[Endogenous Candida endophthalmitis]

Endogenous Candida endophthalmitis is a rare but vision-threatening disease. In most cases, endogenous endophthalmitis caused by Candida species has a better prognosis than endogenous endophthalmitis caused by other fungal species or bacteria but the prognosis still depends heavily on the time required for diagnosis and subsequent treatment as well as the initial visual acuity. Suggestions for treatment algorithms have already been made in the past but binding guidelines in ophthalmology only exist sporadically due to the rarity of the disease. This review discusses the current knowledge on endogenous Candida endophthalmitis and draws conclusions from the current study situation.

Demonstrating Agreement between Radio and Fluorescence Measurements of the Depth of Maximum of Extensive Air Showers at the Pierre Auger Observatory

We show, for the first time, radio measurements of the depth of shower maximum (X_{max}) of air showers induced by cosmic rays that are compared to measurements of the established fluorescence method at the same location. Using measurements at the Pierre Auger Observatory we show full compatibility between our radio and the previously published fluorescence dataset, and between a subset of air showers observed simultaneously with both radio and fluorescence techniques, a measurement setup unique to the Pierre Auger Observatory. Furthermore, we show radio X_{max} resolution as a function of energy and demonstrate the ability to make competitive high-resolution X_{max} measurements with even a sparse radio array. With this, we show that the radio technique is capable of cosmic-ray mass composition studies, both at Auger and at other experiments.

Heart Rate Variability Biofeedback as Adjunctive Treatment of Generalized Anxiety Disorder: A Case Report

Introduction

Generalized anxiety disorder (GAD) is a common psychiatric disorder that can cause significant functional impairment to a patient's life. Mind body therapies (MBT) have increasingly been used as an intervention to manage symptoms of anxiety. Heart rate variability (HRV) biofeedback is a specific MBT that utilizes real-time feedback on autonomic functioning to train the physiological stress response through diaphragmatic breathing.

Case Presentation

A 39-year-old female was referred for a seven-week HRV biofeedback training protocol at Bastyr University Clinic for adjunctive treatment of GAD and depression. She had been taking citalopram for approximately four months prior to the first visit.

Discussion/Conclusion

After completing the seven-week protocol, the patient's anxiety improved from severe to mild, and her depression improved from mild to minimal. This improvement was maintained at a four-week follow-up, and eight weeks after the final visit she reported that her anxiety was no longer a concern to her. HRV biofeedback demonstrated to be an effective adjunctive treatment for GAD in this patient's case; however further research is needed to elucidate the effects of HRV biofeedback in patients with GAD.

Full aperture backscatter diagnostics for characterization of laser plasma instabilities at the extreme light infrastructure (ELI) beamlines

We report on the commissioning of a full aperture backscatter diagnostics station for the kilojoule, nanosecond high repetition rate L4n laser operating at a wavelength of 527 nm at the Extreme Light Infrastructure (ELI) - Beamlines, Dolni Brezany, Czech Republic. Light scattered back from laser-plasma interaction into the cone of the final focusing lens is captured and split into different channels to measure the signatures of laser plasma instabilities from stimulated Brillouin scattering, stimulated Raman scattering, and two plasmon decay with respect to back scattered energy, its spectrum, and its temporal profile. The performance was confirmed in a commissioning experiment with more than 800 shots at laser intensities ranging from 0.5 × 1013 to 1.1 × 1015 W cm-2. These diagnostics are permanently installed at ELI Beamlines, and can be used to understand the details of laser-plasma interactions in experiments with kJ and 527 nm light. The large number of shots that can be collected in an experimental campaign will allow us to study the details of the laser-plasma interaction with a high level of confidence.

Evaluating the prospective utility of pharmacogenetics reporting among Canadian Armed Forces personnel receiving pharmacotherapy: a preliminary assessment towards precision psychiatric care

Pharmacological interventions for treating posttraumatic stress disorder in Canadian Armed Forces (CAF) members and Veterans often achieve modest results. The field of pharmacogenetics, or the study of how genes influence an individual's response to different medications, offers insight into how prior knowledge of gene-drug interactions may potentially improve the trial-and-error process of drug selection in pharmacotherapy, thereby improving treatment effects and remission rates. Given the relative recency of pharmacogenetics testing and sparse research in military samples, we used pharmacogenetics testing in a small pilot group (n=23) of CAF members and Veterans who were already engaged in pharmacotherapy for a service-related mental health condition to better understand the associated opportunities and challenges of pharmacogenetics testing in this population. Our preliminary evaluation involved: (1) reporting the prevalence of pharmacogenetics testing 'bin' status according to participants' reports ('green', 'yellow' or 'red'; intending to signal 'go', 'caution' or 'stop', regarding the potential for gene-drug interactions); (2) calculating the percentage of currently prescribed psychotropic medications that were assessed and included in the reports; (3) evaluating whether prescribers used pharmacogenetics testing information according to clinical notes and (4) collecting informal feedback from participating psychiatrists. While pharmacogenetics testing appeared to provide valuable information for a number of clients, a major limitation was the number of commonly prescribed medications not included in the reports.

[Ocular mucous membrane pemphigoid]

Mucous membrane pemphigoid refers to a heterogeneous group of autoimmune diseases with subepidermal blister formation that can affect all mucous membranes with varying frequencies. This is a rare disease without any geographic or sexual predisposition that is characterized by recurrent inflammation and progressive scarring. The specific diagnostics can be negative in up to 50% of cases. The diagnosis is predominantly made in patients aged 60-80 years. Ophthalmologists play an important role in the care of affected individuals as the conjunctiva is the second most frequent site of involvement. The treatment is often tedious and primarily consists of long-term systemic immunosuppression.

[Treatment of ocular mucous membrane pemphigoid]

Ocular mucous membrane pemphigoid is the manifestation of a systemic autoimmune disease. As autoantibodies circulating in the blood cannot be adequately treated by eye drops, systemic immunosuppressive treatment of this autoimmune disease naturally plays the most important role. Ophthalmic topical or even surgical procedures are only used as supportive measures or usually to control ocular complications that have developed. Patients with the typical clinical picture are treated causally with systemic immunosuppression causally, nurturing eye drops, as well as by minimally invasive surgery if complications arise, if possible in an inflammation-free state, in accordance with the guidelines if the diagnosis is positive but also if the biopsy and serology are repeatedly negative after exclusion of all differential diagnoses. Purely topical anti-inflammatory treatment is insufficient to prevent irreversible progression of scarring conjunctivitis. Corresponding treatment recommendations have been formulated in current European as well as German guidelines and are presented here as an overview.

[Initial results of the German ocular pemphigoid register]

Mucous membrane pemphigoid (MMP) is a rare disease that presents clinicians with a diagnostic and therapeutic challenge. The aim of this article is to present the German ocular pemphigoid register, which is a retrospective data collection and a collaborative network to improve the care of these patients. It was founded in 2020 and currently comprises 17 eye clinics/cooperation partners. An initial evaluation of the results shows a known epidemiological profile and an expected high proportion of patients with negative diagnostics (48.6%) despite a clinically suspected diagnosis. In this register study predominantly recruiting from eye clinics, the proportion of patients with a strictly ocular involvement was 65.4%. Also of interest was the high number of patients with glaucoma (22.3%) as the most frequent comorbidity. Based on the working group formed, a prospective survey will be conducted in the future, which enables a follow-up.

[Clinical aspects of ocular mucosal pemphigoid]

Mucosal pemphigoid is a rare chronic autoimmune disease that also affects the eyes in more than two thirds of all cases. Especially in the early phase of the ocular manifestation, the findings are subtle and the disease is often not recognized. The aim of this article is to provide the clinical aspects of ocular mucosal pemphigoid so that timely diagnostics can be initiated when this disease is suspected.

Clinical utility of moral injury in a treatment-seeking military-Veteran mental health population

LAY SUMMARY

Moral injury (MI) can be defined as a diverse set of outcomes associated with actions that transgress one’s moral beliefs or values. MI can be distressing for an individual at the interpersonal level (e.g., shifting relationships, feelings of betrayal) and the intrapersonal level (e.g., internalized guilt and shame). Indeed, these transgressions of moral beliefs and values have been associated with a high prevalence of mental illnesses, such as posttraumatic stress disorder (PTSD) and depression. Although various forms of assessment exist to identify MI in the individual, treatments for MI are often interlinked or embedded in evidence-based treatments for PTSD and depression. As such, unique contributions of MI as a target of treatment remain largely unclear. In this article, the authors explore existing treatments that may be used to treat MI as a distinct mental health construct and examine their utility in reducing symptoms of MI in military and Veteran populations.

Limits to Gauge Coupling in the Dark Sector Set by the Nonobservation of Instanton-Induced Decay of Super-Heavy Dark Matter in the Pierre Auger Observatory Data

Instantons, which are nonperturbative solutions to Yang-Mills equations, provide a signal for the occurrence of quantum tunneling between distinct classes of vacua. They can give rise to decays of particles otherwise forbidden. Using data collected at the Pierre Auger Observatory, we search for signatures of such instanton-induced processes that would be suggestive of super-heavy particles decaying in the Galactic halo. These particles could have been produced during the post-inflationary epoch and match the relic abundance of dark matter inferred today. The nonobservation of the signatures searched for allows us to derive a bound on the reduced coupling constant of gauge interactions in the dark sector: α_{X}≲0.09, for 10^{9}≲M_{X}/GeV<10^{19}. Conversely, we obtain that, for instance, a reduced coupling constant α_{X}=0.09 excludes masses M_{X}≳3×10^{13}  GeV. In the context of dark matter production from gravitational interactions alone, we illustrate how these bounds are complementary to those obtained on the Hubble rate at the end of inflation from the nonobservation of tensor modes in the cosmological microwave background.

Keratin films for ocular surface reconstruction: Wound healing in an in-vivo model

The most commonly used tissue substitute for ocular surface reconstruction is human amniotic membrane (AM). Because of its low biomechanical strength and intransparency there is a need to search for alternatives of consistent quality. This study, further explored the biocompatibility of Keratin Film (KF) and its ability to sustain corneal epithelial wound healing. In three equal groups of 5 New Zeeland white rabbits a 4 mm superficial keratectomy was created in the right eye. Five eyes received a KF, five a human AM graft and the remaining five no implant. All eyes were treated with ofloxacin and dexamethasone eye drops and followed up for 10 days. Corneal fluorescein staining, vascularization, and transparency were assessed using slit lamp biomicroscopy according to a standardized grading score during and at the end of follow-up. The corneal-scleral-button was excised and processed for histology. After 10 days all eyes which had received a KF showed complete epithelial healing and no signs of neovascularization. In the AM group 1 eye showed a persistent epithelial defect at day 10 and 2 eyes showed neovascularization at day 7 resolving at day 10. Transparency improved progressively both in the KF group as well as in the AM group towards the end of the follow. Histology showed a multilayer epithelium firmly adherent to the KF with no evidence of keratocyte migration or inflammatory reaction in the corneal stroma. In this study on rabbit eyes KF better supported corneal epithelial wound healing than amniotic membrane.

Ocular Syphilis: Experience over 11 Years at a German Ophthalmology Reference Centre

BACKGROUND

In accordance with worldwide data, the Robert Koch Institute (RKI) has reported a constant increase of syphilis cases in Germany over the past decade.

METHODS

We analysed the data of all patients, referred to a Department of Ophthalmology in a tertiary referral centre in Düsseldorf, Germany between 2008 and 2019, who were tested for syphilis. The epidemiologic, demographic, clinical, diagnostic and therapeutic data were retrieved from the records and evaluated in a retrospective, descriptive, non-comparative study.

RESULTS

Syphilis serology was positive in 32/1840 (1.7%) patients, and was evenly distributed over this period. 26 (81.3%) were male, 19 (59.4%) belonged to a risk group. Ocular syphilis was the primary diagnosis for 29 patients (90.6%). The most frequent manifestation was uveitis (n = 20, 62.5%). By the end of therapy, 19 patients (59.4%) had an improved visual acuity.

CONCLUSION

The incidence of ocular syphilis cases has remained stable over the last decade.

Interprofessional collaboration in Austrian primary care: an analysis of requirements and challenges

Background

Primary health care (PHC) is built on interprofessional collaboration (IPC) between health and social professions. According to international frameworks, interprofessional communication, client-centred care, collaborative leadership, role clarification, team functioning and interprofessional conflict resolution are essential for IPC. As of April 2022, 36 PHC units were registered in Austria. This study aims to explore the perspectives of health care professionals on IPC in PHC in Austria.

Methods

Between October 2021 and March 2022, 15 guided group interviews were conducted with a total of 57 representatives of the professional groups biomedical analytics, dietetics, medical training therapy, medicine, midwifery, nursing, occupational therapy, office assistance, orthoptics, pharmacy, physiotherapy, psychotherapy, radiology technology, social work and speech therapy. The data was analysed using qualitative content analysis according to Mayring.

Results

Interdisciplinary counselling and prevention services, monitoring, acute interventions and treatment of chronic diseases are seen as fields of action for increased IPC in PHC. Interprofessional relationships are established during joint home visits and weekly multiprofessional meetings, when communication is collegial. Challenges mentioned for the IPC in PHC were i.e. role ambiguity, lack of time for networking or unclear legal regulations. Taking over responsibility as well as the ability to delegate and to deal with conflict, a sense of justice and willingness to accept criticism are core competences required for IPC in PHC.

Conclusions

The interviewees aim to get more involved in PHC, but not all feel optimally prepared for the necessary collaboration in this setting. In their view, specific training content, focusing on the unique structure of PHC, the roles of all the involved professional groups and conflict management, is necessary to successfully shape IPC in the interest of the clients.

Key messages

Kilotesla plasmoid formation by a trapped relativistic laser beam

A strong quasistationary magnetic field is generated in hollow targets with curved internal surface under the action of a relativistically intense picosecond laser pulse. Experimental data evidence the formation of quasistationary strongly magnetized plasma structures decaying on a hundred picoseconds timescale, with the magnetic field strength of the kilotesla scale. Numerical simulations unravel the importance of transient processes during the magnetic field generation and suggest the existence of fast and slow regimes of plasmoid evolution depending on the interaction parameters. The proposed setup is suited for perspective highly magnetized plasma application and fundamental studies.

Stabilized Radiation Pressure Acceleration and Neutron Generation in Ultrathin Deuterated Foils

Premature relativistic transparency of ultrathin, laser-irradiated targets is recognized as an obstacle to achieving a stable radiation pressure acceleration in the "light sail" (LS) mode. Experimental data, corroborated by 2D PIC simulations, show that a few-nm thick overcoat surface layer of high Z material significantly improves ion bunching at high energies during the acceleration. This is diagnosed by simultaneous ion and neutron spectroscopy following irradiation of deuterated plastic targets. In particular, copious and directional neutron production (significantly larger than for other in-target schemes) arises, under optimal parameters, as a signature of plasma layer integrity during the acceleration.

POS0859 C-REACTIVE PROTEIN AND INTERLEUKIN-6: POTENTIAL BIOMARKERS OF DISEASE ACTIVITY AND TREATMENT RESPONSE IN SYSTEMIC SCLEROSIS-INTERSTITIAL LUNG DISEASE

Background

Clinically feasible and valid biomarkers of systemic sclerosis-interstitial lung disease (SSc-ILD) are needed. While promising candidate biomarkers are under investigation (e.g., KL-6, CCL-8), clinical assays for these proteins are not currently available. C-reactive protein (CRP) measurements are feasible, cost-effective, and have been shown to predict mortality in SSc.1 Measuring interleukin (IL)-6, a proinflammatory cytokine implicated in SSc-ILD pathogenesis, is also feasible in most clinical settings.

Objectives

(1) To investigate whether CRP and IL-6 levels change in response to treatment with immunosuppression in SSc-ILD; (2) To explore whether the change in CRP and IL-6 predict the future course of forced vital capacity (FVC).

Methods

CRP and IL-6 levels were measured in serum at baseline and after 12 months in participants of Scleroderma Lung Study (SLS) II (patients with active SSc-ILD receiving 24 months of mycophenolate or 12 months cyclophosphamide followed by 12 months of placebo2). Measured values were log-transformed to remove skewness. The FVC%-predicted was measured every 3 months over the course of 24 months. Spearman’s correlations evaluated the relationship between baseline CRP or IL-6 measurements and other patient parameters. Paired t-tests were used to compare the change in individual CRP and IL-6 measurements from baseline to 12 months. Linear mixed effects models were used to examine the relationship between the change in CRP and IL-6 (baseline to 12 months) and the subsequent course of the FVC (12 to 24 months). All analysis were performed for the entire cohort and separately by treatment arm.

Results

Of the 142 participants of SLS II, 101 had CRP and IL-6 measurements at baseline and 12 months. Baseline CRP and IL-6 levels correlated significantly with higher modified Rodnan skin score (CRP: r=0.3, P=0.005; IL-6: r=0.2, P=0.01) and shorter disease duration (CRP: r=-0.3, P=0.005; IL-6: r=-0.2, P=0.01) and were higher in patients with diffuse SSc (CRP: P=0.007; IL-6: P=0.01). Relationships to baseline FVC and DLCO were not observed. CRP decreased significantly from baseline to 12 months in the whole group (P=0.01), but the decrease was slightly greater in patients randomized to mycophenolate versus cyclophosphamide (-0.47 vs. -0.33 ug/mL). IL-6 also decreased from baseline to 12 months in the whole group with a trend towards significance (P=0.10) (Figure 1). The mean decrease in IL-6 was again slightly greater in patients randomized to mycophenolate versus cyclophosphamide (-0.31 vs. -0.10 pg/mL). After controlling for baseline FVC and treatment arm in the mixed effects model, there was a relationship between the decrease in CRP from baseline to 12 months and an improved course of FVC 12 to 24 months (Estimate -0.64), but this did not reach significance (P=0.14). However, after controlling for baseline FVC and treatment arm, a greater decrease in IL-6 from baseline to 12 months was significantly associated with a greater improvement in FVC from 12 to 24 months (Estimate -1.28; P=0.01).

Figure 1.

Change in CRP (A) and IL-6 (B) from baseline to 12 months by treatment arm in SLS II. CYC=cyclophosphamide (Blue), MMF=mycophenolate (red)

Conclusion

Patients with active SSc-ILD receiving one year of immunosuppressive therapy in the SLS II study experienced reductions in their CRP and IL-6 levels over this interval. The magnitude of the decrease in CRP and IL-6 over the first year also correlated with the course of FVC over the ensuing 12 months. These findings suggest a dynamic relationship between CRP and IL-6 measurements and the course of SSc-ILD in patients on immunosuppressive therapy. Further investigation of these findings is warranted.

References

[1]Liu et al. Arthritis Care Res 2013.

[2]Tashkin et al. Lancet Resp Med 2016.

Disclosure of Interests

Elizabeth Volkmann Speakers bureau: Boehringer Ingelheim, Consultant of: Boehringer Ingelheim, Grant/research support from: Forbius, Kadmon, Horizon, Boehringer Ingelheim, Donald Tashkin: None declared, Holly Wilhalme: None declared, Marka Lyons: None declared, Grace Kim: None declared, Jonathan Goldin: None declared, Michael Roth Grant/research support from: Genentech, Shervin Assassi Consultant of: Boehringer Ingelheim

POS0852 SYMPTOMS OF GASTROESOPHAGEAL REFLUX ARE A BETTER PREDICTOR OF SYSTEMIC SCLEROSIS-RELATED INTERSTITIAL LUNG DISEASE PROGRESSION THAN QUANTITATIVE RADIOGRAPHIC ASSESSMENT OF ESOPHAGEAL PARAMETERS

Background

Esophageal dysfunction affects the majority of patients with systemic sclerosis (SSc). Gastroesophageal reflux (GERD)-associated microaspiration may serve as an inciting and/or exacerbating factor in the pathogenesis of interstitial lung disease (ILD) in SSc. Few studies have investigated the relationship between objective measures of esophageal involvement in SSc and the progression of SSc-ILD.

Objectives

(1) To investigate whether patient-reported symptoms of GERD predict SSc-ILD severity and progression; (2) To explore whether quantitative radiographic measurements of esophageal parameters predict SSc-ILD severity and progression.

Methods

Participants of Scleroderma Lung Study (SLS) II (24 months of mycophenolate versus 12 months cyclophosphamide followed by 12 months of placebo in patients with active SSc-ILD) were included.1 The UCLA SCTC GIT 2.0 was used to assess the severity of reflux at baseline. Quantitative image analysis was used to calculate the diameter and area of the esophagus in the area of maximum dilation. Univariate and multivariable linear regression analyses were used to evaluate the relationship between baseline reflux scores/esophageal parameters and the severity and progression of SSc-ILD based on the quantitative radiographic extent of ILD (QILD) and fibrosis (QLF) in the lobe of maximum involvement (LM). All multivariable models controlled for treatment arm and baseline ILD severity, as well as proton pump inhibitor (PPI) use.

Results

Among the 141 of 142 SLS II participants with patient-reported reflux scores at baseline, the mean score was 0.57, indicating moderate reflux. The mean maximal esophageal diameter and area at baseline were 22 mm and 242 mm2, respectively. There were no significant correlations between reflux scores, esophageal diameter, esophageal area and QILD-LM and QLF-LM at baseline. However, in the 96 participants with HRCT scans available at 24 months, increased reflux scores were significantly associated with worsening of QLF-LM and QILD-LM (Figure 1). Even after controlling for disease severity at baseline, treatment arm and PPI use, reflux scores remained significantly associated with change in QLF-LM (P-value 0.05) and QILD-LM (P-value 0.003). Neither the maximum esophageal area, nor the maximum esophageal diameter was associated with the change in QILD-LM or QLF-LM in univariate or multivariate analyses.

Figure 1.

Increased reflux scores at baseline are associated with increased progression (worsening) of QILD (A) and QLF (B) in the lobe of maximum involvement in patients with SSc-ILD.

Conclusion

Increased self-reported reflux was independently associated with worsening radiographic fibrosis and ILD in patients receiving treatment for SSc-ILD. The maximum esophageal diameter and esophageal area did not correlate with reflux scores and did not predict severity or progression of SSc-ILD. These findings illustrate the importance of eliciting a careful patient history of reflux symptoms in patients with ILD and further highlight the need for improved objective measures of esophageal dysfunction in SSc.

References

[1]Tashkin et al. Lancet Resp Med 2016.

Disclosure of Interests

Elizabeth Volkmann Speakers bureau: Boehringer Ingelheim, Consultant of: Boehringer Ingelheim, Grant/research support from: Forbius, Horizon, Kadmon, Boehringer Ingelheim, Donald Tashkin: None declared, Mei Leng: None declared, Grace Kim: None declared, Jonathan Goldin: None declared, Michael Roth Grant/research support from: Genentech

Transport of an intense proton beam from a cone-structured target through plastic foam with unique proton source modeling

Laser-accelerated proton beams are applicable to several research areas within high-energy density science, including warm dense matter generation, proton radiography, and inertial confinement fusion, which all involve transport of the beam through matter. We report on experimental measurements of intense proton beam transport through plastic foam blocks. The intense proton beam was accelerated by the 10ps, 700J OMEGA EP laser irradiating a curved foil target, and focused by an attached hollow cone. The protons then entered the foam block of density 0.38g/cm^{3} and thickness 0.55 or 1.00mm. At the rear of the foam block, a Cu layer revealed the cross section of the intense beam via proton- and hot electron-induced Cu-K_{α} emission. Images of x-ray emission show a bright spot on the rear Cu film indicative of a forward-directed beam without major breakup. 2D fluid-PIC simulations of the transport were conducted using a unique multi-injection source model incorporating energy-dependent beam divergence. Along with postprocessed calculations of the Cu-K_{α} emission profile, simulations showed that protons retain their ballistic transport through the foam and are able to heat the foam up to several keV in temperature. The total experimental emission profile for the 1.0mm foam agrees qualitatively with the simulated profile, suggesting that the protons indeed retain their beamlike qualities.

Absolute calibration of Fujifilm BAS-TR image plate response to laser driven protons up to 40 MeV

Image plates (IPs) are a popular detector in the field of laser driven ion acceleration, owing to their high dynamic range and reusability. An absolute calibration of these detectors to laser-driven protons in the routinely produced tens of MeV energy range is, therefore, essential. In this paper, the response of Fujifilm BAS-TR IPs to 1-40 MeV protons is calibrated by employing the detectors in high resolution Thomson parabola spectrometers in conjunction with a CR-39 nuclear track detector to determine absolute proton numbers. While CR-39 was placed in front of the image plate for lower energy protons, it was placed behind the image plate for energies above 10 MeV using suitable metal filters sandwiched between the image plate and CR-39 to select specific energies. The measured response agrees well with previously reported calibrations as well as standard models of IP response, providing, for the first time, an absolute calibration over a large range of proton energies of relevance to current experiments.

Retinal vascular occlusion in pregnancy: three case reports and a review of the literature

Background

Retinal arterial occlusive events in young patients are rare. However, because of physiological multifactorial adaptations during pregnancy, retinal vascular occlusive disease may occur spontaneously. In addition, a patent foramen ovale is a risk factor for an ischemic thromboembolic event. Since fluorescein angiography, a central tool in the evaluation of these occlusions, should be avoided during pregnancy, optical coherence tomography angiography, a novel technique, offers a good opportunity for visualizing vascular perfusion of retinal tissue.

Case presentation

Here we present a case series of three patients (Caucasian, nonsmoker) who visited our clinic owing to acute visual impairment and central scotoma. Using regular optical coherence tomography and optical coherence tomography angiography, retinal vascular occlusions were detected, thus initiating the evaluation of systemic risk factors. We report two patients (30 and 32 years old) who developed cilioretinal artery occlusion but whose etiology differed: one was of thromboembolic origin associated with patent foramen ovale, while the other was caused by hemodynamic blockade secondary to central retinal vein occlusion. In both cases, optical coherence tomography angiography revealed reperfusion of the cilioretinal artery occlusion. However, transient ischemia led to retinal atrophy after a few weeks. In the third patient (32 years old), 8 weeks after onset of scotoma, optical coherence tomography angiography revealed atrophy of the middle layers and impaired perfusion in the deep capillary plexus, and thus a paracentral acute middle maculopathy was diagnosed. All patients regained normal visual acuity and had otherwise uncomplicated pregnancies, and laboratory blood tests did not reveal any defects or alterations.

Conclusions

As shown here, optical coherence tomography angiography enables risk-free imaging of retinal vessel perfusion during pregnancy. Together with regular optical coherence tomography, it allows one to predict functional outcome according to the existing retinal occlusion-related atrophy.

[Current and future effects of climate change on ophthalmology]

BACKGROUND AND OBJECTIVES

Climate change is also an increasingly important issue in the healthcare system. Due to its anatomical and physiological nature, the eye is directly exposed to environmental influences and changes in a special way.

METHODS

The current literature is used to illustrate the effects of climate-induced changes and the respective influences on the eye. A PubMed search (cut-off date 3 October 2021) using the search terms "climate change" or "planetary health" or "global health" and in each case "ophthalmology" or "eye" or "ocular" was used to determine the development of the number of publications between 2011 and 2021.

RESULTS

Measurable effects of climate change are already evident in a wide variety of ophthalmological fields. The significance of this topic, for instance, is reflected in a relatively constant increase in the number of publications and an almost tenfold increase in the number of publications per year from 2011 to 2021.

CONCLUSION

The impact of climate change on eye diseases and on the field of ophthalmology is multifaceted and could be expected to intensify in the coming years. Therefore, the interrelationships need to be further investigated in future studies, preferably on a large scale.

Urban Water Storage Capacity Inferred From Observed Evapotranspiration Recession

Water storage plays an important role in mitigating heat and flooding in urban areas. Assessment of the water storage capacity of cities remains challenging due to the inherent heterogeneity of the urban surface. Traditionally, effective storage has been estimated from runoff. Here, we present a novel approach to estimate effective water storage capacity from recession rates of observed evaporation during precipitation-free periods. We test this approach for cities at neighborhood scale with eddy-covariance based latent heat flux observations from 14 contrasting sites with different local climate zones, vegetation cover and characteristics, and climates. Based on analysis of 583 drydowns, we find storage capacities to vary between 1.3 and 28.4 mm, corresponding to e-folding timescales of 1.8-20.1 days. This makes the urban storage capacity at least five times smaller than all the observed values for natural ecosystems, reflecting an evaporation regime characterized by extreme water limitation.

Well-being of Canadian Armed Forces Veterans and Spouses of Veterans During the COVID-19 Pandemic: Protocol for a Prospective Longitudinal Survey

BACKGROUND

The COVID-19 pandemic has resulted in significant changes to everyday life, including social distancing mandates, changes to health care, and a heightened risk of infection. Previous research has shown that Canadian Armed Forces (CAF) veterans are at higher risk of developing mental and physical health conditions. Veterans and their families may face unique social challenges that can compound with pandemic-related disruptions to negatively impact well-being.

OBJECTIVE

This study aims to longitudinally characterize the mental health of CAF veterans and spouses of CAF veterans throughout the pandemic and to understand the dynamic influences of pandemic-related stressors on psychological health over time.

METHODS

We employed a prospective longitudinal panel design using an online data collection platform. Study participation was open to all CAF veterans and spouses of CAF veterans residing in Canada. Participants were asked to complete a comprehensive battery of assessments representing psychological well-being, chronic pain, health care access patterns, physical environment, employment, social integration, and adjustment to pandemic-related lifestyle changes. Follow-up assessments were conducted every 3 months over an 18-month period. This study was approved by the Western University Health Sciences and Lawson Health Research Institute Research Ethics Boards.

RESULTS

Baseline data were collected between July 2020 and February 2021. There were 3 population segments that participated in the study: 1047 veterans, 366 spouses of veterans, and 125 veterans who are also spouses of veterans completed baseline data collection. As of November 2021, data collection is ongoing, with participants completing the 9- or 12-month follow-up surveys depending on their date of self-enrollment. Data collection across all time points will be complete in September 2022.

CONCLUSIONS

This longitudinal survey is unique in its comprehensive assessment of domains relevant to veterans and spouses of veterans during the COVID-19 pandemic, ranging from occupational, demographic, social, mental, and physical domains, to perceptions and experiences with health care treatments and access. The results of this study will be used to inform policy for veteran and veteran family support, and to best prepare for similar emergencies should they occur in the future.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/34984.

Well-being of Canadian Veterans during the COVID-19 pandemic: cross-sectional results from the COVID-19 Veteran well-being study

BACKGROUND

The impacts of the COVID-19 pandemic have disproportionally affected different population groups. Veterans are more likely to have pre-existing mental health conditions compared to the general Canadian population, experience compounded stressors resulting from disruptions to familial, social, and occupational domains, and were faced with changes in health-care delivery (e.g. telehealth). The objectives of this study are to assess (a) the mental health impact of COVID-19 and related life changes on the well-being of Veterans and (b) perceptions of and satisfaction with changes in health-care treatments and delivery during the pandemic.

METHODS

A total of 1136 Canadian Veterans participated in an online survey. Participants completed questions pertaining to their mental health and well-being, lifestyle changes, and concerns relating to the COVID-19 pandemic, as well as experiences and satisfaction with health-care treatments during the pandemic.

RESULTS

Results showed that 55.9% of respondents reported worse mental health functioning compared to before the pandemic. The frequency of probable posttraumatic stress disorder, major depressive disorder, generalized anxiety disorder, alcohol use disorder, and suicidal ideation were 34.2%, 35.3%, 26.8%, 13.0%, and 22.0%, respectively. Between 38.6% and 53.1% of respondents attributed their symptoms as either directly related to or exacerbated by the pandemic. Approximately 18% of respondents reported using telehealth for mental health services during the pandemic, and among those, 72.8% indicated a choice to use telehealth even after the pandemic.

CONCLUSIONS

This study found that Veterans experienced worsening mental health as a result of the COVID-19 pandemic. The use of telehealth services was widely endorsed by mental health treatment-seeking Veterans who transitioned to virtual care during the pandemic. Our findings have important clinical and programmeadministrator implications, emphasizing the need to reach out to support veterans, especially those with pre-existing mental health conditions and to enhance and maintain virtual care even post-pandemic.

Depression and Anxiety as Mediators of PTSD Symptom Clusters and Pain in Treatment-Seeking Canadian Forces Members and Veterans

INTRODUCTION

Chronic pain (CP) commonly presents alongside psychiatric conditions such as depression, PTSD, and generalized anxiety. The current study sought to better understand this complex relationship by determining whether anxiety and depression symptom severity mediated the relationship between DSM-5 PTSD symptom clusters and pain symptoms in a sample of 663 Canadian Armed Forces (CAF) personnel and veterans seeking treatment for mental health conditions.

MATERIALS AND METHODS

Generalized anxiety disorder, depression, and PTSD symptom severity were measured using self-report scales provided as part of a standard intake protocol. Pain symptoms were measured using the Bodily Pain subscale of the SF-36 (SF-36 BPS). Linear regressions were used to explore the relationship between PTSD symptom clusters, depression, anxiety, and pain. Bootstrapped resampling analyses were employed to test mediation effects.

RESULTS

The average SF-36 BPS score in this sample was 36.6, nearly 1.5 SDs below the population health status, enforcing the salience of pain symptoms as a concern for veterans and CAF seeking treatment for military-related psychiatric conditions. The effects of PTSD symptom clusters avoidance, negative mood and cognitions, and arousal on pain were fully mediated by anxiety and depression severity. However, the effect of intrusion on pain was not mediated by depression and only partly mediated by anxiety.

CONCLUSION

Findings emphasize the importance of including anxiety and depression in models of PTSD and pain, particularly in samples where psychiatric comorbidity is high. Clinically, results highlight the need for improved treatment regimens that address pain symptoms alongside common psychiatric comorbidities.

Microstructured layered targets for improved laser-induced x-ray backlighters

We present the usage of two-layer targets with laser-illuminated front-side microstructures for x-ray backlighter applications. The targets consisted of a silicon front layer and copper back side layer. The structured layer was irradiated by the 500-fs PHELIX laser with an intensity above 10^{20}Wcm^{-2}. The total emission and one-dimensional extent of the copper Kα x-ray emission as well as a wide spectral range between 7.9 and 9.0 keV were recorded with an array of crystal spectrometers. The measurements show that the front-side modifications of the silicon in the form of conical microstructures maintain the same peak brightness of the Kα emission as flat copper foils while suppressing the thermal emission background significantly. The observed Kα source sizes can be influenced by tilting the conical microstructures with respect to the laser axis. Overall, the recorded copper Kα photon yields were in the range of 10^{11}sr^{-1}, demonstrating the suitability of these targets for probing applications without subjecting the probed material to additional heating from thermal line emission.

Frequently assessed and used prognostic factors for outcome after macular hole surgery: which is better?

BACKGROUND

The aim of this retrospective study was to evaluate commonly used clinical and OCT-morphological parameters, including perifoveal pseudocysts, as prognostic factors for postoperative outcome after macular hole surgery in a retinal referral clinic in North Rhine-Westphalia, Germany.

METHODS AND MATERIAL

This was a retrospective analysis of all patients who underwent surgery because of idiopathic MH between 2011 and 2017 in Augenklinik Tausendfensterhaus, Duisburg, Germany. Statistical evaluation of clinical and OCT-based parameters, including the areas of intraretinal pseudocysts, was conducted. The main statistical outcomes were surgical success and visual acuity. Only parameters with a highly significant correlation to the outcome parameters (postoperative visual acuity (VA); surgical success) in univariate analysis were entered in linear and logistic regression analyses.

RESULTS

A total of 189 eyes of 178 patients (71.4% female; mean age 67.5 ± 8.2 a) who underwent surgery because of MH were included. The overall closure rate was 86.8%. The mean best corrected VA increased from 0.7 ± 0.3 logMAR before surgery to 0.5 ± 0.3 logMAR (p < 0.0001). While several clinical and OCT-based parameters as well as calculated indices showed a significant correlation with the outcome measures, the regression analysis showed that the minimum linear diameter was the only parameter that both predicted surgical success (p = 0.015) and was correlated with postoperative VA (p < 0.001).

CONCLUSION

The minimum linear diameter serves as an easily assessed prognostic factor with the best predictive properties. This result is of great importance for clinical practice, as it simplifies the postsurgical prognosis.

Four Decades of Military Posttraumatic Stress: Protocol for a Meta-analysis and Systematic Review of Treatment Approaches and Efficacy

BACKGROUND

Over 85% of active members of the Canadian Armed Forces have been exposed to potentially traumatic events linked to the development of posttraumatic stress disorder (PTSD). At the time of transition to civilian life, as high as 1 in 8 veterans may be diagnosed with PTSD. Given the high prevalence of PTSD in military and veteran populations, the provision of effective treatment considering their unique challenges and experiences is critical for mental health support and the well-being of these populations.

OBJECTIVE

This paper presents the protocol for a meta-analysis and systematic review that will examine the effectiveness of treatment approaches for military-related PTSD.

METHODS

This PROSPERO-preregistered meta-analysis is being conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and Cochrane guidelines. A comprehensive search of the literature was conducted using the databases PsycInfo, Medline, Embase, CINAHL, and ProQuest Dissertation & Theses. Effect sizes will be computed based on changes in PTSD symptom scores over time across studies using validated PTSD scales. A multilevel meta-analysis will examine the overall effects, between-study effects, and within-study effects of available evidence for PTSD treatments in military populations. Effect sizes will be compared between pharmacotherapeutic, psychotherapeutic, and alternative/emerging treatment interventions. Finally, meta-regression and subgroup analyses will explore the moderating roles of clinical characteristics (eg, PTSD symptom clusters), treatment approaches (eg, therapeutic orientations in psychotherapy and alternative therapies and classifications of drugs in pharmacotherapy), as well as treatment characteristics (eg, length of intervention) on treatment outcomes.

RESULTS

The literature search was completed on April 14, 2021. After the removal of duplicates, a total of 12,002 studies were screened for inclusion. As of July 2021, title and abstract screening has been completed, with 1469 out of 12,002 (12.23%) studies included for full-text review. Full review is expected to be completed in the summer of 2021, with initial results expected for publication by early winter of 2021.

CONCLUSIONS

This meta-analysis will provide information on the current state of evidence on the efficacy and effectiveness of various treatment approaches for military-related PTSD and identify factors that may influence treatment outcomes. The results will inform clinical decision-making for service providers and service users. Finally, the findings will provide insights into future treatment development and practice recommendations to better support the well-being of military and veteran populations.

TRIAL REGISTRATION

PROSPERO CRD42021245754; https://tinyurl.com/y9u57c59.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/33151.

Analysis of laser-proton acceleration experiments for development of empirical scaling laws

Numerous experiments on laser-driven proton acceleration in the MeV range have been performed with a large variety of laser parameters since its discovery around the year 2000. Both experiments and simulations have revealed that protons are accelerated up to a maximum cut-off energy during this process. Several attempts have been made to find a universal model for laser proton acceleration in the target normal sheath acceleration regime. While these models can qualitatively explain most experimental findings, they can hardly be used as predictive models, for example, for the energy cut-off of accelerated protons, as many of the underlying parameters are often unknown. Here we analyze experiments on laser proton acceleration in which scans of laser and target parameters were performed. We derive empirical scaling laws from these parameter scans and combine them in a scaling law for the proton energy cut-off that incorporates the laser pulse energy, the laser pulse duration, the focal spot radius, and the target thickness. Using these scaling laws, we give examples for predicting the proton energy cut-off and conversion efficiency for state-of-the-art laser systems.

European Guidelines (S3) on diagnosis and management of mucous membrane pemphigoid, initiated by the European Academy of Dermatology and Venereology - Part II

This guideline has been initiated by the task force Autoimmune Blistering Diseases of the European Academy of Dermatology and Venereology, including physicians from all relevant disciplines and patient organizations. It is a S3 consensus-based guideline that systematically reviewed the literature on mucous membrane pemphigoid (MMP) in the MEDLINE and EMBASE databases until June 2019, with no limitations on language. While the first part of this guideline addressed methodology, as well as epidemiology, terminology, aetiology, clinical presentation and outcome measures in MMP, the second part presents the diagnostics and management of MMP. MMP should be suspected in cases with predominant mucosal lesions. Direct immunofluorescence microscopy to detect tissue-bound IgG, IgA and/or complement C3, combined with serological testing for circulating autoantibodies are recommended. In most patients, serum autoantibodies are present only in low levels and in variable proportions, depending on the clinical sites involved. Circulating autoantibodies are determined by indirect IF assays using tissue substrates, or ELISA using different recombinant forms of the target antigens or immunoblotting using different substrates. The major target antigen in MMP is type XVII collagen (BP180), although in 10-25% of patients laminin 332 is recognized. In 25-30% of MMP patients with anti-laminin 332 reactivity, malignancies have been associated. As first-line treatment of mild/moderate MMP, dapsone, methotrexate or tetracyclines and/or topical corticosteroids are recommended. For severe MMP, dapsone and oral or intravenous cyclophosphamide and/or oral corticosteroids are recommended as first-line regimens. Additional recommendations are given, tailored to treatment of single-site MMP such as oral, ocular, laryngeal, oesophageal and genital MMP, as well as the diagnosis of ocular MMP. Treatment recommendations are limited by the complete lack of high-quality randomized controlled trials.

Exploring the Well-being of Health Care Workers During the COVID-19 Pandemic: Protocol for a Prospective Longitudinal Study

BACKGROUND

Health care workers (HCWs) have experienced several stressors associated with the COVID-19 pandemic. Structural stressors, including extended work hours, redeployment, and changes in organizational mandates, often intersect with interpersonal and personal stressors, such as caring for those with COVID-19 infections; worrying about infection of self, family, and loved ones; working despite shortages of personal protective equipment; and encountering various difficult moral-ethical dilemmas.

OBJECTIVE

The paper describes the protocol for a longitudinal study seeking to capture the unique experiences, challenges, and changes faced by HCWs during the COVID-19 pandemic. The study seeks to explore the impact of COVID-19 on the mental well-being of HCWs with a particular focus on moral distress, perceptions of and satisfaction with delivery of care, and how changes in work structure are tolerated among HCWs providing clinical services.

METHODS

A prospective longitudinal design is employed to assess HCWs' experiences across domains of mental health (depression, anxiety, posttraumatic stress, and well-being), moral distress and moral reasoning, work-related changes and telehealth, organizational responses to COVID-19 concerns, and experiences with COVID-19 infections to self and to others. We recruited HCWs from across Canada through convenience snowball sampling to participate in either a short-form or long-form web-based survey at baseline. Respondents to the baseline survey are invited to complete a follow-up survey every 3 months, for a total of 18 months.

RESULTS

A total of 1926 participants completed baseline surveys between June 26 and December 31, 2020, and 1859 participants provided their emails to contact them to participate in follow-up surveys. As of July 2021, data collection is ongoing, with participants nearing the 6- or 9-month follow-up periods depending on their initial time of self-enrollment.

CONCLUSIONS

This protocol describes a study that will provide unique insights into the immediate and longitudinal impact of the COVID-19 pandemic on the dimensions of mental health, moral distress, health care delivery, and workplace environment of HCWs. The feasibility and acceptability of implementing a short-form and long-form survey on participant engagement and data retention will also be discussed.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/32663.

European guidelines (S3) on diagnosis and management of mucous membrane pemphigoid, initiated by the European Academy of Dermatology and Venereology - Part I

This guideline on mucous membrane pemphigoid (MMP) has been elaborated by the Task Force for Autoimmune Blistering Diseases of the European Academy of Dermatology and Venereology (EADV) with a contribution of physicians from all relevant disciplines and patient organizations. It is a S3 consensus-based guideline encompassing a systematic review of the literature until June 2019 in the MEDLINE and EMBASE databases. This first part covers methodology, the clinical definition of MMP, epidemiology, MMP subtypes, immunopathological characteristics, disease assessment and outcome scores. MMP describes a group of autoimmune skin and mucous membrane blistering diseases, characterized by a chronic course and by predominant involvement of the mucous membranes, such as the oral, ocular, nasal, nasopharyngeal, anogenital, laryngeal and oesophageal mucosa. MMP patients may present with mono- or multisite involvement. Patients' autoantibodies have been shown to be predominantly directed against BP180 (also called BPAG2, type XVII collagen), BP230, laminin 332 and type VII collagen, components of junctional adhesion complexes promoting epithelial stromal attachment in stratified epithelia. Various disease assessment scores are available, including the Mucous Membrane Pemphigoid Disease Area Index (MMPDAI), the Autoimmune Bullous Skin disorder Intensity Score (ABSIS), the 'Cicatrising Conjunctivitis Assessment Tool' and the Oral Disease Severity Score (ODSS). Patient-reported outcome measurements (PROMs), including DLQI, ABQOL and TABQOL, can be used for assessment of quality of life to evaluate the effectiveness of therapeutic interventions and monitor disease course.

Spatially resolved online particle detector using scintillators for laser-driven particle sources

Laser-based particle accelerators have been an active field of research for over two decades moving from laser systems capable of one shot every hour to systems able to deliver repetition rates in the Hz regime. Based on the advancements in laser technology, the corresponding detection methods need to develop from single to multiple use with high readout speed. Here, we present an online compact tracker of particles using scintillators with nine resolvable energy levels and a spatial resolution of 3.6 × 3.6 mm² over the whole active area. This paper describes the design and construction of the detector, which is based on pixellated scintillators embedded inside an absorber matrix. The scintillator pixels are fiberoptically coupled to a camera system for online readout and analysis. Calibration with a radioactive source and first experimental data measuring laser accelerated ions at the PHELIX laser at GSI, Darmstadt, Germany, are presented and discussed.

[Assessment of subjective risk of infection and willingness to vaccinate against SARS-CoV-2 among German ophthalmologists : Results of a survey by DOG and BVA]

BACKGROUND AND OBJECTIVE

After approval of the first COVID-19 vaccines in Germany, vaccination prioritization and vaccination preparedness are central topics in the discussion on strategies to end the pandemic. How ophthalmologists evaluate their risk of infection and whether they are willing to be vaccinated has not been investigated so far. The aim of this project was to assess the subjective rating of the risk of infection and the willingness to be vaccinated among German ophthalmologists.

METHODS

Data were collected by an anonymous online survey conducted by the Professional Association of Ophthalmologists in Germany (BVA) and the German Ophthalmological Society (DOG) under the auspices of the University Eye Hospital Düsseldorf. The questionnaire was open for participation from 22 January to 12 February 2021. The survey was addressed to all colleagues in ophthalmology.

RESULTS

A total of 1162 completed questionnaires were analyzed. On average, survey respondents rated their risk of infection as 7.5 ± 1.9 (scale of 1-10; 1 = very low risk, 10 = very high risk). Of the respondents 971 (83.6%) rated their risk of infection as higher compared to other disciplines and 92.9% (n = 1079) indicated they would be willing to be vaccinated.

CONCLUSION

The ophthalmologists interviewed consider their professional group to be exposed to an above-average risk of SARS-COV‑2 infection compared to other disciplines. They frequently criticized the prioritization ranking of the German Ministry of Health (BMG), which deviated from the suggestions of the Standing Vaccination Committee of Germany (STIKO). The willingness to be vaccinated was very high among the surveyed German ophthalmologists.

OP0268 TREATMENT STATUS AFFECTS HOW PULMONARY BIOMARKERS PREDICT PROGRESSION OF SYSTEMIC SCLEROSIS-RELATED INTERSTITIAL LUNG DISEASE

Background:

The course of interstitial lung disease (ILD) varies considerably in patients with systemic sclerosis (SSc), and no biomarkers have been found to consistently predict ILD progression in this population. Treatment may affect how a candidate biomarker correlates with improvement/worsening of SSc-ILD. We hypothesized that specific proteins recovered from bronchoalveolar lavage (BAL) would differentially predict progression of SSc-ILD based on whether a patient was receiving ILD therapy.

Objectives:

(1) To assess the relationship between 68 unique BAL proteins measured in participants of Scleroderma Lung Study (SLS) I1 and changes in radiographic extent of SSc-ILD; (2) To determine if treatment affects whether a specific protein predicts improvement or worsening of SSc-ILD.

Methods:

Bronchoscopy was performed on 144 of the 158 participants in SLS I (Cyclophosphamide [CYC] vs. placebo) with 103 BAL samples available for analysis. BAL was lyophilized, concentrated 10X and used in a multiplex protein analysis of 68 distinct cytokines, chemokines and growth factors. Quantitative imaging analysis (QIA) was used to calculate the extent of radiographic fibrosis (QLF) in the whole lung using HRCT of the chest at baseline and 12 months. Multivariable linear regression models were created to determine the key BAL proteins associated with change in QLF scores using a backward selection process adjusting for treatment arm and ILD severity. The bootstrap procedure was employed for internal validation.

Results:

A number of BAL proteins were significantly associated with change in QLF scores at 12 months; however, the directionality of these associations was often based on the presence/absence of treatment. For example, increased levels of granulocyte-macrophage colony-stimulating factor (GM-CSF), interleukin (IL)-1, monocyte chemoattractant protein (MCP)-3, chemokine ligand (CCL)-5, transforming growth factor (TGF)-β, hepatocyte growth factor (HGF), stem cell factor (SCF), IL-4, TGF-α, were associated with worse QLF scores in patients who received placebo; whereas, increased levels of these same proteins were associated with improved QLF scores in patients who received CYC (Figure). Increased levels of Fractalkine were associated with worse in QLF scores, and increased levels of IL-7 were associated with improved QLF scores, regardless of treatment arm. In the multivariable model adjusting for treatment arm and baseline severity of ILD, IL-1, MCP-3, surfactant protein C, IL-7, and CCL-5 were independently associated with change in QLF scores.

Figure 1.

Example of a specific BAL protein (GM-CSF) that predicts worse QLF scores in patients receiving placebo (Group B, Red dotted line) and improved QLF scores in patients receiving CYC (Group A, Blue solid line). Shaded areas represent 95% confidence intervals.

Conclusion:

Proteins that mediate both inflammation and fibrosis differentially affected progression of SSc-ILD based on treatment status. Higher levels of certain proteins predicted worsening of ILD in patients receiving placebo, but improvement in patients receiving CYC. Measuring these proteins could help to identify patients who: (1) are at risk for ILD progression, and (2) may preferentially benefit from treatment with immunosuppression.

References:

[1]Tashkin DP, et al. NEJM 2006.

Disclosure of Interests:

Elizabeth Volkmann Consultant of: Boehringer Ingelheim, Grant/research support from: Corbus, Forbius, Donald Tashkin: None declared, Mei Leng: None declared, Ning Li: None declared, Grace Kim: None declared, Jonathan Goldin: None declared, Airi Harui: None declared, Michael Roth Grant/research support from: Genentech/Roche

OP0267 SHORT-TERM CHANGES IN THE RADIOGRAPHIC EXTENT OF INTERSTITIAL LUNG DISEASE PREDICT LONG-TERM MORTALITY IN SYSTEMIC SCLEROSIS

Background:

The forced vital capacity (FVC) is often used as the primary endpoint in treatment trials for systemic sclerosis-interstitial lung disease (SSc-ILD), and while trends in FVC have been found to predict mortality in SSc-ILD,1,2 FVC measurements are also influenced by extra-pulmonary factors, such as cutaneous sclerosis, myopathy, and patient/technician effort. Change in the quantitative extent of ILD (QILD) on HRCT is an emerging endpoint in clinical trials; however, no studies have evaluated whether changes in radiographic extent ILD predict mortality in SSc-ILD.

Objectives:

To evaluate the relationship between changes QILD in the whole lung (WL) and long-term survival in patients who participated in the Scleroderma Lung Study (SLS) I3 and II.4

Methods:

SLS I randomized 158 SSc-ILD patients to 12 months of cyclophosphamide (CYC) vs. placebo. SLS II randomized 142 SSc-ILD patients to 12 months of CYC, followed by 12 months of placebo vs. 24 months of mycophenolate (MMF). QILD-WL scores were calculated at baseline and 12 months (SLS I) and 24 months (SLS II). Participants were followed for up to 12 (SLS I) and 8 years (SLS II). Using landmark survival analysis, Kaplan Meier curves were generated to compare survival between participants who had worse QILD-WL scores (≥2% increase) and those who had stable/improved QILD-WL scores (<2% increase). Cox proportional hazards models were created to determine whether the change in QILD-WL scores predicted survival after controlling other variables found to affect survival in these cohorts.

Results:

Among all the SLS I and II participants, 82 and 90 had follow up HRCT scans, respectively, and were included in these analyses. SLS I participants with an increase in QILD-WL scores of ≥2% at 12 months had significantly worse long-term survival (P= 0.01; Figure). Similarly, SLS II participants with an increase in QILD-WL scores of ≥2% at 24 months had significantly worse long-term survival (P= 0.019; Figure). After adjusting for baseline FVC, age, and modified Rodnan skin score (mRSS), an increase in QILD-WL scores of ≥2% remained associated with worse long-term survival in SLS I (trend: P=0.089) and SLS II (P=0.014).

Conclusion:

Progression of the radiographic extent of ILD of ≥2% was associated with worse long-term survival in two independent SSc cohorts with extensive long-term follow up. The findings provide compelling evidence that short-term changes in the radiographic extent of ILD may serve as a surrogate endpoint for mortality in patients with SSc.

References:

[1]Goh NS, et al. Arthritis Rheum 2017.

[2]Volkmann ER, et al. Ann Rheum Dis 2019.

[3]Tashkin DP, et al. NEJM 2006.

[4]Tashkin DP, et al. Lancet Resp Med 2016.

Disclosure of Interests:

Elizabeth Volkmann Consultant of: Boehringer Ingelheim, Grant/research support from: Forbius, Corbus, Donald Tashkin: None declared, Michael Roth Grant/research support from: Genentech/Roche, Jonathan Goldin: None declared, Grace Kim: None declared

Measurement of the Fluctuations in the Number of Muons in Extensive Air Showers with the Pierre Auger Observatory

We present the first measurement of the fluctuations in the number of muons in extensive air showers produced by ultrahigh energy cosmic rays. We find that the measured fluctuations are in good agreement with predictions from air shower simulations. This observation provides new insights into the origin of the previously reported deficit of muons in air shower simulations and constrains models of hadronic interactions at ultrahigh energies. Our measurement is compatible with the muon deficit originating from small deviations in the predictions from hadronic interaction models of particle production that accumulate as the showers develop.

[Cooperation between the department of ophthalmology at the University of Düsseldorf (Germany) and the Fundación Visión in Asunción (Paraguay) as an example of the German hospital partnerships programm]

BACKGROUND

A hospital partnership between the University Eye Hospital Düsseldorf (UAK Düsseldorf) and Fundación Visión in Asunción has existed since 2014 based on a memorandum of understanding. Fundación Visión plays a leading role in ophthalmological treatment and prevention of blindness in Paraguay. Since 2016 a program for the promotion of international hospital partnerships of the German government has been in place.

MATERIAL AND METHODS

Following a written application in 2016 the hospital partnership Düsseldorf-Asunción is funded by the Federal Ministry for Economic Cooperation in Germany. The aim of the project was to establish modern minimally invasive corneal transplantation techniques with faster postoperative rehabilitation and less follow-up in Paraguay with the help of several activities within a defined schedule. Secondary aims were to obtain first data on the prevalence of eye diseases in a typical patient cohort of the Fundación Visión and to establish an infrastructure for modern eye banking techniques in Paraguay.

RESULTS

First a Paraguayan surgeon was trained to carry out Descemet membrane endothelial keratoplasty (DMEK) transplantations in Germany. At the same time, the surgical instruments required for the DMEK technique were purchased and delivered to the Fundación Visión. In September 2018 the first lamellar corneal transplantations were successfully performed in Paraguay by the team from the Fundación Visión under the supervision of an experienced surgical team from Düsseldorf. Subsequently, the split cornea approach using a donor cornea for a posterior and an anterior lamellar keratoplasty (DMEK and DALK) was also implemented in Asunción. In November 2019 epidemiological data on eye diseases were collected during a field campaign of the Fundación Visión in a rural region of Paraguay. In the course of data collection an employee of the University Eye Hospital Düsseldorf learned small incision cataract surgery. In March 2019, a technician from the Fundación Visión was trained in Düsseldorf in corneal tissue culture techniques and preparation of amniotic membrane transplants in the Lions eye bank North-Rhine/Westfalia.

CONCLUSION

With the aid of a supported hospital partnership modern minimally invasive corneal transplantation techniques can be successfully transferred to the eye hospital of a developing country and in return surgical skills can be taught to surgeons from Germany who are in training. Therefore, an efficient hospital partnership is the basis for a mutual exchange and is not purely one-way traffic.

On the influence of magnetic topology on the propagation of internal gravity waves in the solar atmosphere

The solar surface is a continuous source of internal gravity waves (IGWs). IGWs are believed to supply the bulk of the wave energy for the lower solar atmosphere, but their existence and role for the energy balance of the upper layers is still unclear, largely due to the lack of knowledge about the influence of the Sun's magnetic fields on their propagation. In this work, we look at naturally excited IGWs in realistic models of the solar atmosphere and study the effect of different magnetic field topographies on their propagation. We carry out radiation-magnetohydrodynamic simulations of a magnetic field free and two magnetic models-one with an initial, homogeneous, vertical field of 100 G magnetic flux density and one with an initial horizontal field of 100 G flux density. The propagation properties of IGWs are studied by examining the phase-difference and coherence spectra in the kh - ω diagnostic diagram. We find that IGWs in the upper solar atmosphere show upward propagation in the model with predominantly horizontal field similar to the model without magnetic field. In contrast to that the model with predominantly vertical fields show downward propagation. This crucial difference in the propagation direction is also revealed in the difference in energy transported by waves for heights below 0.8 Mm. Higher up, the propagation properties show a peculiar behaviour, which require further study. Our analysis suggests that IGWs may play a significant role in the heating of the chromospheric layers of the internetwork region where horizontal fields are thought to be prevalent. This article is part of the Theo Murphy meeting issue 'High-resolution wave dynamics in the lower solar atmosphere'.

Re-expression of miR-200s in claudin-low mammary tumor cells alters cell shape and reduces proliferation and invasion potentially through modulating other miRNAs and SUZ12 regulated genes

Background

MicroRNAs are a class of non-coding RNAs that regulate gene expression through binding to mRNAs and preventing their translation. One family of microRNAs known as the miR-200 family is an important regulator of epithelial identity. The miR-200 family consists of five members expressed in two distinct clusters; the miR-200c/141 cluster and the miR-200b/200a/429 cluster. We have found that murine and human mammary tumor cells with claudin-low characteristics are associated with very low levels of all five miR-200s.

Methods

To determine the impact of miR-200s on claudin-low mammary tumor cells, the miR-200c/141 cluster and the miR-200b/200a/429 cluster were stably re-expressed in murine (RJ423) and human (MDA-MB-231) claudin-low mammary tumor cells. Cell proliferation and migration were assessed using BrdU incorporation and transwell migration across Matrigel coated inserts, respectively. miRNA sequencing and RNA sequencing were performed to explore miRNAs and mRNAs regulated by miR-200 re-expression while Enrichr-based pathway analysis was utilized to identify cellular functions modified by miR-200s.

Results

Re-expression of the miR-200s in murine and human claudin-low mammary tumor cells partially restored an epithelial cell morphology and significantly inhibited proliferation and cell invasion in vitro. miRNA sequencing and mRNA sequencing revealed that re-expression of miR-200s altered the expression of other microRNAs and genes regulated by SUZ12 providing insight into the complexity of miR-200 function. SUZ12 is a member of the polycomb repressor complex 2 that suppresses gene expression through methylating histone H3 at lysine 27. Flow cytometry confirmed that re-expression of miR-200s increased histone H3 methylation at lysine 27.

Conclusions

Re-expression of miR-200s in claudin-low mammary tumor cells alters cell morphology and reduces proliferation and invasion, an effect potentially mediated by SUZ12-regulated genes and other microRNAs.

Impacts of morally distressing experiences on the mental health of Canadian health care workers during the COVID-19 pandemic

BACKGROUND

Research is urgently needed to understand health care workers' (HCWs') experiences of moral-ethical dilemmas encountered throughout the COVID-19 pandemic, and their associations with organizational perceptions and personal well-being. This research is important to prevent long-term moral and psychological distress and to ensure that workers can optimally provide health services.

OBJECTIVE

Evaluate associations between workplace experiences during COVID-19, moral distress, and the psychological well-being of Canadian HCWs.

METHOD

A total of 1362 French- and English-speaking Canadian HCWs employed during the COVID-19 pandemic were recruited to participate in an online survey. Participants completed measures reflecting moral distress, perceptions of organizational response to the pandemic, burnout, and symptoms of psychological disorders, including depression, anxiety, and posttraumatic stress disorder (PTSD).

RESULTS

Structural equation modelling showed that when organizational predictors were considered together, resource adequacy, positive work life impact, and ethical work environment negatively predicted severity of moral distress, whereas COVID-19 risk perception positively predicted severity of moral distress. Moral distress also significantly and positively predicted symptoms of depression, anxiety, PTSD, and burnout.

CONCLUSIONS

Our findings highlight an urgent need for HCW organizations to implement strategies designed to prevent long-term moral and psychological distress within the workplace. Ensuring availability of adequate resources, reducing HCW risk of contracting COVID-19, providing organizational support regarding individual priorities, and upholding ethical considerations are crucial to reducing severity of moral distress in HCWs.

Features of the Energy Spectrum of Cosmic Rays above 2.5×10^{18} eV Using the Pierre Auger Observatory

We report a measurement of the energy spectrum of cosmic rays above 2.5×10^{18}  eV based on 215 030 events. New results are presented: at about 1.3×10^{19}  eV, the spectral index changes from 2.51±0.03(stat)±0.05(syst) to 3.05±0.05(stat)±0.10(syst), evolving to 5.1±0.3(stat)±0.1(syst) beyond 5×10^{19}  eV, while no significant dependence of spectral features on the declination is seen in the accessible range. These features of the spectrum can be reproduced in models with energy-dependent mass composition. The energy density in cosmic rays above 5×10^{18}  eV is [5.66±0.03(stat)±1.40(syst)]×10^{53}  erg Mpc^{-3}.

Development and Assessment of a Simulator for in Vivo Confocal Microscopy in Fungal and Acanthamoeba Keratitis

BACKGROUND AND PURPOSE

In vivo confocal microscopy (IVCM) is a non-invasive imaging technique that allows morphological analysis as a diagnostic approach of the cornea in real time, thus providing a suspected diagnosis of fungal or amoebic keratitis immediately, whereas culture or PCR require several days or even weeks. Since these infections are rare, it is difficult for ophthalmologists to gain the experience necessary to differentiate infection from normal findings or artefacts. The purpose of this project was to establish a simulator, on which physicians could practice as well as acquiring a database of IVCM images of fungal or amoebic keratitis and respective analyses.

PATIENTS AND METHODS

An IVCM simulator was set up with cadaver human corneas, infected with either acanthamoeba, candida or aspergillus. Twenty-one ophthalmologists were trained in IVC microscopy first in a Dry Lab, then practically on the simulator. For evaluation, the participants were asked to fill out a standardized questionnaire, with a pre- and post-course self-assessment.

RESULTS

The self-assessed theoretical and practical skills in differentiating infectious from non-infectious keratitis in IVCM significantly increased (p = 0.0001, p = 0.0002, respectively). The barrier to use this technique decreased (p = 0.0474).

CONCLUSION

A very simple protocol based on a model of ex vivo corneal mycotic and amoebic infections can be used to train novices in the structured approach and diagnostic use of IVCM for corneal infections.

SAT0286 BIOLOGICAL CORRELATES OF RADIOGRAPHIC FEATURES OF INTERSTITIAL LUNG DISEASE IN SYSTEMIC SCLEROSIS: AN IN DEPTH ANALYSIS OF BRONCHOALVEOLAR PROTEINS OF SCLERODERMA LUNG STUDY I PARTICIPANTS

Background:

Systemic sclerosis-related interstitial lung disease (SSc-ILD) involves a combination of inflammation, fibrosis and vascular pathology that is typically assessed on CT imaging as a mixture of ground-glass opacification (GGO) and fibrotic changes. We hypothesized that proteins recovered from bronchoalveolar lavage (BAL) could be used to probe the underlying pathobiology associated with GGO and fibrotic changes.

Objectives:

(1) To assess the relationship between 68 unique BAL proteins measured in participants of Scleroderma Lung Study (SLS) I1and radiographic and physiologic measures of ILD; (2) To identify inter-correlations among specific proteins to enlighten our understanding of how specific biological pathways contribute to SSc-ILD.

Methods:

Bronchoscopy was performed on 144 of the 158 participants in SLS I with 103 BAL samples available for analysis. BAL was lyophilized, concentrated 10X and used in a multiplex protein analysis for 68 different cytokines, chemokines and other factors. Kendall tau correlations were performed to assess the relationship between individual proteins and baseline measures of pulmonary function and quantitative CT scores for fibrosis, GGO and total ILD. Those proteins found to correlate significantly with at least 2 clinical measures of ILD were entered into a cluster analysis with inter-correlations expressed as a heatmap.

Results:

Significant correlations were observed between fibrosis scores and several biologic pathways including pro-fibrotic factors (transforming growth factor beta [TGF-β], platelet-derived growth factor [PDGF]), proteins involved in tissue remodeling (Matrix metallopeptidase [MMP]-1,7,8,9; Hepatocyte growth factor [HGF]), and those involved in monocyte/macrophage migration and activation (Monocyte chemoattractant protein [MCP]-1,3; macrophage colony-stimulating factor [MCSF]). These same pathways correlated with the diffusing capacity for carbon monoxide (DLCO). In contrast, GGO scores correlated primarily with immune and inflammatory mediators (interleukin [IL]-5,8,13,15, IL-1 receptor antagonist and interferon gamma) with only limited overlap to proteins that related to fibrosis. Vascular endothelial growth factor (VEGF) levels were lower in patients with more extensive GGO, fibrosis and diffusion impairment, suggesting that vascular changes are a central feature of SSc-ILD. Specific proteins were highly correlated with one another in a pattern suggesting biologically-related networks (Figure) that might provide additional insight regarding disease pathogenesis.

Conclusion:

Combining a diverse analysis of BAL proteins with the rich dataset available from SSc-ILD patients participating in SLS I, the study findings suggest the involvement of distinct biologic pathways, inter-related networks, and specific biologic signatures associated with unique radiographic features of ILD. The relationship of these factors to other SSc disease features, patient outcomes and as predictors of treatment responses will be studied in future analyses.

References:

[1]Tashkin DP, et al. NEJM 2006.

Figure.

Correlation heatmap of BAL proteins associated with at least 2 clinical measures of ILD in SSc patients. Absolute correlations are depicted, and darker colors signify stronger correlations.

Disclosure of Interests:

Elizabeth Volkmann Grant/research support from: Forbius, Corbus Pharmaceuticals, Consultant of: Boehringer Ingelheim, Forbius, Speakers bureau: Boehringer Ingelheim, Donald Tashkin: None declared, Ning Li: None declared, Grace Kim: None declared, Jonathan Goldin: None declared, Airi Harui: None declared, Michael Roth Grant/research support from: Genentech/Roche