Worse scores but similar patterns of disease activity: interpreting outcomes in women with axial spondyloarthropathy

OBJECTIVE

The aim of this study was to evaluate the impact of sex on disease activity in axial spondylitis (axSpA).

METHOD

Data were extracted from the Ankylosing Spondylitis Registry of Ireland (ASRI). In this cross-sectional study, patients were analysed on the basis of sex, with a series of comparison analyses performed.

RESULTS

Overall, 886 participants were enrolled in the ASRI [232 (26.2%) women, 644 (72.6%) men]. Females recorded significantly worse Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) (4.57 vs 3.83, p < 0.01) and Ankylosing Spondylitis Quality of Life questionnaire (ASQoL) (7.51 vs 6.12, p < 0.01) scores than males. There was a stronger correlation in the Bath Ankylosing Spondylitis Functional and Metrology Indices (BASFI and BASMI) in females (r_s = 0.619, p < 0.01) than in males (r_s = 0.572, p < 0.01). Analysis of factors in BASDAI revealed that the higher total scores in females compared to males were due not to any single component, but to worse scores in all six components of the BASDAI combined. Ranking of components by severity between sexes revealed identical ranking in four of the six components of the BASDAI.

CONCLUSIONS

Women with axSpA reported significantly worse disease activity, quality of life, and functional ability than men. However, the BASDAI capturedsimilar patterns of disease activity. Limitation of spinal mobility in women with axSpA corresponded to greater impairment in functional ability. Further evaluation of disease monitoring tools is required to ensure that disease activity is accurately captured in men and women with axSpA.

241 STOPPCASCADE: DEVELOPMENT OF A NOVEL EXPLICIT SCREENING TOOL FOR POTENTIALLY CLINICALLY RELEVANT PRESCRIBING CASCADES IN OLDER ADULTS

Background

Prescribing cascades represent an important, often underrecognized, element of problematic polypharmacy. Cascades occur when an Adverse Drug Event (ADE) is misinterpreted as a new medical condition, with the subsequent prescription of another, potentially inappropriate drug. Our objective was to develop and validate an explicit list of potentially clinically relevant prescribing cascades in older adults to facilitate the detection of more common and clinically important prescribing cascades and assist clinicians in medication review.

Methods

A structured literature search of PubMed, Cinahl and Google Scholar was undertaken. Search terms included Prescribing Cascades OR Cascades OR Cascade AND Older Adults OR Adults Over 65 OR Older People OR Gero* OR Geri*. We included adults aged ≥65 including studies in all settings i.e. community, hospital and residential care. We included all study designs including reviews, experimental and observational studies, case series and case reports. We also included published abstracts from scientific meetings in the literature search. Studies that didn’t include prescribing cascades in the abstract, studies with no access to full text article or English version of article and studies exclusively describing patients aged ≤65 were excluded. A physiological systems-based short-list was compiled with Anatomical Therapeutic Chemical codes identifying the initial prescribed drug (Drug A). Three assessment panellists (academic geriatricians) were asked to evaluate each individual published cascade and the accompanying evidence using a 5-point Likert scale to evaluate each cascade for inclusion/exclusion in the list. Potential cascades scored Likert 4 or 5 by 2 or 3 of the panellists were included in the final list.

Results

131 potential cascades were reviewed by the panel, 71 individual cascades were accepted, involving 41 drugs/drug classes.

Conclusion

The STOPPCascade list comprises 71 potentially important prescribing cascades in older adults. This novel explicit list is designed to identify potential prescribing cascades and to facilitate appropriate deprescribing.

242 FALLS-RISK INCREASING DRUGS AND FRAILTY IN OLDER ADULTS EXPERIENCING FALLS: A PROSPECTIVE OBSERVATIONAL STUDY

Background

Frailty characteristics such as compromised response to stressors and accumulation of deficits in physiological systems may leave frailer older adults at higher risk of falls, a leading cause of injury and injury-related mortality. One of the more prominent extrinsic risk factors for falls in older adults is the use of Falls-Risk Increasing Drugs (FRIDS). This study aims to examine the relationship between measured frailty and FRIDS in older people who have experienced a fall in the previous 12 months.

Methods

A prospective observational study was undertaken. Inclusion criteria were age ≥ 65 years and a history of falling in the preceding 12 months. Exclusion criteria were age &lt;65 years of age, inability to provide informed consent or participation declined. Medical chart and drugs Kardex review was carried out, followed by a short interview with the patient using a standardised data collection proforma. Frailty was measured using the Clinical Frailty Scale (CFS) and the point-prevalence of FRIDS was established using the STOPPFall screening tool.

Results

Results are presented for the first 100 participants: The mean (±standard deviation [SD]) age of study participants was 82.1 (±6.2), 63% were female. The prevalence of frailty measured using the CFS was 60% (CFS ≥5). The median number of falls in the previous 12 months was 3 (IQR 3). 82% of people who had fallen in the previous 12 months had ≥1 STOPPFall FRID. The difference between number of FRIDs in Frail vs Non-Frail people was not statistically significant.

Conclusion

Prescription of FRIDS was detected in over 4 out 5 older fallers. Structured medication review using the STOPPFall screening tool for older adults at risk of falls is one useful and easy way of detecting FRIDS with a view to deprescription. Measured frailty does not appear to increase the prevalence of FRIDS in older fallers.

67 TECHNOLOGY TO SUPPORT INDEPENDENT LIVING AT HOME: ONLINE SURVEY OF USER NEEDS AND REQUIREMENTS

Background

Technology can play a key role in supporting older adults to live independently at home. A User Needs and Requirements study including co-design workshops and an online survey was conducted to inform the development of a technological solution aimed at supporting older adults to remain living independently at home. The online survey component is reported here.

Methods

Eligibility criteria included that respondents were older adults living at home or caregiving stakeholders providing care to older adults at home e.g. family caregivers or health/social care professionals. Recruitment took place throughout Ireland through civil society organisations and age friendly networks in local councils. Quantitative and qualitative data were gathered from June to July 2020. Descriptive statistics were applied to quantitative data and inductive thematic analysis was performed on free text responses.

Results

In total, 380 respondents completed the survey (n= 235 older adults, n=77 family caregivers, n=47 healthcare professionals and n=21 home support workers). Older adults identified key issues where technology might support them to live independently, these included, home security (33% n=77), falls (30% n=69), reduced mobility (23% n=55) and loneliness (23% n=54). Thematic analysis highlighted key areas where technology could assist stakeholders in providing care for older adults living independently, these included, remote monitoring of family members (family caregivers), communication with clients (healthcare professionals) and falls (home support workers). Older adults reported that data privacy and the cost of technology were key concerns. All groups reported a high level of willingness to use technology such as ambient sensors, wearable devices and voice activated assistants to support independent living.

Conclusion

Results of this survey provide insights into user needs and requirements in combination with results from co-design workshops to inform the design, development and trial of a technology system to support independent living at home.

181 UNDERSTANDING OLDER ADULTS’ PERCEPTIONS AND EXPERIENCES OF NOVELTY: A PILOT STUDY

Background

Our institution is currently developing a technology solution to support adults to live well at home for longer. As the system develops, there is an emerging emphasis on strict structure/routine in older adults’ activities of daily living. In contrast, engagement in novel experiences is widely endorsed as a buffer against cognitive decline. Despite this, there is scant research into the perceptions and experiences of novelty in older adults. Understanding older adults’ views on novelty is necessary to inform the advancement of the current project.

Methods

A multiple-methods, exploratory approach was used. A 90-minute focus group was held with 4 older adults to explore their conceptualisations of novelty, discussing what constitutes a novel experience and gauging the value placed on routine and novelty in daily life. Questionnaires measuring Mental Well-Being (MWB), personality, Novelty-Need Satisfaction (NNS), and preference for routine were subsequently completed by each participant.

Results

Four main themes emerged from the qualitative data. They comprised the contrast between planned and unplanned novel experiences, the influence of context on the enjoyment of novelty, the value of the vicarious experience of novelty and the challenge associated with change at a social/global level. The quantitative data revealed that 91.9% of the variation in MWB is attributed to its relationship with NNS.

Conclusion

The focus group served as a strong foundation; especially into the contextual influence of both internal (psychological/attitude-related) and external (environmental/social) factors upon the enjoyment of novelty; as well as indicating that further research is merited into the contrasting views on planned and unplanned novel experiences. The quantitative data corroborate the importance of maintaining novelty in older age. Understanding how to preserve novelty while supporting routines will allow assistive technology projects such as this, to adopt a holistic approach and encourage consideration for this aspect of life, often neglected in the lives of older adults.

POS0999 HIGHER CARDIOVASCULAR MORBIDITY SEEN IN MEN WITH LONGER DELAY TO THE DIAGNOSIS OF AXIAL SPONDYLOARTHRITIS

Background

Diagnostic delay in axial spondyloarthritis (axSpA) is a well-defined feature of the disease, despite increased awareness. Morbidity and mortality are higher in axSpA than the general population1. Much of this excess burden is due to increased comorbidity. However, the association between delayed diagnosis and increased comorbidity in this population is unknown.

Objectives

(1)Examine the relationship between delayed diagnosis and comorbidity in a large cohort of well characterised individuals with axSpA

(2)Assess the impact of sex on the relationship between diagnostic delay and comorbidity.

Methods

The Ankylosing Spondylitis Registry of Ireland (ASRI), a descriptive epidemiological study of the Irish axSpA population, provided the cohort for this study. A standardised clinical assessment was performed on each patient. Delay to diagnosis was calculated as age at diagnosis minus age at symptom onset. Comorbidities were considered as any condition present in addition to axial SpA, excluding extra-musculoskeletal manifestations (EMM). SPSS was used for statistical analysis, with appropriate tests used for normally and non-normally distributed data.

Results

Of the 913 included patients, 659 (72%) were male and mean age was 46 years (SD 13). Detailed baseline clinical and demographic characteristics are outlined in Table 1. Median delay to diagnosis was 5 (2, 12) years. Comorbidity was present in 37% (n=341) of the cohort, with hypertension the most prevalent (see Figure 1).

Table 1.

Baseline demographic and clinical characteristics

VariableAge, mean (SD)45.8 (12.6)Female, n (%)254 (27.8)Caucasian, n (%)819 (96.5)Ever Smoker, n (%)*527 (57.7)HLA-B27 positive, n (%)631 (89.9)Disease duration, median (25th,75th)17.1 (9.5, 27.8)Delay to diagnosis, median (25th, 75th)5.0 (2.0, 12.0)AAU, n (%)308 (34.4)PsO, n (%)150 (16.7)IBD, n (%)96 (10.7)Biologic use, n (%)628 (68.5)BASMI, mean (SD)3.6 (2.1)BASFI, mean (SD)3.4 (2.9)BASDAI, mean (SD)3.9 (2.4)HAQ, median (25th, 75th)0.38 (0.0, 0.9)

The median delay to diagnosis was significantly longer in those with ≥1 comorbidity compared to those with none (7 v 5 years, p<0.01). Hypertension (6 v 5 years, p=0.1) and cerebrovascular disease (10 v 5 years, p=0.03) were associated with a significantly longer delay to diagnosis, with a similar trend seen in those with hyperlipidaemia (7 v 5 years, p=0.09) and ischaemic heart disease (10 v 5 years, p=0.07). The delay to diagnosis was also longer in those that currently (7 v 5 years, p=0.03) or ever smoked (6 v 5 years, p<0.01). The delay to diagnosis was significantly longer in those with depression (9 v 5, p<0.05). The presence of EMM did not contribute to a delay to diagnosis, and there was no association with any categories of medication.

There was no significant difference in the median delay to diagnosis between females (5 v 6 years) for males. However, there were differences in the relationship between delay to diagnosis and the pattern of comorbidities between sexes. There was a significantly (p<0.05) longer delay to diagnosis in men with cerebrovascular disease (12 v 6 years), ischaemic heart disease (10 v 6 years) and diabetes (10 v 6 years), which wasn’t evident in females. Depression was associated with a longer delay to diagnosis in males (10 v 6 years, p<0.05), but not females (6 v 5 years, p=0.5).

Conclusion

Delay to diagnosis of axSpA was associated with a higher prevalence of comorbidities. This was particularly evident in men, with higher cardiovascular morbidity in those with a longer delay to diagnosis. Further research is needed to determine if shortening the delay to diagnosis would reduce the burden of cardiovascular morbidity.

References

[1]Chaudhary et al. All-Cause and Cause-Specific Mortality in Psoriatic Arthritis and Ankylosing Spondylitis: A Systematic Review and Meta-Analysis. Arthritis Care Res. 2021 Nov 17 (online).

Disclosure of Interests

None declared

POS1001 CURRENT SMOKING IS ASSOCIATED WITH LOWER RISK OF UVEITIS AND PERIPHERAL ARTHRITIS IN MALES WITH AXIAL SPONDYLOARTHRITIS

Background

The associations between smoking and extra-axial manifestations of axial spondyloarthritis (axSpA) are inadequately described. Previous observational studies have demonstrated smoking as protective against some but not other manifestations. However, the impact of sex on these associations is unknown.

Objectives

Using a large descriptive epidemiological dataset, we performed a sex-stratified analysis of the association between smoking status and extra-axial manifestations in axSpA.

Methods

This study was carried out within the framework of ASRI (Ankylosing Spondylitis Registry of Ireland), a descriptive epidemiological study of the axSpA population of Ireland. A standardised clinical assessment was performed on each patient, collecting demographic and clinical data. Smoking status was characterised as current, previous or never. The number of cigarettes per day, plus number of years smoking was also collected. Data on the following extra-axial manifestations was collected: arthritis, enthesitis, dactylitis, acute anterior uveitis (AAU), psoriasis (PsO), inflammatory bowel disease (IBD). Standardised measures of disease severity were also collected. Separate logistic regression models were used to define the association between extra-axial manifestations and smoking, controlling for potential confounders. SPSS was used for statistical analysis.

Results

Smoking data was available for 913 out of the 917 axSpA individuals with data in ASRI (mean age 46 (SD 13) years, disease duration 19 (SD 12) years, 72% male, 97% Caucasian). Twenty eight percent (n=259) were current smokers, 29% (n=268) were past smokers and 42% (n=386) were never smokers. Of the current smokers, the mean number of cigarettes per day was 12 (SD 7) and number of years smoking was 22 (SD 12). Thirty one percent had peripheral arthritis, 7% had dactylitis, 18% had enthesitis, 34% had AAU, 17% had psoriasis and 11% had IBD.

Current smokers had a significantly lower prevalence of arthritis and uveitis than past or non-smokers (see Table 1). A sex-stratified analysis was performed. There was no association between smoking status and any extra-axial manifestation in females. However, current smoking was associated with lower prevalence of arthritis in males compared to past or non-smokers (22% v 36% v 42%, p=0.002). A similar pattern was seen for uveitis, where male current smokers had a lower prevalence than non-smokers (24% v 38%, p=0.01). In contrast, psoriasis was more prevalent in men who were current smokers compared to non-smokers (18% v 12%, p=0.01), with no difference seen in females. There was no association with number of cigarettes smoked or number of years smoking.

Table 1.

Association between smoking status and extra-axial manifestations in axSpA.

AxSpA cohortCurrent smokerPast smokerNon-smokerArthritis30.9%22.4%a35.5%b33.3%bDactylitis6.7%5.5%a6.7% a7.4% aEnthesitis18.1%17.4% a16.2% a19.9% aUveitis34.3%27.4%a35.0%b38.6%bPsoriasis16.7%18.5% a19.3% a13.8% aInflammatory bowel disease10.7%9.9% a13.2% a9.5% a

Different subscript letters denote significant (p<0.05) differences between groups. Significant values highlighted in bold.

There was no association between smoking status and disease severity by subjective or objective measures, either for the cohort as a whole or by sex.

When compared to non- or ex-smokers and controlled for potential confounders including sex, age, biologic use, the association remained only between current smokers and lower risk of uveitis (OR 0.68, 95% CI 0.49 to 0.96) and arthritis (OR 0.62, 95% CI 0.43 to 0.88), in separate logistic regression models. The association between current smoking and increased prevalence of psoriasis in males did not remain significant once controlled for confounders (OR 1.10, 96% CI 0.73 to 1.65).

Conclusion

We demonstrated that current smoking is independently associated with a lower risk of uveitis and arthritis in males with axSpA, but not females. More research is needed to further investigate this paradoxical finding.

Disclosure of Interests

None declared

OP0013 LOSS OF SYNOVIAL TISSUE MACROPHAGE HOMEOSTASIS PRECEDES RHEUMATOID ARTHRITIS CLINICAL ONSET

Background

Synovial tissue macrophages significantly contribute to Rheumatoid Arthritis, yet the precise nature/function of macrophage subsets within the inflamed joint remains unexplored.

Objectives

To fully explore the spectrum of distinct macrophage activation states residing within the synovium of RA, at risk and healthy individuals.

Methods

Single-cell synovial tissue suspensions from RA (n=44), IAR (n=5), HC (n=11), PsA (n=11) and OA (n=4) were obtained, and synovial macrophage subsets examined by advanced multiparameter flow cytometric analysis, bulk RNA-sequencing, metabolic and functional assays.

Results

Multidimensional analysis identifies enrichment of CD206+CD163+ synovial-tissue macrophages co-expressing CD40 in the RA joint compared to healthy synovial-tissue, with frequency of CD206+CD163+CD40+ macrophages associated with increased disease activity and treatment response. In contrast, CX3CR1-expressing macrophages which form a protective barrier in healthy synovium are significantly depleted in RA. Importantly this signature of enriched CD40 expression coupled with depleted CX3CR1 expression is an early phenomenon, occurring prior to clinical manifestation of disease in individuals ‘at-risk’ of RA (IAR). RNAseq and metabolic profiling of sorted RA synovial-macrophages identified that this population is transcriptionally distinct, displaying unique inflammatory, phagocytic and tissue-resident gene signatures, paralleled by a bioenergetically stable profile as indicated by NAD(P)H emission. Functionally CD206+CD163+ RA macrophages are potent producers of pro-inflammatory mediators (reversed by CD40-signalling inhibition) and induce an invasive phenotype in healthy synovial-fibroblasts. These findings identify a distinct pathogenic population of synovial-tissue macrophage involved in shaping the immune response in RA. Crucially, this signature is present pre-disease representing a unique opportunity for early diagnosis and therapeutic intervention.

Conclusion

We have identified a novel population of tissue-resident macrophages in the RA synovium which are transcriptionally/metabolically distinct and capable of contributing to disease pathology. Uncovering the molecular patterns and cues that transform this immunoregulatory macrophage population into a dysfunctional inflammatory activation state may provide opportunities to reinstate joint homeostasis in RA patients.

Disclosure of Interests

Megan Hanlon: None declared, Mary Canavan: None declared, Nuno Neto: None declared, Qingxuan Song Employee of: Employee of Janssen Pharmaceuticals, Phil Gallagher: None declared, Ronan Mullan: None declared, Conor Hurson: None declared, Barry Moran: None declared, Michael Monaghan: None declared, Sunil Nagpal Employee of: Employee of Janssen Pharmaceuticals, Douglas Veale Consultant of: Janssen, Eli Lilly, Pfizer, Ursula Fearon Consultant of: Janssen, Eli Lilly, Pfizer

The relationship between physical activity, BMI, circadian rhythm, and sleep with cognition in bipolar disorder

BACKGROUND

Cognitive deficits affect a significant proportion of patients with bipolar disorder (BD). Problems with sustained attention have been found independent of mood state and the causes are unclear. We aimed to investigate whether physical parameters such as activity levels, sleep, and body mass index (BMI) may be contributing factors.

METHODS

Forty-six patients with BD and 42 controls completed a battery of neuropsychological tests and wore a triaxial accelerometer for 21 days which collected information on physical activity, sleep, and circadian rhythm. Ex-Gaussian analyses were used to characterise reaction time distributions. We used hierarchical regression analyses to examine whether physical activity, BMI, circadian rhythm, and sleep predicted variance in the performance of cognitive tasks.

RESULTS

Neither physical activity, BMI, nor circadian rhythm predicted significant variance on any of the cognitive tasks. However, the presence of a sleep abnormality significantly predicted a higher intra-individual variability of the reaction time distributions on the Attention Network Task.

CONCLUSIONS

This study suggests that there is an association between sleep abnormalities and cognition in BD, with little or no relationship with physical activity, BMI, and circadian rhythm.

243 MEASURED FRAILTY AND POTENTIALLY INAPPROPRIATE PRESCRIBING IN ACUTELY HOSPITALISED OLDER ADULTS: A PROSPECTIVE OBSERVATIONAL STUDY

Background

Frailty characteristics such as compromised response to stressors and accumulation of deficits in physiological systems may leave frailer older adults at higher risk of adverse outcomes from PIP, compared with their non-frail counterparts of the same age. This study aims to examine the relationship between measured frailty and potentially inappropriate prescribing in older adults presenting acutely to hospital.

Methods

A prospective observational study was conducted. Participants were acutely hospitalised older adults. Inclusion Criteria: Age ≥ 65 years old, acute admission &lt;72 hours, expected length of stay &gt;24 hrs. Exclusion Criteria: &lt;65 years of age, actively dying, direct admission to ICU, inability to provide informed consent and next of kin declined consent, patients in isolation for infection control purposes. Medical chart review was carried out, followed by a short interview using a standardised data collection proforma. Frailty was measured using the Clinical Frailty Scale and the Frail-VIG frailty index. Potentially Inappropriate Prescribing was identified using the STOPP/START criteria. Results are presented for the first 200 participants.

Results

The mean (±standard deviation [SD]) age of study participants was 79.25[±7.14], 56.5% were female. The prevalence of frailty measured using the CFS and Frail-VIG were 61.5% and 50.5% respectively. Applying the CFS, the mean number of STOPP criteria in non-frail patients was 1.03 and 1.87 for frail patients (p = 0.001 CI 95%) and 1.14 and 2.10 (p = 0.001 CI 95%) using the Frail-Vig Index.

Conclusion

Frailty is associated with functional decline, falls, hospitalisation and death. Frail patients had a higher mean number of STOPP criteria. As medication side effects are themselves included as part of the frailty syndrome, in-hospital medication review and patient centred medication optimisation should be guided by patient’s frailty status to reduce adverse outcomes.

The toll of unemployment in axial spondyloarthropathy: high prevalence and negative impact on outcomes captured in a national registry

OBJECTIVE

Axial spondyloarthropathy (axSpA) is an inflammatory arthritis of the axial skeleton. Persistent disease activity can result in significant disability and affect the ability to maintain employment. This study aimed to determine the prevalence of unemployment in axSpA and the impact on patient outcomes.

METHOD

Data from the Ankylosing Spondylitis Registry of Ireland (ASRI) were cleaned, and information on employment, demographics, and disease characteristics was extracted. Patients were analysed on the basis of employment and categorized as employed or unemployed.

RESULTS

Of the 759 participants included in the analysis, 23.5% (178) were unemployed, higher than national averages of 6.2-13.1% during the study period. Unemployed participants reported significantly worse Bath Ankylosing Spondylitis Disease Activity Index (BASDAI; 5.1 vs 3.6), Metrology Index (BASMI; 4.8 vs 3.4), Functional Index (BASFI; 5.2 vs 3.0), Health Assessment Questionnaire (HAQ; 0.82 vs 0.40), and Ankylosing Spondylitis Quality of Life (ASQoL; 9.4 vs 5.4) scores compared to employed (all p < 0.01). Male gender (odds ratio, 95% confidence interval: 2.65, 1.46-4.83), worse BASMI (1.16, 1.02-1.33), and worse HAQ scores (2.18, 1.13-4.19) were significantly associated with unemployment.

CONCLUSION

The prevalence of unemployment in axSpA patients is higher than in the general population, and is associated with worse quality of life, poorer levels of function, and higher levels of disease activity. Predictors of unemployment in axSpA were male gender, worse spinal mobility, and poorer level of function. Recognition of patients at risk of unemployment will improve opportunities for intervention and maintain participation in the workforce.

AB0018 ACCUMULATION OF FUNCTIONALLY MATURE CD1C+ DENDRITIC CELLS CONTRIBUTES TO SYNOVIAL INFLAMMATION IN INFLAMMATORY ARTHRITIS

Background:

Myeloid Dendritic Cells (DC) are potent antigen presenting cells that can be subdivided into CD141 and CD1c+ DC. We have previously reported an unacknowledged role for CD141+DC in the IA synovium. However, the identification and function of CD1c+ DC in the IA synovium has yet to be fully elucidated.

Objectives:

To investigate if CD1c+DC reside in the IA synovium and ascertain if they represent a unique population, distinct from peripheral CD1c+DC and if they contribute to synovial inflammation.

Methods:

Synovial tissue (ST) biopsies and synovial fluid mononuclear cells (SFMC) were obtained via arthroscopy and healthy control (HC) ST was obtained during ACL surgery. Synovial tissue single cells suspensions were generated following enzymatic and mechanical digestion. Single cell analysis of synovial tissue cell suspensions, along with PBMC and SFMC was performed by multicolour flow cytometry. CD1c+DC were sorted from IA synovial fluid and peripheral blood and bulk RNA sequencing was performed. CD1c+DC functionality and maturation was assessed using OVA DQ phagocytosis assays, multiplex ELISA and DC: T cell cocultures.

Results:

Within the circulation the frequency of CD1c+DC are significantly decreased in IA peripheral blood compared to HC (p<0.01) in addition to expressing significantly higher levels of the maturation markers CD80 (p<0.01) and CD40 (p=0.08). IA peripheral blood DC also express significantly higher levels of CXCR3 (p<0.01) and CCR7 (p<0.05) compared to HC - suggestive of DC migration from the periphery to the synovium. Following RNA-seq analysis, IPA and differentially expressed gene (DEG) analysis revealed an enrichment in genes involved in DC maturation, TLR signalling and chemokine signalling in IA peripheral blood compared to HC. In support of the hypothesis that DC migrate and accumulate in the IA synovium, CD1c+ DC were identified in IA ST and were significantly enriched compared to IA peripheral blood (p<0.01). IA ST CD1c+DC express significantly higher levels of the activation marker CD80 compared to IA peripheral blood (p<0.05) or HC ST (p<0.05). Upon examination of IA synovial fluid, we report similar findings to ST, whereby CD1c+DC are enriched in synovial fluid compared to PB (p<0.001). Moreover, RNA sequencing and PCA analysis of synovial versus blood CD1c+DC revealed distinct transcriptional variation between both sites. Functionally, synovial CD1c+DC express higher levels of the maturation markers CD80, CD83, CD40, PD-L1 and BTLA (all p<0.05) and have distinct coexpression of these maturation markers which is unique to the synovium. Synovial CD1c+DC are less phagocytic compared to peripheral blood DC, have decreased production of MMP1 and MMP9 and importantly are still capable of additional activation in-vitro. Finally, synovial CD1c+DC induce the proinflammatory cytokines TNFα, GMCSF, IL-17a and IFNγ from CD4+ T-cells in allogeneic DC: T cells cocultures.

Conclusion:

Mature circulatory CD1c+DC migrate and accumulate in the IA synovium. Synovial DC are present in the IA synovium in a mature state, have distinct tissue specific characteristics and can induce proinflammatory CD4+T cell responses.

Acknowledgements:

We would like to thank all the patients who contributed to this study

Disclosure of Interests:

Mary Canavan: None declared, Viviana Marzaioli: None declared, Vipul Bhargava Employee of: Janssen Research and Development, Sunil Nagpal Employee of: Janssen Research and Development, Phil Gallagher: None declared, Conor Hurson: None declared, Ronan Mullan: None declared, Douglas Veale Speakers bureau: Abbvie, Janssen, Novartis, Pfizer, MSD, UCB, Consultant of: Abbvie, Janssen, Novartis, Pfizer, MSD, UCB, Grant/research support from: Pfizer, Janssen, AbbVie, UCB, Ursula Fearon Speakers bureau: Abbvie, Grant/research support from: Pfizer, Janssen, Abbvie, UCB

OP0028 CD206+CD163+ PATHOGENIC MACROPHAGES ENRICHED IN RHEUMATOID ARTHRITIS SYNOVIAL TISSUE WITH DISTINCT TRANSCRIPTIONAL SIGNATURES

Background:

Synovial tissue macrophages are an exquisitely plastic pool of innate cells that play a key role in RA disease progression. However, the precise nature, diversity, and function of macrophage subsets within the inflamed joint remains unexplored.

Objectives:

Therefore, the aims of this study are to phenotypically, transcriptionally and functionally characterise synovial tissue macrophages residing within the inflamed joint.

Methods:

Rheumatoid Arthritis, Psoriatic Arthritis, Osteoarthritis and healthy control synovial-tissue biopsies and synovial-fluid mononuclear cells were analysed using the following panel (CD40,-CD45,-CD64,-CD68,-CD163,-CD206,-CD253,-CCR4,-CCR7,-CXCR1,-CXCR3). CD206+CD163+ and CD206-CD163- macrophages were sorted from RA synovial-tissue by FACSAria sorter; RNAseq and FLIM analysis, autologous T-cell co-culture and heathy fibroblast experiments performed. Cytokine expression was measured by MSD immunoassay.

Results:

RA synovial tissue and fluid macrophages display markers typical of both M1 (CD40+CD253+) and M2 (CD206+CD163+) macrophages with a spectrum of macrophage activation states identified. Within this spectrum, significant enrichment of dominant CD206+CD163+ macrophage-subtype is present in synovial tissue versus fluid (p<0.05). CD206+CD163+ synovial tissue macrophages express significantly more CD40 than synovial fluid (p<0.0003), positively correlate with disease activity (r=0.6, p<0.01), with baseline levels predicting response to therapy (p<0.05). Moreover, CD206+CD163+CD40+ macrophages are enriched in RA synovial tissue compared to PsA and OA pathotypes (p<0.05). While the CD206+CD163+ subset is present in healthy synovial tissue, expression of CD40 is completely absent in healthy synovium (p<0.05) with dramatically decreased expression of CX3CR1 on RA macrophages. RNA-seq analysis indicates that CD206+CD163+ population is transcriptionally distinct from synovial tissue CD206-CD163-, synovial fluid CD206+CD163+, and RA monocyte-derived M1/M2 macrophages, with unique tissue-resident gene signatures. Moreover, differing metabolic demands between CD206+CD163+ and CD206-CD163- subsets was demonstrated by RNAseq and FLIM analysis. CD206+CD163+ macrophages enhance autologous T-cell responses, spontaneously secrete high levels of pro-inflammatory cytokines and activate healthy fibroblasts towards pro-inflammatory mechanisms thus further contributing to the local inflammatory response. Finally, inhibition of CD40 activity abrogates the expression of pro-inflammatory mediators (TNFa, IL-1B, IL-6, IFNy) and induces IL-10 expression in sorted CD206+CD163+ synovial tissue-macrophages suggesting a key role for CD40 in driving this pathogenic phenotype.

Conclusion:

This data identifies for the first-time enrichment of a previously undescribed dysfunctional dominant and transcriptionally distinct macrophage subtype in RA synovial tissue. Taken together, this data provides a greater understanding of the critical role tissue-resident macrophages play in perpetuating inflammation in RA. Further investigation of the molecular patterns and cues that shape specific synovial macrophage subsets may provide opportunities to reinstate RA joint homeostasis.

Disclosure of Interests:

Megan Hanlon: None declared, Mary Canavan: None declared, Qingxuan Song Employee of: Janssen Research & Development, Nuno Neto: None declared, Phil Gallagher: None declared, Ronan Mullan: None declared, Conor Hurson: None declared, Michael Monaghan: None declared, Sunil Nagpal Employee of: Janssen Research & Development, Douglas Veale Speakers bureau: Abbvie, Janssen, Novartis, MSD, Pfizer, UCB, Consultant of: Abbvie, Janssen, Novartis, MSD, Pfizer, UCB, Grant/research support from: Janssen, Abbvie, Pfizer, UCB, Ursula Fearon Speakers bureau: Abbvie, Grant/research support from: Janssen, Abbvie, Pfizer, UCB

OP0051 LOOKING BEYOND BASDAI TOTAL SCORES: ANALYSIS OF THE BASDAI ON THE BASIS OF SEX

Background:

Females with axial spondyloarthropathy (axSpA) average scores on patient reported outcomes (PROs) than males. However, this does not necessarily correlate to worse clinical findings. The Ankylosing Spondylitis Registry of Ireland (ARSI) is a national registry on patients with axSpA in Ireland and a source of epidemiological data.

Objectives:

The purpose of this study was to compare the scores of each sex across the individual components of the BASDAI to understand why females report worse scores than males.

Methods:

Analysis of the ASRI was preformed using IBM SPSS version 26. Patients were analyzed on the basis of gender. Comparison of baseline characteristics and mean BASMI, BASFI, HAQ and ASQoL were tested for significance using an independent two tailed t-test and a Mann Whitney U test. Mean total BASDAI score and mean score for each component of the BASDAI were compared and tested for significance with the same statistical tests. A chi-squared test for independence was used to determine significance in variation of HLA-B27 status and radiographic findings.

Results:

A total of 857 patients were included in the analysis. Patient population was 24.9% (213) female and 75.1% (644) male with a mean age of 45.9 years and mean disease duration of 19.4 years (means: BASDAI 4.02, BASMI 4, BASFI 3.67, HAQ 0.53, ASQoL 6.48). Females had worse BASDAI(4.6 vs 3.83, p<0.01), HAQ(0.6 vs 0.51, p=0.03) and ASQoL scores (7.62 vs 6.12, p<0.01) than males. BASFI scores were worse in females which did not reach significance (3.89 vs 3.63, p=0.26). However, females had significantly better BASMI scores than males (3.51 vs 4.16, p<0.01). Within the BASDAI, females scored significantly worse than males across all components (Fatigue: 5.56 vs 4.51, p<0.01; Spinal pain: 5.51 vs 4.63, p<0.01; Other pain: 3.82 vs 3.19, p=0.01; Discomfort: 4.05 vs 3.29, p<0.01; EMS: 4.55 vs 3.94, p=0.01), however duration of EMS did not reach significance (3.54 vs 3.12, p=0.07)(graph 1). Within the BASDAI, females recorded highest mean scores for fatigue (5.56), while males recorded highest mean scores for spinal pain(4.63). Lowest mean scores for both genders was for EMS duration (3.54 vs 3.12). Ranking of the BASDAI components by mean scores show similarity in the ranking of discomfort, EMS, other pain and EMS duration(Table 1).

Table 1.

Ranking in order of severity by mean score

FemalesMales1 -most severeFatigueSpinal pain2Spinal PainFatigue3EMSEMS4DiscomfortDiscomfort5Other painOther pain6 -least severeEMS durationEMS durationGraph 1.

Breakdown of BASDAI scores in Females compared to Males

Conclusion:

AxSpA females have consistently worse PROs but have better spinal mobility than males. Despite females recording worse BASDAI scores than males, the pattern of active disease is similar in 4 of the 6 components of the BASDAI. However, fatigue is the most problematic symptom in females with active axSpA while spinal pain is the most problematic symptom for males. This variation by gender should be kept in consideration when evaluating a patient with suspected active axSpA.

References:

Disclosure of Interests:

Sinead Maguire Grant/research support from: Recipient of the Gilead Inflammation Fellowship, Phil Gallagher: None declared, Finbar Barry O’Shea: None declared

POS0462 ALCOHOL AND INFLAMMATORY ARTHRITIS DISEASE ACTIVITY: PERSPECTIVES FROM A 979-PATIENT COHORT WITH SYSTEMATIC REVIEW AND META-ANALYSIS

Background:

The effect of alcohol on disease activity in inflammatory arthritis remains poorly understood. Studies of alcohol and the incidence or risk of inflammatory arthritis are conflicting [1,2]. Alcohol does downregulate pro-inflammatory cytokines and may therefore reduce immune-mediated disease activity.

Objectives:

This study investigates the relationship between alcohol consumption and disease activity in our inflammatory arthritis patient cohort and performs a systematic review with meta-analysis.

Methods:

Cohort Study Design and data analysis

Patients attending a rheumatology clinic between 2010-2020 were prospectively followed. Information on demographics, alcohol use, smoking habits, and disease outcome measures were collected. Statistical analysis included univariate and multivariate linear and binary logistic regressions, Mann Whitney-U tests, and one-way ANOVA with Tukey’s HSD.

Meta-analysis

EMBASE, Pubmed, the Cochrane library, and Web of Science were searched. Studies reporting on alcohol consumption and disease activity in a cohort of RA patients were included for further investigation. Forest plots were generated from 95% confidence intervals of extracted data using mean differences. Linear regression was used to determine correlations between alcohol and antibody status, gender, and smoking status.

Results:

Cohort Study

Of the 979 analysed patients, 62% had RA, 26.7% had PsA, and 11.2% had AS. Mean DAS28-CRP in RA and PsA at one year was 2.96 ± 1.39, and 64.2% of patients were in remission (DAS28-CRP ≤ 2.6 or BASDAI ≤ 4). Both male gender and risky drinking (>15 units of weekly alcohol) were both significantly associated with remission. Compared to women, men had an odds ratio of 1.78 [1.04, 2.52] (p=0.034) for any alcohol consumption and 6.9 [4.7, 9.1] (p=0.001) for drinking at least 15 weekly drinks. when adjusted for gender, there was no significant association between alcohol and disease activity. Yet, when adjusted for alcohol consumption, gender still influenced disease activity.

Meta-analysis

The search identified 4126 citations of which 14 were included. The pooled mean difference in DAS28 (95% CI) was 0.34 (0.24,0.44) (p<10-5) between non-drinkers and drinkers, 0.33 (0.05,0.62) (p=0.02) between non-drinkers and heavy drinkers, and 0 (-0.3,0.3) (p=0.98). between low- and high-risk drinkers. There was a significant difference in the mean difference of HAQ assessments between those who drink alcohol compared to those who do not (0.3 (0.18,0.41), p<10-5). There was no significant correlation between drinking and gender, smoking status, or antibody positivity.

Conclusion:

While it appears that alcohol is linked to remission in inflammatory arthritis, this association is lost when adjusted for gender. Men with inflammatory arthritis drink significantly more than women and men generally have less severe disease activity. However, the meta-analysis suggests alcohol consumption is associated with lower disease activity and self-reported health assessment in rheumatoid arthritis.

References:

[1]Bae S-C, Lee YH. Alcohol intake and risk of rheumatoid arthritis: a Mendelian randomization study. Z Rheumatol 2019;78:791–6. doi:10.1007/s00393-018-0537-z

[2]Scott IC, Tan R, Stahl D, et al. The protective effect of alcohol on developing rheumatoid arthritis: a systematic review and meta-analysis. Rheumatology (Oxford) 2013;52:856–67. doi:10.1093/rheumatology/kes376

Figure 1.

Mean differences in DAS28 between drinking groups. A between non-drinkers and drinkers. B between non-drinkers and high-risk drinkers. C between low-risk and high-risk drinkers.

Disclosure of Interests:

None declared

POS0625 ASSOCIATIONS OF REMISSION AND PERSISTENCE OF BIOLOGICS AT 1 AND 12 YEARS

Background:

Biologic therapies have greatly improved outcomes in rheumatoid arthritis (RA) and psoriatic arthritis (PsA). Yet, our ability to predict long-term remission and persistence or continuation of therapy remains limited.

Objectives:

To compare RA and PsA outcomes at 1 and 12 years after commencing biologic DMARDs and to identify predictors of remission and persistence of therapy.

Methods:

RA and PsA patients were prospectively recruited from a biologic clinic. Outcomes on commencing therapy, at 1 year and 12 years were reviewed. Demographics, medications, morning stiffness, patient global health score, tender and swollen joint counts, antibody status, CRP and HAQ were collected. Outcomes at 1 and 12 years are reported and predictors of EULAR-defined remission (DAS28-CRP < 2.6) and biologic persistence are examined with univariate and multivariate analysis.

Results:

A total of 403 patients (274 RA and 129 PsA) were analysed. PsA patients were more likely to be male, in full-time employment and have completed higher education. PsA had higher remission rates than RA at both 1 year (60.3% versus 34.5%, p < 0.001) and 12 years (91.3% versus 60.6%, p < 0.001). This difference persisted when patients were matched for baseline disease activity (p < 0.001). Biologic continuation rates were high for RA and PsA at 1 year (49.6% versus 58.9%) and 12 years (38.2% versus 52.3%). In PsA, patients starting on etanercept had lower CRP at 12 years (p = 0.041). Multivariate analysis showed 1-year continuation [OR 4.28 (1.28–14.38)] and 1-year low-disease activity [OR 3.90 (95% CI 1.05–14.53)] was predictive of a 12-year persistence. Persistence with initial biologic at 12 years [OR 4.98 (95% CI 1.83–13.56)] and male gender [OR 4.48 (95% CI 1.25–16.01)] predicted 12 year remission.

Conclusion:

This is the first real world data to show better response to biologic therapy in PsA compared to RA at 12 years. Long-term persistence with initial biologic agent was high and predicted by biologic persistence and low-disease activity at 1 year. Interestingly, PsA patients had higher levels of employment, educational attainment, and long-term remission rates compared to RA patients.

Disclosure of Interests:

Kieran Murray Grant/research support from: Bresnihan Molloy and Newman Fellowships, Matthew Turk: None declared, Yousef Alammari: None declared, Francis Young: None declared, Phil Gallagher: None declared, Tajvur Parveen Saber: None declared, Ursula Fearon: None declared, Douglas Veale: None declared

POS0949 HIGH PREVALENCE OF ABDOMINAL OBESITY IN FEMALES WITH AXIAL SPONDYLOARTHROPATHY

Background:

Worldwide prevalence of obesity has been steadily increasing, despite significant public health campaigns to raise health awareness. In axial spondyloarthropathy (axSpA) obesity has been shown to be associated with higher levels of disease activity and decreased response to treatment. The waist to hip ratio (WtHpR) is a tool to screen for abdominal obesity. Abdominal deposition of adipose tissue is associated with increased risk of cardiovascular disease, type II diabetes and premature death. Abdominal obesity is more commonly found in males, while females are more prone to gluteal-femoral fat deposition. The Ankylosing Spondylitis Registry of Ireland (ASRI) is a source of epidemiological data of axSpA patients in Ireland.

Objectives:

To capture the prevalence of abdominal obesity in a large cohort of axSpA patients and assess for variation in prevalence between sexes.

Methods:

Participants were analysed on the basis of sex and presence of obesity by BMI and WtHpR. Obesity was defined by body mass index (BMI) with a result of >30 categorised as obese as per CDC definitions. Abdominal obesity was assessed by WtHpR and defined as per WHO guidelines. Categorical variables were recorded as frequencies, with a chi2 test for independence used to test for statistical significance. Numerical variables were recorded as means within each group and an independent t-test or Mann Whitney U test was used to test for statistical significance between groups. A p-value of <0.05 was deemed significant. IBM SPSS version 26 was used for statistical analysis of the patient population captured within the ASRI.

Results:

At the time of analysis, physical measurements were available on 692 patients in the ASRI made up of 96.2% (666) Caucasians with 22.3% (154) females and 77.7% (538) males. The average age was 45.9 years with a mean disease duration of 18.8 years (mean scores: BASDAI 4.09, BASFI 3.71, BASMI 3.99, HAQ 0.54, ASQoL 6.72). 80.9% (560) of patients had radiographic sacroiliitis while 49.1% (340) had sacroiliitis on MRI.

Overall 29.5% (215) patients were obese based on BMI results, while 37.5% (274) were centrally obese as per the WtHpR. Analysis on the basis of sex revealed no significant variation in mean BMI (28.1 vs 27.7, p=0.45) or prevalence of obesity as assessed by BMI (29.9% vs 28.6%, p=0.49) between males and females(table 1). As expected analysis of WtHpR revealed higher mean ratios in males compared to females (0.96 vs 0.89, p<0.01), however there was a significantly higher prevalence of abdominal obesity in females (29.9% vs 68.2%, p<0.01).

Table 1.

Assessment of Obesity by Sex

MalesFemalesp valuen77.7% (538)22.3% (154)Weight (kg)84.9872.76<0.01BMI28.0827.690.45Underweight0.9% (5)0.06% (1)0.49Normal Weight29.2% (157)36.4% (56)Overweight39.2% (211)34.4% (53)Obese29.9% (161)28.6% (44)Waist Circumference (cm)97.4390.03<0.01Hip Circumference (cm)102.11101.270.56Waist to Hip Ratio0.9560.8901<0.01Normal Weight23.8% (128)17.5% (27)<0.01Overweight46.3% (249)14.3% (22)Obese29.9% (161)68.2% (105)

Conclusion:

There is a high prevalence of abdominal obesity as assessed by WtHpR in axSpA, this is especially high in females with axSpA. Use of WtHpR should be considered when screening for obesity in this population.

Disclosure of Interests:

Sinead Maguire Grant/research support from: Recipient of the Gilead Inflammation fellowship grant, Phil Gallagher: None declared, Fiona Wilson: None declared, Finbar Barry O’Shea: None declared

POS0964 CHARACTERISTICS AND BURDEN OF DISEASE IN PATIENTS WITH RADIOGRAPHIC VERSUS NON-RADIOGRAPHIC AXIAL SPONDYLOARTHRITIS IN THE ANKYLOSING SPONDYLITIS REGISTRY OF IRELAND COHORT

Background:

Axial spondyloarthritis (axSpA) is an umbrella term for types of inflammatory arthritis that primarily affect the spine and the sacroiliac joints. It is comprised of patients with both radiographic (r-axSpA) and non-radiographic features (nr-axSpA). R-axSpA was historically known as Ankylosing Spondylitis. Previous studies have shown the burden of disease to be largely similar in patients with radiographic versus non-radiographic axial spondyloarthritis in cohorts both in the US and Europe [1]. The Ankylosing Spondylitis Registry of Ireland (ASRI) was formed with the objective to measure the burden of axial spondyloarthritis in the population and identify early predictors of a poor outcome. All patients in the registry are 18 years or older and meet Assessment of Spondyloarthritis International Society (ASAS) criteria for a diagnosis of SpA.

Objectives:

To compare the characteristics and burden of disease in patients with radiographic versus non-radiographic axial spondyloarthritis in the ASRI cohort.

Methods:

Patients with radiographic axial spondyloarthritis (r-axSpA) were defined as those with x-ray evidence of sacroiliitis. Patients with non-radiographic axial spondyloarthritis (nr-axSpA) were defined as having MRI evidence of sacroiliitis but no x-ray evidence of sacroiliitis. A standardised clinical assessment was performed on each patient and structured interviews provided patient-reported data. For each patient the following scores were captured: Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Bath Ankylosing Spondylitis Functional Index (BASFI), Bath Ankylosing Spondylitis Metrology Index (BASMI), Health Assessment Questionnaire (HAQ) assesses the self-reported functional status for performing activities of daily living, and the Ankylosing Spondylitis Quality of Life (ASQoL) questionnaire. Categorical variables were summarized as percentages with frequency counts, and continuous variables with a mean and standard deviation. Statistical comparisons between subgroups were evaluated using 2 sample t-tests for continuous variables and chi-square tests for categorical variables.

Results:

764 patients were available for analysis. Analysis of radiographic status showed 88.1% (n=673) of patients with r-axSpA and 11.9% (n=91) with nr-axSpA. Patients with nr-axSpA were younger (41.3 vs. 46.6 years, p<0.01), had shorter disease duration (14.8 vs. 20.2 years, p<0.01), lower proportion of males (66.6% vs. 78.4%, p=0.02) with lower rates of HLA-B27 positivity (73.6% vs. 90.5%, p<0.01). The nr-axSpA group had lower BASDAI (3.37 vs. 4.05, p=0.01), BASFI (2.46 vs. 3.88, p<0.01), BASMI (2.33 vs. 4.34, p<0.01), ASQoL (5.2 vs. 6.67, p=0.02), and HAQ scores (0.38 vs. 0.57, p<0.01). There were no significant differences in the prevalence of extra-articular manifestations.

Conclusion:

This study provides evidence that the burden of disease is less in patients with non-radiographic axial spondyloarthritis than radiographic axial spondyloarthritis, as demonstrated by better BASDAI, BASFI, BASMI, HAQ and ASQoL scores.

References:

[1]López-Medina C, et al. Characteristics and burden of disease in patients with radiographic and non-radiographic axial Spondyloarthritis: a comparison by systematic literature review and meta-analysis. RMD Open, 2019. 5(2) p1108.

Table 1.r-axSpAnr-axSpAp valuen67391Age (years)46.6 (+/-12.4)41.3 (+/-12.4)<0.01Disease duration (years)20.2 (+/-12.4)14.8 (+/-11.7)<0.01Delay to diagnosis (years)8.41 (+/-8.6)6.34 (+/-7.2)0.03Males78.8% (528)65.9% (60)0.02Females21.5% (145)34.1% (31)0.02HLA-B27+90.50%(440 of 486 available results)73.60%(53 of 72 available results)<0.01BASDAI4.05 (+/-2.39)3.37 (+/-2.31)0.01BASFI3.88 (+/-3.00)2.46 (+/-2.39)<0.01BASMI4.34 (+/-2.08)2.33 (+/-1.42)<0.01ASQoL6.67 (+/-5.55)5.2 (+/-5.53)0.02HAQ0.57 (+/-0.54)0.38 (+/-0.44)<0.01Psoriasis17.8% (120)15.4% (14)0.31IBD11% (74)8.8% (8)0.58Uveitis33.9% (228)34.1% (31)0.54

Disclosure of Interests:

Sean Quinn: None declared, Sinead Maguire: None declared, Finbar Barry O’Shea: None declared, Lorraine O’Neill: None declared, Eamonn Molloy: None declared, Ursula Fearon Speakers bureau: Abbvie, Grant/research support from: Janssen, Abbvie, Pfizer, UCB, Phil Gallagher: None declared, Douglas Veale Speakers bureau: AbbVie, BMS, Celgene, Pfizer, MSD, Roche, Consultant of: AbbVie, Actelion, BMS, Novartis, Pfizer, MSD, Roche, Regeneron/Sanofi, Grant/research support from: AbbVie, Pfizer, MSD, Novartis, Roche, Janssen.

Awareness in severe Alzheimer's disease: a systematic review

Objective: There is limited understanding about how people in the severe stages of Alzheimer's disease (AD) experience and demonstrate awareness. We synthesised all available evidence with the aim of understanding how awareness is preserved or impaired in severe AD and what evidence there is for different levels of awareness according to the levels of awareness framework.Method: A systematic search of the following databases: Embase, PsycINFO, MEDLINE and Web of Science was carried out. A narrative synthesis and analysis was conducted of all included studies. All studies were assessed for quality using the AXIS and CASP tools.Results: Our findings suggest that lower level sensory awareness is relatively maintained in severe AD. Findings for higher level awareness are variable and this may be related to the diversity of methods that have been used to explore awareness in these circumstances.Conclusion: Awareness is complex, heterogeneous and varies significantly between individuals. Environmental and contextual factors have a significant impact on whether awareness is observed in people with severe AD. Adaptation of the environment has the potential to facilitate the expression of awareness while education of caregivers may increase understanding of people with severe AD and potentially improve the quality of care that is received.

SAT0382 THE SAME BUT DIFFERENT? ANALYSIS OF A COHORT OF PATIENTS WITH LATE ONSET ANKYLOSING SPONDYLITIS

Background:

Ankylosing spondylitis(AS) has long been described as presenting in the third decade of life with the onset rarely occurring over the age of 45 years old. Previous research has shown there are small numbers of patients being diagnosed with AS later in life. These studies have been limited to small numbers limiting the ability to detect patterns in disease. The Ankylosing Spondylitis Registry of Ireland (ASRI) is an epidemiological data source on patients with AS in Ireland. Large registries, such as this, are an opportunity to further study this subtype in large numbers with greater power to detect differences between late and typical onset.

Objectives:

The purpose of this study was to examine late onset AS in a large, well characterized cohort.

Methods:

Patient registered in ASRI were analysed on the basis of their age of symptom onset using IBM SPSS version 26. Patients were divided into two groups with an age over 45 years old at symptoms onset categorized at late onset. Mean BASMI, BASFI, BASDAI, HAQ, and ASQoL scores were compared between the two groups and tested for statistical significance using an independent two tailed t-test. Further analysis looking at differences in gender, HLA B27 status, sacroiliitis on MRI, medication use and extra-articular manifestations(EAMs) was also performed using a chi-squared test for independence.

Results:

A total of 851 patients with AS were included in the analysis. Of these patients 659(77.4%) were males, with 192(22.6%) females, mean age of 45.8 years and mean disease duration of 19.4 years (means: ASQoL 6.52, HAQ 0.54, BASDAI 4.03, BASFI 3.7, BASMI 4.03). Patient population was made up of 797 patients(93.7%) categorized as typical onset, 54 patients(6.3%) categorized as late onset(table 1). Males had a higher rate of late onset AS than females, but this did not reach significance (6.8% vs 4.7%, p=0.19). Patients with late onset AS were noted to have higher BASFI (5.53 vs 3.58, p<0.01), HAQ (0.75 vs 0.53, p<0.01) and ASQoL scores (7.68 vs 6.44, p<0.01). Late onset patients also had lower rates of HLA-B27 positivity (76.5% vs 91.2%, p<0.01). No significant difference was detected in BASDAI or BASMI scores. No difference was detected between groups regarding rates EAMs. The late onset AS patients were noted to have lower rates of biologic therapy use (50% vs 72%, p<0.01). No significant difference was detected in rates of NSAID use.

Table 1.Onset < 45 years (n=797)Late Onset (n=54)pvalueMales (n=659)93.2% (614)6.8% (83.3)0.19Females (n=192)23% (183)16.6% (9)HLA B27+ (n=580)90.5% (554)76.5% (26)<0.01Enthesitis (n=146)16.9% (135)20.4% (11)0.45Dactylitis (n=54)6% (48)11.1% (6)0.21Arthritis (n=256)29.7% (237)35.2% (19)0.4MRI Sacroiliitis (n=384)45.3% (361)42.6% (23)0.69Bilateral sacroiliits (n=668)79% (628)74% (40)0.07BASDAI4.024.190.6BASFI3.585.53<0.01BASMI3.964.970.12HAQ0.530.75<0.01ASQoL6.447.68<0.01Uveitis28.5% (227)24.1% (13)0.07IBD9.9% (79)14.8% (8)0.32Psoriasis16.4% (131)18.5% (10)0.54Smokers (ever)57.3% (457)64.8% (35)0.01Alcohol consumption (ever)82% (654)75.9% (41)0.53Biologic tx69.1% (551)48.1% (26)<0.01NSAID tx54.2% (432)61.1% (33)0.2Figure 1.

Conclusion:

This analysis shows that late onset AS does occur in up to 6.3% of patients with AS. Patients with late onset disease were noted to have similar patterns of disease, EAMs and radiological findings consistent with current classification criteria for AS. Less patients with late onset disease were HLA-B27 positive, the reason for this is unknow. These patients had worse functional outcomes, which could reflect the older age of symptom onset. It is notable that patients with late onset AS are being treated with less biologic agents, and have a slightly higher rate of NSAID usage. Additional registry studies into this subgroup would help to understand these variations in medication usage and prescribing practices.

Disclosure of Interests:

Sinead Maguire Grant/research support from: ASRI is supported by funding from Pfizer, AbbVie and UCB, Phil Gallagher: None declared, Finbar Barry O’Shea Grant/research support from: ASRI is supported by funding from Pfizer, AbbVie and UCB

SAT0381 UNDERSTANDING JOINT REPLACEMENT SURGERY IN AXIAL SPONDYLOARTHROPATHY

Background:

Axial spondyloarthropathy(axSpA) is a form of inflammatory arthritis that primarily affects the axial skeleton and sacroiliac joint, but can be associated with a peripheral arthritis. Rapid advances in the field of axSpA has led to faster detection, diagnosis and treatment of this disease. This improved management has led to improved level of function and quality of life for patients, despite this a proportion of patients are still requiring joint replacement surgery. The Ankylosing Spondylitis Registry of Ireland (ASRI) is a source of epidemiological data on patients with axSpA in Ireland. Given the large size of the ASRI to date, this is a prime opportunity to analyze patients with axSpA requiring joint replacement surgery.

Objectives:

Detailed analysis of a large cohort of patients with axSpA with a focus on those who underwent joint replacement to determine trends in disease and baseline demographics.

Methods:

The patient population registered in the ASRI was analysed using IBM SPSS version 26. Analysis was performed by comparing patients who underwent joint replacement surgery to the rest of the ASRI cohort. Mean age, disease duration, delay to diagnosis and scores of disease activity (BASDAI, BASFI, HAQ, ASQoL and BASMI) were compared between these two groups. Differences between the groups was tested for significance using an independent two tailed t-test. Further analysis on gender, HLA-B27 status, co-morbidities and medication exposure was done using a chi-squared test for independence. A p value of less than 0.05 was deemed significant.

Results:

At present 860 patients are currently enrolled in the ASRI with 76.6% (659) males and 23.4% (201) females. Average age of patients is 45.8 years, mean disease duration of 19.4 years with 95.5% (821) of patients listed as Caucasian. Mean scores were BASDAI 4.02, BASFI 3.7, BASMI4.02, HAQ 0.55, and ASQoL of 6.51. In total 33 (3.8%) of patients underwent joint replacement surgery. These patients were noted to be significantly older than the rest of the rest of the cohort (55.3 years old vs 45.1, p<0.01), with a longer disease duration (31.6 years vs 18.3, p<0.01) and higher rates of HLA-B27 positivity (94.7% vs 80.2%, p<0.01). No significant differences were noted between gender(table 1). No significant difference was found between medication exposure rates, although the joint replacement population did have higher rates of NSAID, sDMARD and biologic therapy usage than the rest of the population although this did not reach significance. These patients also scored worse in all measures of disease activity, although this only reached significance in the BASFI (5.67 vs 3.64, p<0.01), HAQ (0.9 vs 0.54, p<0.01) and the BASMI (6.07 vs 3.94, p<0.01).

Table 1.Joint replacement (n=33)No Joint Replacement (n=827)p valueAge55.345.1<0.01Disease duration31.618.31<0.01Delay to dx6.977.970.51HLA-B27+94.7% (18)71.9% (491)<0.01Males78.8% (26)64.7% (535)0.76Females21.2% (7)19.3% (160)0.76Mean ScoresBASDAI4.914.060.06BASFI5.673.64<0.01HAQ0.90.54<0.01ASQoL7.426.670.45BASMI6.073.94<0.01MedicationsNSAIDs51.5% (17)47% (389)0.21Bio tx72.7% (24)57.2% (473)0.9DMARDs33.3% (11)15.7% (130)0.1

Conclusion:

Patients requiring joint replacement surgery, although few in number, represent a cohort with significantly impaired function and quality of life. This is likely due to the fact that these patients were older with more established disease. It is therefore not surprising that this cohort had significantly worse spinal mobility. As registries continues to develop, it will be interesting to see if rates of joint replacement surgery will decline with increased use of biologic therapy at an earlier stage of disease. This will help to differentiate patients requiring joint replacement surgery due to underlying inflammatory arthritis and those with osteoarthritis.

Disclosure of Interests:

Sinead Maguire Grant/research support from: ASRI is supported by funding from Pfizer, AbbVie and UCB, Phil Gallagher: None declared, Finbar Barry O’Shea Grant/research support from: ASRI is supported by funding from Pfizer, AbbVie and UCB

AB0704 PRESCRIBING PRACTICES IN AXIAL SPONDYLOARTHROPATHY

Background:

Axial spondyloarthropathy(axSpA) treatment has undergone a number of significant developments over the past number of decades. Previously limited to non-steroidal anti-inflammatories (NSAIDs) and corticosteroids, treatment options now include synthetic disease modifying anti-rheumatic drugs(sDMARDs) and biologic agents. The development of national registries for inflammatory arthritis provides an opportunity to study medication usage in a large cohort of patients with axSpA. The Ankylosing Spondylitis Registry of Ireland (ASRI) is a source of epidemiological data on patients with axSpA in Ireland. The aim of this study was to examine medication exposure and outcomes.

Objectives:

To characterize a large cohort of patients with axSpA in terms of medications usage, burden of disease and patient reported outcomes.

Methods:

The patient population registered in the ASRI was analysed using IBM SPSS version 26. Patients were analyzed on the basis of medication exposure. The four treatment groups were classified as no treatment, NSAIDs only, biologics only, or biologics and NSAIDs. Mean age, duration of disease and delay to diagnosis was compared between groups. Burden of disease was assessed via mean BASDAI, BASFI, BASMI, HAQ and ASQoL between the four groups. Differences between groups was tested for statistical significance a one-way analysis of variance (ANOVA). A chi-squared test for independence was used to compare differences in rates of HLA-B27 positivity rates and gender. Results were deemed significant where p < 0.05.

Results:

At present 860 patients are currently enrolled in the ASRI with 76.6% (659) males and 23.4% (201) females. Average age of patients is 45.8 years, mean disease duration of 19.4 years with 95.5% (821) of patients listed as Caucasian. Mean scores were BASDAI 4.02, BASFI 3.7, BASMI 4.02, HAQ 0.55, and ASQoL of 6.51. Treatment groups were made up of 9.9%(85) on no treatment, 22.2%(191) NSAIDs treatment only, 34.8%(299) biologics treatment only and 32.1%(276) treated with both NSAIDs and biologics. Patients only on NSAIDs were noted to be older than patients on biologics, and those on both biologics and NSAIDs (p=0.02). Patients on NSAIDs were older at symptom onset than those on both biologic and NSAID treatment (p=0.02), however the effect size is small(0.012). No significant difference was noted between groups regarding disease duration, delay to diagnosis or distribution between genders (table 1). Difference in BASDAI scores between groups was significant between all groups, with patients on both biologics and NSAIDs having the highest scores and those on no treatment with the lowest scores(4.74 vs 3.37) possibly a reflection of disease severity(table 2).

Table 1.ASRINo txNSAIDs txBiologic txBiologic & NSAIDsp valueNumber8609.9% (85)22.2% (191)37.8% (299)32.1% (276)Age45.849.746.245.345.10.02Symptom onset26.427.528.226.125.20.02Disease duration19.422.21819.119.80.06Delay to dx89.88.17.480.13Table 2.ASRINo txNSAIDs txBiologic txBiologic & NSAIDsp valueEffect SizeBASDAI4.023.374.213.44.740.063.374.210.043.374.74<0.014.213.4<0.013.44.74<0.01

Conclusion:

A large proportion of patients in the ASRI were treated with either biologics only or both biologics and NSAIDs. No treatment was the least common treatment within this cohort. Patients not on treatment tended to be older than those on any type of treatment. Overall patients on biologics alone tended to have better patient reported outcomes as compared to all other treatment groups. The development of longitudinal data for the ASRI will help to further understand the reason behind these differences.

Disclosure of Interests:

Sinead Maguire Grant/research support from: ASRI is supported by funding from Pfizer, AbbVie and UCB, Phil Gallagher: None declared, Finbar Barry O’Shea Grant/research support from: ASRI is supported by funding from Pfizer, AbbVie and UCB

Barriers and facilitators to discussing HPV with head and neck cancer patients: A qualitative study using the theoretical domains framework

OBJECTIVE

The incidence of human papillomavirus-associated head and neck cancers (HPV-HNC) is increasing worldwide. Research in other clinical contexts has shown that healthcare professionals (HCPs) can find discussing HPV with patients challenging. However, limited research has been conducted in HNC. This study aimed to investigate barriers and facilitators to, discussing HPV among HCPs caring for patients with HNC in Ireland.

METHODS

Semi-structured telephone/face-to-face interviews were conducted with HCPs. Barriers and facilitators to discussing HPV with patients were identified using the Theoretical Domains Framework (TDF).

RESULTS

20 HCPs (8 clinicians, 3 nurses, 9 allied healthcare professionals) were interviewed. Barriers to discussing HPV included professionals' lack of HPV knowledge, difficulties in talking about sexual issues with patients and lack of privacy to discuss HPV in busy clinic settings. Facilitators included increasing public and patient awareness of the link between HPV and HNC and professional education and skills development.

CONCLUSIONS

This is the first theoretically informed study to identify barriers and facilitators to discussing HPV with HNC patients. HCPs consider HPV discussions to be an essential part of HNC patient care.

PRACTICE IMPLICATIONS

Understanding the issues associated with patient-provider HPV communication will help develop effective interventions to support HCPs in their HPV discussions.

Parent and adolescent communication with healthcare professionals about Type 1 diabetes management at adolescents' outpatient clinic appointments

AIM

This study aimed to identify the ways in which adolescents living with Type 1 diabetes and their parents communicate about Type 1 diabetes management with healthcare professionals in a clinical setting.

METHODS

Twenty-nine adolescents (aged 11-17 years) and their parents were purposively recruited from two outpatient clinics for non-participant observations. Outpatient clinic appointments, which consisted of multiple consultations with healthcare professionals, were observed and audio-recorded. Outpatient clinic appointments were categorized based on the nature and extent of communication by the adolescent and their parent(s) in relation to Type 1 diabetes management activities.

RESULTS

Data from 29 outpatient clinic appointments, consisting of a total of 68 observed consultations, were analysed and a continuum consisting of three patterns of communication was identified (parent-led, collaborative and adolescent-led). Healthcare professionals should attend to the nature and extent of communication by adolescents and their parents in relation to Type 1 diabetes management activities because parent and adolescent engagement in communication during clinic appointments may also reflect their degree of involvement in daily Type 1 diabetes management.

CONCLUSIONS

This continuum provides a framework for healthcare professionals to use to identify communication patterns in consultations which in turn may allow healthcare professionals to encourage more effective communication about Type 1 diabetes management from adolescents and their parents in clinic consultations. This may have a positive impact on the sharing of Type 1 diabetes management responsibilities and adolescents' developing self-management skills as roles change during this developmental period.

A four-year naturalistic prospective study of cardiometabolic disease in antipsychotic-treated patients

The relationship between antipsychotic use and cardiovascular morbidity and mortality is controversial. There is a lack of long-term prospective studies investigating changes in cardiometabolic risk in patients treated with antipsychotic drugs. We report data from a 4-year prospective study. Patients (89) underwent detailed metabolic and cardiovascular risk assessment at 4-years which included anthropometric assessment, blood pressure, lipid profile, and an oral glucose tolerance test. We used the homeostatic model assessment to determine insulin resistance, and calculated 10-year cardiovascular risk scores. Mean age of subjects was 44.7 (±11.5) years, and 52% were male. The prevalence of type 2 diabetes was 8%, and 38.4% fulfilled diagnostic criteria for the metabolic syndrome. With the exception of increased central adiposity over the 4-year follow-up period (p < 0.001), other cardiometabolic parameters were generally unchanged. There was a high prevalence of dyslipidaemia, but only 16.9% were prescribed lipid-lowering treatment. Commencing lipid-lowering therapy was associated with a reduction in cardiovascular risk score (OR 7.9, 95% CI = 1.3 to 48.7; p = 0.02). Patients established on longer-term antipsychotic treatment show less dramatic metabolic changes than those occurring in the early stages of treatment, but have a high burden of cardiovascular risk. Lipid-lowering therapy is associated with a significant reduction in cardiovascular risk.

Communicating about HPV in the context of head and neck cancer: A systematic review of quantitative studies

OBJECTIVE

Rising incidence of HPV-positive head and neck cancers (HPV-HNC) means HPV infection is increasingly relevant to patient-provider consultations. We performed a systematic review to examine, in the context of patient-provider HNC consultations: discussions about HPV, attitudes towards discussing HPV and information needs.

METHODS

We searched Embase, PsychINFO, and CINAHL + for studies to August 2018. Eligible studies included: HNC healthcare professionals (HCPs) and/or HNC patients investigated HNC patient-provider communication about HPV.

RESULTS

Ten studies were identified: six including HCPs and four including HNC patients. HCPs varied in confidence in HPV discussions, which was related to their HPV knowledge. Both HCPs and patients acknowledged the need for reliable HPV information. Factors which facilitated HPV discussions included accessible HPV information for patients and HCPs and good HPV knowledge among HCPs. Barriers included the perception, among HCPs, that HPV was a challenging topic to discuss with patients.

CONCLUSIONS

Information deficits, communication challenges and barriers to discussing HPV were identified in HNC patient-provider consultations.

PRACTICE IMPLICATIONS

Appropriate HPV information is needed for HCPs and patients. Professional development initiatives which increase HCPs' HPV knowledge and build their communication skills would be valuable.

The association between sleep and cognitive abnormalities in bipolar disorder

BACKGROUND

Bipolar disorder (BD) is associated with attentional and processing abnormalities. Such abnormalities are also seen in healthy subjects with sleep disruption. We hypothesised cognitive abnormalities in BD patients would be worse in those with objectively verified sleep abnormalities.

METHODS

Forty-six BD patients and 42 controls had comprehensive sleep/circadian rhythm assessment over 21 days alongside mood questionnaires. Cognitive function was assessed with a range of tasks including Psychomotor Vigilance Test (PVT), Attention Network Task (ANT) and Digit Symbol Substitution Test (DSST). BD participants with normal and abnormal sleep were compared with age- and sex-matched controls.

RESULTS

BD patients had longer response times and made more lapses (responses >500 ms) than controls on the PVT (both p < 0.001). However, patients with normal sleep patterns did not differ from controls while those with sleep abnormalities did (p < 0.001). An identical pattern of effects were seen with the ANT response times, with the abnormality in bipolar abnormal sleepers related to the executive attentional network. Similarly, patients made fewer correct responses on the DSST compared with the controls (p < 0.001). Bipolar normal sleepers did not differ while those with abnormal sleep did (p < 0.001). All these differences were seen in bipolar abnormal sleepers who were euthymic (p < 0.01) and across the main abnormal sleep phenotypes.

CONCLUSIONS

We confirm impairment in attention and processing speed in BD. Rather than sleep abnormalities exacerbating such dysfunction, the impairments were confined to bipolar abnormal sleepers, consistent with sleep disturbance being the main driver of cognitive dysfunction.

Minority stress, intra-minority stress and social anxiety: Examining an extended psychological mediation framework among sexual minority men

Background

Compared to their heterosexual counterparts, sexual minority men (SMM) are at an increased risk of social anxiety disorder. Distal (i.e., everyday discrimination) and proximal (i.e., internalised homophobia, rejection sensitivity, concealment of sexual orientation) minority stress processes are associated with heightened social anxiety for SMM. Stressors emerging from within the sexual minority male community, termed intra-minority stress, and psychological processes that may foster resilience (i.e., a sense of coherence, connectedness to the LGBT community) are less explored in this area. This study examined potential pathways between everyday discrimination, intra-minority stress, proximal minority stressors, resilience and social anxiety.

Methods

Self-identified SMM (N = 255) residing in the Republic of Ireland completed an online survey containing measures of minority stress, intra-minority stress, resilience and social anxiety. Structural equation modelling was used to examine the model.

Results

The model yielded a good fit to the data, X2(16) = 26.61, CFI = .99, TLI = .97, RMSEA = .05, and SRMR = .03. Rejection sensitivity and a sense of coherence had a significant indirect effect in the relationships between both exogenous variables (i.e., discrimination and intra-minority stress) and social anxiety. There were no significant pathways to social anxiety involving concealment of sexual orientation, internalised homophobia or LGBT community connectedness.

Conclusions

For SMM, minority stress processes and intra-minority stress are important determinants of social anxiety. Our findings demonstrate that proximal minority stressors may operate differently in a social anxiety context for SMM in western European countries. A sense of coherence was an integral factor in the model and demonstrated the strongest association with social anxiety.

Fetal abdominal circumference in the second trimester and prediction of small for gestational age at birth

Background: Infants that are small for gestational age (SGA) at birth are at increased risk for morbidity and mortality. Unfortunately, the antenatal prediction of SGA is suboptimal.Objectives: We sought to: (1) examine the association between second trimester fetal abdominal circumference < 10% (2T-AClag) with SGA and other gestational and neonatal adverse outcomes; (2) assess 2T-AClag as a predictor of SGA.Study design: Retrospective study of 212 singleton gestations with 2T-AClag on routine ultrasound between 18-24 weeks. The study group was compared to 424 gestations without 2T-AClag for maternal characteristics as well as pregnancy and neonatal adverse outcomes. A multivariate logistic regression was used to determine the predictive value of 2T-AClag for SGA, adjusting for maternal and pregnancy characteristics. The screening model accuracy was assessed through receiver operating characteristic (ROC) curves. Fetal growth restriction (FGR) was defined as an estimated fetal weight (EFW) less than the 10th percentile.Results: Gestations with 2T-AClag had higher rates of SGA (35.7 versus 11.6%, p  <  .0001), FGR (17 versus 1.7%, p < .0001), pregnancy induced hypertension (31.1 versus 17%, p < .0001), preeclampsia (14.6 versus 7.8%, 0  =  0.01), abnormal umbilical artery Doppler (30 versus 5.1%, p < .0001), indicated preterm birth (5.7 versus 1.9%, p = .01), primary cesarean birth (29.6 versus 20.1%, p = .01) and NICU admission (12.9 versus 6.4%, p = .009). After adjusting for maternal and gestational risk factors, 2T-AClag remained an independent risk factor for SGA (OR 4.53, 95%CI 2.91-7.05, p < .0001) and FGR (OR 11.57, 95%CI 5.02-26.65, p < .0001). The inclusion of 2T-AClag in a regression model with traditional risk factors, significantly improved the model's predictability for SGA and FGR (area under ROC curve increased from 0.618 to 0.723 and 0.653 to 0.819, respectively, p < .0001).Conclusions: Second trimester abdominal circumference (AC) lag is associated with an increased risk of SGA, FGR and other adverse outcomes. The inclusion of 2T-AClag in a screening model for prediction of SGA and FGR may improve the identification of this at-risk group and assist in customizing surveillance plans.Brief rationaleScreening for newborns that are small for gestational age (SGA) at birth is currently suboptimal. Our study shows that second trimester abdominal circumference (AC) lag, using a parameter already routinely assessed during anatomic survey, is associated with SGA at birth and can improve current screening for growth restriction and other gestational, fetal and neonatal complications.

Drug consumption and futile medication prescribing in the last year of life: an observational study

Background

the last year of life for many older people is associated with high symptom burden and frequent hospitalizations. Hospital physicians have an opportunity to prioritize essential medications and deprescribe potentially futile medications.

Objective

to measure medication consumption during hospitalization in the last year of life and the prevalence of potentially inappropriate medications (PIMs) at hospital discharge.

Design

retrospective chart review.

Setting

acute hospital.

Subjects

≥65 years, hospitalized in the last year of life.

Methods

medication consumption was determined by examining hospital Medication Administration Records. PIMs were defined using STOPPFrail deprescribing criteria.

Results

the study included 410 patients. The mean age of participants was 80.8, 49.3% were female, and 63.7% were severely frail. The median number of days spent in hospital in the last year of life was 32 (interquartile range 15-59). During all hospitalizations, the mean number of individual medications consumed was 23.8 (standard deviation 10.1). One-in-six patients consumed 35 or more medications in their last year. Over 80% of patients were prescribed at least one PIM at discharge and 33% had ≥3 PIMs. Lipid-lowering medications, proton pump inhibitors, anti-psychotics and calcium supplements accounted for 59% of all PIMs. Full implementation of STOPPFrail recommendations would have resulted in one-in-four long-term medications being discontinued.

Conclusion

high levels of medication consumption in the last year of life not only reflect high symptom burden experienced by patients but also continued prescribing of futile medications. Physicians assisted by the STOPPFrail tool can reduce medication burden for older people approaching end of life.

Assessing and addressing cognitive impairment in bipolar disorder: the International Society for Bipolar Disorders Targeting Cognition Task Force recommendations for clinicians

OBJECTIVES

Cognition is a new treatment target to aid functional recovery and enhance quality of life for patients with bipolar disorder. The International Society for Bipolar Disorders (ISBD) Targeting Cognition Task Force aimed to develop consensus-based clinical recommendations on whether, when and how to assess and address cognitive impairment.

METHODS

The task force, consisting of 19 international experts from nine countries, discussed the challenges and recommendations in a face-to-face meeting, telephone conference call and email exchanges. Consensus-based recommendations were achieved through these exchanges with no need for formal consensus methods.

RESULTS

The identified questions were: (I) Should cognitive screening assessments be routinely conducted in clinical settings? (II) What are the most feasible screening tools? (III) What are the implications if cognitive impairment is detected? (IV) What are the treatment perspectives? Key recommendations are that clinicians: (I) formally screen cognition in partially or fully remitted patients whenever possible, (II) use brief, easy-to-administer tools such as the Screen for Cognitive Impairment in Psychiatry and Cognitive Complaints in Bipolar Disorder Rating Assessment, and (III) evaluate the impact of medication and comorbidity, refer patients for comprehensive neuropsychological evaluation when clinically indicated, and encourage patients to build cognitive reserve. Regarding question (IV), there is limited evidence for current evidence-based treatments but intense research efforts are underway to identify new pharmacological and/or psychological cognition treatments.

CONCLUSIONS

This task force paper provides the first consensus-based recommendations for clinicians on whether, when, and how to assess and address cognition, which may aid patients' functional recovery and improve their quality of life.

Methodological recommendations for cognition trials in bipolar disorder by the International Society for Bipolar Disorders Targeting Cognition Task Force

OBJECTIVES

To aid the development of treatment for cognitive impairment in bipolar disorder, the International Society for Bipolar Disorders (ISBD) convened a task force to create a consensus-based guidance paper for the methodology and design of cognition trials in bipolar disorder.

METHODS

The task force was launched in September 2016, consisting of 18 international experts from nine countries. A series of methodological issues were identified based on literature review and expert opinion. The issues were discussed and expanded upon in an initial face-to-face meeting, telephone conference call and email exchanges. Based upon these exchanges, recommendations were achieved.

RESULTS

Key methodological challenges are: lack of consensus on how to screen for entry into cognitive treatment trials, define cognitive impairment, track efficacy, assess functional implications, and manage mood symptoms and concomitant medication. Task force recommendations are to: (i) enrich trials with objectively measured cognitively impaired patients; (ii) generally select a broad cognitive composite score as the primary outcome and a functional measure as a key secondary outcome; and (iii) include remitted or partly remitted patients. It is strongly encouraged that trials exclude patients with current substance or alcohol use disorders, neurological disease or unstable medical illness, and keep non-study medications stable. Additional methodological considerations include neuroimaging assessments, targeting of treatments to illness stage and using a multimodal approach.

CONCLUSIONS

This ISBD task force guidance paper provides the first consensus-based recommendations for cognition trials in bipolar disorder. Adherence to these recommendations will likely improve the sensitivity in detecting treatment efficacy in future trials and increase comparability between studies.

Physical after-effects of colposcopy and related procedures, and their inter-relationship with psychological distress: a longitudinal survey

OBJECTIVE

To estimate prevalence of post-colposcopy physical after-effects and investigate associations between these and subsequent psychological distress.

DESIGN

Longitudinal survey.

SETTING

Two hospital-based colposcopy clinics.

POPULATION

Women with abnormal cytology who underwent colposcopy (±related procedures).

METHODS

Questionnaires were mailed to women 4, 8 and 12 months post-colposcopy. Details of physical after-effects (pain, bleeding and discharge) experienced post-colposcopy were collected at 4 months. Colposcopy-specific distress was measured using the Process Outcome-Specific Measure at all time-points. Linear mixed-effects regression was used to identify associations between physical after-effects and distress over 12 months, adjusting for socio-demographic and clinical variables.

MAIN OUTCOME MEASURES

Prevalence of post-colposcopy physical after-effects. Associations between the presence of any physical after-effects, awareness of after-effects, and number of after-effects and distress.

RESULTS

Five-hundred and eighty-four women were recruited (response rate = 73, 59 and 52% at 4, 8 and 12 months, respectively). Eighty-two percent of women reported one or more physical after-effect(s). Multiple physical after-effects were common (two after-effects = 25%; three after-effects = 25%). Psychological distress scores declined significantly over time. In adjusted analyses, women who experienced all three physical after-effects had on average a 4.58 (95% CI: 1.10-8.05) higher distress scored than those who experienced no after-effects. Women who were unaware of the possibility of experiencing after-effects scored significantly higher for distress during follow-up.

CONCLUSIONS

The prevalence of physical after-effects of colposcopy and related procedures is high. The novel findings of inter-relationships between awareness of the possibility of after-effects and experiencing multiple after-effects, and post-colposcopy distress may be relevant to the development of interventions to alleviate post-colposcopy distress.

TWEETABLE ABSTRACT

Experiencing multiple physical after-effects of colposcopy is associated with psychological distress.

Outcomes of an innovative training course in laparoscopic hernia repair

Introduction The Ethicon™ laparoscopic inguinal groin hernia training (LIGHT) course is an educational course based on three days of teaching on laparoscopic hernia surgery. The first day involves didactic lectures with tutorials. The second day involves practical cadaveric procedures in laparoscopic hernia surgery. The third day involves direct supervision by a consultant surgeon during laparoscopic hernia surgery on a real patient. We reviewed our outcomes for procedures performed on real patients on the final day of the course for early complications and outcomes. Methods A retrospective study was undertaken of patients who had laparoscopic hernia surgery as part of the LIGHT course from 2013 to 2015. A matched control cohort of patients who had elective laparoscopic hernia surgery over the study period was identified. These patients had their surgery performed by the same consultant general surgeons involved in delivering the course. All patients were followed up at 6 weeks postoperatively. Results A total of 60 patients had a laparoscopic inguinal hernia repair and 23 patients had a laparoscopic ventral hernia repair during the course. The mean operative time for laparoscopic inguinal hernia repair was 48 minutes for trainees (range 22-90 minutes) and 35 minutes for consultant surgeons (range 18-80 minutes). There were no intraoperative injuries or returns to theatre in either group. All the patients operated on during the course were successfully performed as daycase procedures. The mean operative time for laparoscopic ventral hernia repair was 64 minutes for trainees (range 40-120 minutes) and 51 minutes for consultant surgeons (range 30-130 minutes). Conclusions The outcomes of patients operated on during the LIGHT course are comparable to procedures performed by a consultant. Supervised operating by trainees is a safe and effective educational model in hernia surgery.

Modeling observations of solar coronal mass ejections with heliospheric imagers verified with the Heliophysics System Observatory

We present an advance toward accurately predicting the arrivals of coronal mass ejections (CMEs) at the terrestrial planets, including Earth. For the first time, we are able to assess a CME prediction model using data over two thirds of a solar cycle of observations with the Heliophysics System Observatory. We validate modeling results of 1337 CMEs observed with the Solar Terrestrial Relations Observatory (STEREO) heliospheric imagers (HI) (science data) from 8 years of observations by five in situ observing spacecraft. We use the self-similar expansion model for CME fronts assuming 60° longitudinal width, constant speed, and constant propagation direction. With these assumptions we find that 23%-35% of all CMEs that were predicted to hit a certain spacecraft lead to clear in situ signatures, so that for one correct prediction, two to three false alarms would have been issued. In addition, we find that the prediction accuracy does not degrade with the HI longitudinal separation from Earth. Predicted arrival times are on average within 2.6 ± 16.6 h difference of the in situ arrival time, similar to analytical and numerical modeling, and a true skill statistic of 0.21. We also discuss various factors that may improve the accuracy of space weather forecasting using wide-angle heliospheric imager observations. These results form a first-order approximated baseline of the prediction accuracy that is possible with HI and other methods used for data by an operational space weather mission at the Sun-Earth L5 point.

Sleep and circadian rhythm disturbance in bipolar disorder

BACKGROUND

Subjective reports of insomnia and hypersomnia are common in bipolar disorder (BD). It is unclear to what extent these relate to underlying circadian rhythm disturbance (CRD). In this study we aimed to objectively assess sleep and circadian rhythm in a cohort of patients with BD compared to matched controls.

METHOD

Forty-six patients with BD and 42 controls had comprehensive sleep/circadian rhythm assessment with respiratory sleep studies, prolonged accelerometry over 3 weeks, sleep questionnaires and diaries, melatonin levels, alongside mood, psychosocial functioning and quality of life (QoL) questionnaires.

RESULTS

Twenty-three (50%) patients with BD had abnormal sleep, of whom 12 (52%) had CRD and 29% had obstructive sleep apnoea. Patients with abnormal sleep had lower 24-h melatonin secretion compared to controls and patients with normal sleep. Abnormal sleep/CRD in BD was associated with impaired functioning and worse QoL.

CONCLUSIONS

BD is associated with high rates of abnormal sleep and CRD. The association between these disorders, mood and functioning, and the direction of causality, warrants further investigation.

A study of wrist-worn activity measurement as a potential real-world biomarker for late-life depression

BACKGROUND

Late-life depression (LLD) is associated with a decline in physical activity. Typically this is assessed by self-report questionnaires and, more recently, with actigraphy. We sought to explore the utility of a bespoke activity monitor to characterize activity profiles in LLD more precisely.

METHOD

The activity monitor was worn for 7 days by 29 adults with LLD and 30 healthy controls. Subjects underwent neuropsychological assessment and quality of life (QoL) (36-item Short-Form Health Survey) and activities of daily living (ADL) scales (Instrumental Activities of Daily Living Scale) were administered.

RESULTS

Physical activity was significantly reduced in LLD compared with controls (t = 3.63, p < 0.001), primarily in the morning. LLD subjects showed slower fine motor movements (t = 3.49, p < 0.001). In LLD patients, activity reductions were related to reduced ADL (r = 0.61, p < 0.001), lower QoL (r = 0.65, p < 0.001), associative learning (r = 0.40, p = 0.036), and higher Montgomery-Åsberg Depression Rating Scale score (r = -0.37, p < 0.05).

CONCLUSIONS

Patients with LLD had a significant reduction in general physical activity compared with healthy controls. Assessment of specific activity parameters further revealed the correlates of impairments associated with LLD. Our study suggests that novel wearable technology has the potential to provide an objective way of monitoring real-world function.

Predictors of the discrepancy between objective and subjective cognition in bipolar disorder: a novel methodology

OBJECTIVE

The poor relationship between subjective and objective cognitive impairment in bipolar disorder (BD) is well-established. However, beyond simple correlation, this has not been explored further using a methodology that quantifies the degree and direction of the discrepancy. This study aimed to develop such a methodology to explore clinical characteristics predictive of subjective-objective discrepancy in a large BD patient cohort.

METHODS

Data from 109 remitted BD patients and 110 healthy controls were pooled from previous studies, including neuropsychological test scores, self-reported cognitive difficulties, and ratings of mood, stress, socio-occupational capacity, and quality of life. Cognitive symptom 'sensitivity' scores were calculated using a novel methodology, with positive scores reflecting disproportionately more subjective complaints than objective impairment and negative values reflecting disproportionately more objective than subjective impairment ('stoicism').

RESULTS

More subsyndromal depressive and manic symptoms, hospitalizations, BD type II, and being male positively predicted 'sensitivity', while higher verbal IQ predicted more 'stoicism'. 'Sensitive' patients were characterized by greater socio-occupational difficulties, more perceived stress, and lower quality of life.

CONCLUSION

Objective neuropsychological assessment seems especially warranted in patients with (residual) mood symptoms, BD type II, chronic illness, and/or high IQ for correct identification of cognitive deficits before commencement of treatments targeting cognition.

The effectiveness of person-centred planning for people with intellectual disabilities: A systematic review

OBJECTIVES

To evaluate the effectiveness of Person-Centred Planning (PCP) on outcomes for individuals with intellectual disabilities (ID) across the age range.

METHOD

The electronic databases PsycInfo, Embase, CINHAL, PubMed, Web of Science, Scopus and Medline were searched for studies evaluating the impact of PCP on people with ID, published between 1990 and 2014; these were supplemented by manual searches of reference lists. Studies were considered irrespective of methodology, sample size and publication source, if outcomes reflected the impact of PCP on individuals with ID.

RESULTS

Seven quantitative, five qualitative and four mixed methods studies were included in the review. The overall quality of the evidence was low but suggestive that PCP may have a positive, yet moderate, impact on some outcomes for individuals with ID, particularly community-participation, participation in activities and daily choice-making. For other outcomes such as employment the findings were inconsistent.

CONCLUSION

The evidence supporting the effectiveness of PCP is limited and does not demonstrate that PCP can achieve radical transformations in the lives of people with ID. Clearer descriptions of PCP and its components are needed. Small-scale successful demonstrations of effectiveness exist, but its clinical, cost-effectiveness and wider implementation must be investigated in large scale studies.