenya during the 8-month implementation period (2014-2015) of the intervention. We constructed a simulation model using empirical arrival distributions, activity durations and client pathways of women seeking MCH services. We removed the intervention from the model to obtain wait times, length-of-stay and nurse utilization rates for the baseline scenario where only HIV testing was offered for ANC. Additionally, we modelled a scenario where nurse consultations were set to have minimum durations for sufficient delivery of all WHO-recommended services.

RESULTS

A total of 183 women visited the dispensary for MCH services and 14 of these women received point-of-care testing (POCT). The mean difference in total waiting time was 2 min (95%CI: < 1-4 min, p = 0.026) for MCH women when integrated POCT was given, and 9 min (95%CI: 4-14 min, p < 0.001) when integrated POCT with adequate ANC consult times was given compared to the baseline scenario. Mean length-of-stay increased by 2 min (95%CI: < 1-4 min, p = 0.015) with integrated POCT and by 16 min (95%CI: 10-21 min, p < 0.001) with integrated POCT and adequate consult times compared to the baseline scenario. The two nurses' overall daily utilization in the scenario with sufficient minimum consult durations were 72 and 75%.

CONCLUSION

The intervention had a modest overall impact on wait times and length-of-stay for women seeking MCH services while ensuring pregnant women received essential diagnostic testing. Nurse utilization rates fluctuated among days: nurses experienced spikes in workload on some days but were under-utilized on the majority of days. Overall, our model suggests there was sufficient time to deliver all WHO's required ANC activities and offer integrated testing for ANC first and re-visits with the current number of healthcare staff. Further investigations on improving healthcare worker, availability, performance and quality of care are needed. Delivering four point-of-care tests together for ANC at dispensary level would be a low burden strategy to improve ANC.

Factors affecting the growth of infants diagnosed with cystic fibrosis by newborn screening

Background

Newborn screening (NBS) for cystic fibrosis (CF) improves nutritional outcomes. Despite early dietetic intervention some children fail to grow optimally. We report growth from birth to 2 years in a cohort of children diagnosed with CF by NBS and identify the variables that influence future growth.

Methods

One hundred forty-four children were diagnosed with CF by the West Midlands Regional NBS laboratory between November 2007 and October 2014. All anthropometric measurements and microbiology results from the first 2 years were collated as was demographic and CF screening data. Classification modelling was used to identify the key variables in determining future growth.

Results

Complete data were available on 129 children. 113 (88%) were pancreatic insufficient (PI) and 16 (12%) pancreatic sufficient (PS). Mean birth weight (z score) was 3.17 kg (− 0.32). There was no significant difference in birth weight (z score) between PI and PS babies: 3.15 kg (− 0.36) vs 3.28 kg (− 0.05); p = 0.33. By the first clinic visit the difference was significant: 3.42 kg (− 1.39) vs 4.60 kg (− 0.48); p < 0.0001. Weight and height remained lower in PI infants in the first year of life. In the first 2 years of life, 18 (14%) infants failed to regain their birth weight z score. The median time to achieve a weight z score of − 2, − 1 and 0 was 18, 33 and 65 weeks respectively. The median times to reach the same z scores for height were 30, 51 and 90 weeks. Birth weight z score, change in weight z score from birth to first clinic, faecal elastase, isolation of Pseudomonas aeruginosa, isolation of Staphylococcus aureus and sweat chloride were the variables identified by the classification models to predict weight and height in the first and second year of life.

Conclusions

Babies with CF have a lower birth weight than the healthy population. For those diagnosed with CF by NBS, the weight difference between PI and PS babies was not significantly different at birth but became so by the first clinic visit. The presence of certain factors, most already identifiable at the first clinic visit can be used to identify infant at increased risk of poor growth.

Mycobacterium abscessus: Environmental Bacterium Turned Clinical Nightmare

Mycobacteria are a large family of over 100 species, most of which do not cause diseases in humans. The majority of the mycobacterial species are referred to as nontuberculous mycobacteria (NTM), meaning they are not the causative agent of tuberculous (TB) or leprosy, i.e., Mycobacterium tuberculous complex and Mycobacterium leprae, respectively. The latter group is undoubtedly the most infamous, with TB infecting an estimated 10 million people and causing over 1.2 million deaths in 2017 alone TB and leprosy also differ from NTM in that they are only transmitted from person to person and have no environmental reservoir, whereas NTM infections are commonly acquired from the environment. It took until the 1950′s for NTM to be recognised as a potential lung pathogen in people with underlying pulmonary disease and another three decades for NTM to be widely regarded by the medical community when Mycobacterium avium complex was identified as the most common group of opportunistic pathogens in AIDS patients. This review focuses on an emerging NTM called Mycobacterium abscessus (M. abs). M. abs is a rapidly growing NTM that is responsible for opportunistic pulmonary infections in patients with structural lung disorders such as cystic fibrosis and bronchiectasis, as well as a wide range of skin and soft tissue infections in humans. In this review, we discuss how we came to understand the pathogen, how it is currently treated and examine drug resistance mechanisms and novel treatments currently in development. We highlight the urgent need for new and effective treatments for M. abs infection as well as improved in vivo methods of efficacy testing.