Triplet Rydberg States of Aluminum Monofluoride

Aluminum monofluoride (AlF) is a suitable molecule for laser cooling and trapping. Such experiments require extensive spectroscopic characterization of the electronic structure. Two of the theoretically predicted higher-lying triplet states of AlF, the counterparts of the well-characterized D1Δ and E1Π states, had not been experimentally identified yet. We here report on the characterization of the d3Π (v = 0-6) and e3Δ (v = 0-2) states, confirming the predicted energetic ordering of these states (J. Chem. Phys. 1988, 88, 5715-5725), as well as of the f3Σ+ (v = 0-2) state. The transition intensity of the d3Π, v = 3 - a3Π, v = 3 band is negligibly small. This band gets its weak, unexpected rotational structure via intensity borrowing from the nearby e3Δ, v = 2 - a3Π, v = 3 band, made possible via spin-orbit and spin-rotation interaction between the d3Π and e3Δ states. This interaction affects the equilibrium rotational constants in both states; their deperturbed values yield equilibrium internuclear distances that are consistent with the observations. We determined the ionization potential of AlF to be 78,492(1) cm-1 by ionization from the d3Π state.

Achievement of Target Gain Larger than Unity in an Inertial Fusion Experiment

On December 5, 2022, an indirect drive fusion implosion on the National Ignition Facility (NIF) achieved a target gain G_{target} of 1.5. This is the first laboratory demonstration of exceeding "scientific breakeven" (or G_{target}>1) where 2.05 MJ of 351 nm laser light produced 3.1 MJ of total fusion yield, a result which significantly exceeds the Lawson criterion for fusion ignition as reported in a previous NIF implosion [H. Abu-Shawareb et al. (Indirect Drive ICF Collaboration), Phys. Rev. Lett. 129, 075001 (2022)PRLTAO0031-900710.1103/PhysRevLett.129.075001]. This achievement is the culmination of more than five decades of research and gives proof that laboratory fusion, based on fundamental physics principles, is possible. This Letter reports on the target, laser, design, and experimental advancements that led to this result.

Estimating meaningful change thresholds for Skin Pain-Numeric Rating Scale, Sleep-Numeric Rating Scale and Dermatology Life Quality Index in patients with prurigo nodularis

BACKGROUND

Prurigo nodularis (PN) is characterized by intensely itchy nodules/lesions and skin pain, which can have a substantial impact on health-related quality of life (HRQoL). Treatment benefits on such symptoms and impacts are best assessed in trials using patient-reported outcome (PROs) instruments such as Skin Pain Numerical Rating Scale (NRS), Sleep-NRS and Dermatology Life Quality Index (DLQI). However, no guidance exists for interpreting meaningful changes in scores using these PROs in patients with PN.

OBJECTIVES

The main objective was to derive within-patient (responder definition) and between-group improvement thresholds for interpreting Skin Pain-NRS, Sleep-NRS and DLQI total scores in patients with PN. The measurement properties of the three PROs were also evaluated.

METHODS

Intention-to-treat (ITT), blinded and pooled data were used from the Phase 3 PRIME (NCT04183335) and PRIME2 (NCT04202679) studies evaluating the efficacy of dupilumab in adult patients with PN. Anchor- and distribution-based methods were applied to derive responder definition and between-group thresholds for Skin Pain-NRS, Sleep-NRS and DLQI. Data were additionally used to examine the instrument measurement properties, including reliability, validity and responsiveness.

RESULTS

A total of 311 patients (mean age 49.5 years, 65.3% female) were included in the pooled ITT population. The within-patient improvement threshold for Skin Pain-NRS was estimated as 4.0 points, 2.0 points for Sleep-NRS and 9.0 points for DLQI total score. A 1.5-point improvement in Skin Pain-NRS scores, 1.0-point in Sleep-NRS and 4.0-point in DLQI indicated a between-group meaningful change. Adequate to good psychometric properties were demonstrated for all three instruments.

CONCLUSIONS

The results of this study can aid interpretation of Skin Pain-NRS, Sleep-NRS and DLQI scores in patients with PN in both clinical trials and clinical practice to better understand and treat PN-related skin pain and the impact of PN on sleep quality and HRQoL.

An established abdominal wall multidisciplinary team improves patient care and aids surgical decision making with complex ventral hernia patients

INTRODUCTION

Abdominal wall reconstruction (AWR) is an emerging subspecialty within general surgery. The practice of multidisciplinary team (MDT) meetings to aid decision making and improve patient care has been demonstrated, with widespread acceptance. This study presents our initial experience of over 150 cases of complex hernia patients discussed in a newly established MDT setting.

METHODS

From February 2020 to July 2022 (30-month period), abdominal wall MDTs were held bimonthly. Key stakeholders included upper and lower gastrointestinal surgeons, a gastrointestinal specialist radiologist, a plastic surgeon, a high-risk anaesthetist and two junior doctors integrated into the AWR clinical team. Meetings were held online, where patient history, past medical and surgical history, hernia characteristics and up-to-date computed tomography scans were discussed.

RESULTS

Some 156 patients were discussed over 18 meetings within the above period. Ninety-five (61%) patients were recommended for surgery, and 61 (39%) patients were recommended for conservative management or referred elsewhere. Seventy-eight (82%) patients were directly waitlisted, whereas seventeen (18%) required preoperative optimisation: three (18%) for smoking cessation, eleven (65%) for weight-loss management and three (18%) for specialist diabetic assessment and management. In total, 92 (59%) patients (including operative and nonoperative management) have been discharged to primary care.

DISCUSSION

A multidisciplinary forum for complex abdominal wall patients is a safe process that facilitates decision making, promotes education and improves patient care. As the AWR subspecialty evolves, our view is that the "complex hernia MDT" will become commonplace. We present our experience and share advice for others planning to establish an AWR centre.

Maximizing use of existing carcinogenicity data to support acceptable intake levels for mutagenic impurities in pharmaceuticals: Learnings from N-nitrosamine case studies

The unexpected finding of N-nitrosamine (NA) impurities in many pharmaceutical products raised significant challenges for industry and regulators. In addition to well-studied small molecular weight NAs, many of which are potent rodent carcinogens, novel NAs associated with active pharmaceutical ingredients have been found, many of which have limited or no safety data. A tiered approach to establishing Acceptable Intake (AI) limits for NA impurities has been established using chemical-specific data, read-across, or a class-specific TTC limit. There are ∼140 NAs with some rodent carcinogenicity data, but much of it is older and does not meet current guidelines for what constitutes a 'robust' bioassay. Nevertheless, these data are an important source of information to ensure the best science is used for assessing NA impurities and assuring consumer safety while minimizing impact that can lead to drug shortages. We present several strategies to maximize the use of imperfect data including using a lower confidence limit on a rodent TD50, and leveraging data from multiple NAs. Information on the chemical structure known to impact potency can also support development of an AI or potentially conclude that a particular NA does not fall in the cohort of concern for potent carcinogenicity.

Experimental determination of concentration factors of Ni, Ru and Sb in the model diatom Phaeodactylum tricornutum

This paper describes the experimental determination of concentration factors (CF) for nickel, ruthenium and antimony in the model diatom Phaeodactylum tricornutum Bohlin (Bacillariophyceae), which was chosen as a representative of marine phytoplankton. Better determinations of these CF are needed to improve the modelling of marine ecosystems at release points, where radioactive pollutants enter the ecosystem, for more accurate predictions of radiation dose to humans caused by these pollutants. A literature study revealed that the currently implemented values of these CF are based on very scarce data, and a computational sensitivity study showed that the radiation dose caused by radioisotopes of these elements depend strongly on the phytoplankton CF. Nutrient-enriched water samples from Swedish coastal waters were used as a medium for growing of the diatom species P. tricornutum and radioactive isotopes of the studied elements were added to the cultures during the exponential growth phase. The radioactivity in the P. tricornutum and in the culture medium were measured separately and used for determination of CF. Conservative estimates of the CF based on this phytoplankton proxy on the present data are 6400 L/kg for nickel, 20,000 L/kg for ruthenium and 890 L/kg for antimony, with P. tricornutum biomass masses referring to dry weight. The estimates for nickel and ruthenium are similar to previously published values, which underpins the credibility of radiation dose calculations based on these values. The estimate for antimony is uncertain, but also, to our knowledge, represents the first published experimentally based data on this CF.

A portable primary-standard level graphite calorimeter for absolute dosimetry in clinical pencil beam scanning proton beams

Objective. To report the use of a portable primary standard level graphite calorimeter for direct dose determination in clinical pencil beam scanning proton beams, which forms part of the recommendations of the proposed Institute of Physics and Engineering in Medicine (IPEM) Code of Practice (CoP) for proton therapy dosimetry.Approach. The primary standard proton calorimeter (PSPC) was developed at the National Physical Laboratory (NPL) and measurements were performed at four clinical proton therapy facilities that use pencil beam scanning for beam delivery. Correction factors for the presence of impurities and vacuum gaps were calculated and applied, as well as dose conversion factors to obtain dose to water. Measurements were performed in the middle of 10 × 10 × 10 cm3homogeneous dose volumes, centred at 10.0, 15.0 and 25.0 g·cm-2depth in water. The absorbed dose to water determined with the calorimeter was compared to the dose obtained using PTW Roos-type ionisation chambers calibrated in terms of absorbed dose to water in60Co applying the recommendations in the IAEA TRS-398 CoP.Main results.The relative dose difference between the two protocols varied between 0.4% and 2.1% depending on the facility. The reported overall uncertainty in the determination of absorbed dose to water using the calorimeter is 0.9% (k= 1), which corresponds to a significant reduction of uncertainty in comparison with the TRS-398 CoP (currently with an uncertainty equal or larger than 2.0% (k= 1) for proton beams).Significance. The establishment of a purpose-built primary standard and associated CoP will considerably reduce the uncertainty of the absorbed dose to water determination and ensure improved accuracy and consistency in the dose delivered to patients treated with proton therapy and bring proton reference dosimetry uncertainty in line with megavoltage photon radiotherapy.

Biodistribution of naturally occurring radionuclides and radiocesium in wild European perch (Perca fluviatilis)

Wild European perch (Perca fluviatilis) is one of the most important freshwater fish species, in Sweden, due to its widespread and his value for recreational fishing. Little it is known regarding the biodistribution of naturally occurring radionuclides such as ²³⁸U, ²³⁴U, ²²⁶Ra, ²¹⁰Po in perch. Therefore, in this study, perches from five lakes located in different counties in Sweden were collected to investigate the biodistribution of ²³⁸U, ²³⁴U, ²²⁶Ra, ²¹⁰Po and ¹³⁷Cs in organs and tissues of perch as well as their radiological impact. The results showed that uranium radionuclides ranged between 0.1 and 6 Bq/kg with an average value of 1.1 ± 1.5 Bq/kg. ²²⁶Ra varied from 0.4 to 8 Bq/kg with a mean concentration of 1.7 ± 1.9 Bq/kg. The ranged of ²¹⁰Po was 0.5 - 250 Bq/kg, with an average value of 24 ± 52 Bq/kg. On the other hand, the highest activity concentration of ¹³⁷Cs, 151 ± 1 Bq/kg, was detected in muscle samples of perch from Redsjösjön lake. For uranium radionuclides and ²²⁶Ra uptake from water is the main source whereas for ²¹⁰Po and ¹³⁷Cs the uptake is controlled by the perch diet. Regarding naturally occurring radionuclides, the perch tended to accumulated uranium radionuclides in fins, gills, and skin; ²²⁶Ra in bones, fins and skin and ²¹⁰Po in the organs linked to digestive system. Finally, in case of consumption, it is advised the consumption of skinned fillets of perch due to the higher bioaccumulation of the radionuclides investigated in the skin and scales.

Experimental determination of concentration factors of Mn, Zn and I in the phytoplankton species Phaeodactylum Tricornutum

Anthropogenic radionuclides released into the environment cause a radiation dose to wildlife and humans which must be quantified, both to assess the effect of normal releases, and to predict the consequences of a larger, unplanned release. To estimate the spread of the radioactive elements, the ecosystem around release points is modelled, and element uptake is usually quantified by concentration factors (CF), which relates the concentration of an element in an organism to the concentration of the same element in a medium under equilibrium conditions. In this work, we experimentally determine some phytoplankton CF that are needed for improved modelling of the marine ecosystems around nuclear facilities and release points. CFs that require better determination have been identified through literature search. Sensitivity studies, using the currently used ecosystem modelling software PREDO, show that for most studied groups, the dose committed by the respective radionuclides is almost proportional to the corresponding phytoplankton CFs. In the present work, CFs are determined through laboratory experiments with cultured phytoplankton and radionuclides of the concerned elements, assessing the element uptake by the phytoplankton through detection of the emitted radiation. The three CF assessed in this work were those for manganese, zinc and iodine in phytoplankton. Conservative estimates of these CF based on the present data are 40 000 L/kg for manganese, 50 000 L/kg for zinc and 180 L/kg for iodine with the phytoplankton masses referring to their dry weight.

First Constraints from DAMIC-M on Sub-GeV Dark-Matter Particles Interacting with Electrons

We report constraints on sub-GeV dark matter particles interacting with electrons from the first underground operation of DAMIC-M detectors. The search is performed with an integrated exposure of 85.23 g days, and exploits the subelectron charge resolution and low level of dark current of DAMIC-M charge-coupled devices (CCDs). Dark-matter-induced ionization signals above the detector dark current are searched for in CCD pixels with charge up to 7e^{-}. With this dataset we place limits on dark matter particles of mass between 0.53 and 1000  MeV/c^{2}, excluding unexplored regions of parameter space in the mass ranges [1.6,1000]  MeV/c^{2} and [1.5,15.1]  MeV/c^{2} for ultralight and heavy mediator interactions, respectively.

Use of the Arctic Sun™ 5000 targeted temperature management system to achieve rewarming during a prolonged hypothermic cardiorespiratory arrest

Cardiorespiratory arrest due to severe hypothermia may require prolonged cardiopulmonary resuscitation whilst the patient is rewarmed. There are reported cases of successful resuscitation with good neurological outcomes after prolonged arrests and resuscitation up to 9 h. However, in the majority of these cases, extracorporeal life support was used to maintain perfusion and rewarm the patient. Here, we report a case of successful cardiopulmonary resuscitation lasting 6.5 h, following cardiac arrest secondary to severe hypothermia, with rewarming using an Arctic Sun™ 5000. The Arctic Sun 5000 is a targeted temperature management device which is conventionally used to prevent hyperthermia post-cardiac arrest. In this report, we discuss the reasons why the device was used in this case and the effects of severe hypothermia on cardiac arrest management. We believe that this is the longest reported successful cardiopulmonary resuscitation in a severely hypothermic patient without the use of extracorporeal life support.

Vaccination policy strategies before and during the COVID-19 pandemic: an overview

Background

The debate on vaccination strategies has been periodically involving researchers, policymakers, and also the population. Interest waves have occurred both after a revival of childhood infectious diseases in 2016-2017, due to low vaccine coverages, and during the recent Coronavirus outbreak. This study aimed at overviewing vaccination strategies (and corresponding vaccine coverages) for childhood vaccinations and SARS-CoV-2.

Methods

Measles was chosen as a childhood vaccination indicator. Policy data were retrieved from health institutions (either European or national/regional) and, for COVID-19, also from press agencies and newspaper websites. Vaccine coverage data were retrieved from the World Bank, World Health Organisation, and UNICEF databases (for childhood vaccines), and from the “Our World in Data” platform for SARS-CoV-2. A qualitative comparison was performed between the two contexts.

Results

Unlike childhood vaccinations, few countries (and only Austria in Europe) imposed generalised COVID-19 mandates, most countries preferring targeted mandates for higher-risk groups. Many countries confirmed their traditional voluntary vaccination approach also for COVID-19, while countries historically relying on compulsory vaccination strategies, such as Slovenia and Hungary, surprisingly opted for voluntary SARS-CoV-2 vaccination, with unsatisfactory results. However, no tangible crude association was generally found between vaccination policies and achieved coverages, although factors such as cultural background, education, and religion appeared to influence the impact of vaccination policies.

Conclusions

The COVID-19 experience has enriched pre-existent vaccination strategy debates by adding interesting elements concerning attitudes toward vaccines in a novel context. Reading the available results in the frame of vaccine hesitancy determinants can help to understand the relationship between policies and actual coverages.

Key messages

Lawson Criterion for Ignition Exceeded in an Inertial Fusion Experiment

For more than half a century, researchers around the world have been engaged in attempts to achieve fusion ignition as a proof of principle of various fusion concepts. Following the Lawson criterion, an ignited plasma is one where the fusion heating power is high enough to overcome all the physical processes that cool the fusion plasma, creating a positive thermodynamic feedback loop with rapidly increasing temperature. In inertially confined fusion, ignition is a state where the fusion plasma can begin "burn propagation" into surrounding cold fuel, enabling the possibility of high energy gain. While "scientific breakeven" (i.e., unity target gain) has not yet been achieved (here target gain is 0.72, 1.37 MJ of fusion for 1.92 MJ of laser energy), this Letter reports the first controlled fusion experiment, using laser indirect drive, on the National Ignition Facility to produce capsule gain (here 5.8) and reach ignition by nine different formulations of the Lawson criterion.

O102 We know about left gastric artery embolisation and will embio provide the next solution to treat obesity?

Introduction

Left gastric artery embolisation (LGAE) is a minimally invasive procedure which has shown promising results for weight loss in recent studies and could play a key role as a treatment option in-between our current tier-3 and tier-4 services. Imperial College NHS Trust will sponsor the EMBIO trial, the first multi-centre double blinded randomised controlled trial comparing LGAE vs Placebo procedure to evaluate its efficacy on weight loss and obesity related comorbidities over a 12 month follow up period. Here, we perform a systematic review of the existing literature.

Methods

9 studies were reviewed. Studies which investigated weight loss as a % +- Ghrelin % change at 3,6 and 12 months were included as these pre-defined time points correlate with the EMBIO protocol. 6 studies met our inclusion criteria, 5 single arm studies and 1 single blinded RCT.

Results

N=62 patients were included in our analysis. Mean weight loss reported was 8.5%, 8.8% and 10% at 3, 6 and 12 months respectively post LGAE. Ghrelin levels reduced by 36%, 16.2% and 16.5% at 3, 6 and 12 months respectively post LGAE. To date, the only reported adverse events recorded include superficial gastric erosions healed on endoscopy by day 90 and one case of subclinical pancreatitis.

Conclusion

LGAE potentially offers a day case procedure under local anaesthesia and sedation to treat obesity and its metabolic complications. The EMBIO trial will provide level 1 evidence to confirm if LGAE is a viable intervention for obesity and evaluate its safety profile.

Take-home message

Left gastric artery embolisation could be the perfect solution to treat obesity in between existing tier-3 and tier-4 treatments.

POS1329 SECONDARY HAEMOPHAGOCYTIC LYMPHOHISTIOCYTOSIS: A SINGLE-CENTRE EXPERIENCE

Background

Haemophagocytic lymphohistiocytosis (HLH) is a life-threatening hyperinflammatory syndrome characterised by fever, organomegaly, cytopaenias, activated macrophages in haematopoietic organs and elevated ferritin. Primary HLH is caused by inherited defects in cytolytic pathway proteins and manifests in infancy[1]. Secondary HLH (sHLH) develops in individuals with a genetic susceptibility to hyperinflammation triggered by strongly immunogenic stimulus such as autoimmune conditions, haematological malignancy, organ transplantation or infection[2].

We present a cohort of patients with sHLH and detail their characteristics.

Objectives

To evaluate the characteristics and aetiology of sHLH patients at our Centre.

Methods

A single-centre retrospective observational study of all cases of sHLH between January 2018 and July 2021. Patients were identified from referrals and included if there was a diagnosis of HLH made by a rheumatologist with an H-score of 169 or greater. P-values were calculated using the Mann-Whitney test, unpaired t-test or Fisher exact as appropriate.

Results

30 patients (10 female) with sHLH were identified with a median age of 46, a mean H-score of 238 (range 186-317). 15 (50%) had pre-existing immunosuppression, which did not influence mortality (p=0.26). The following primary drivers were identified: lymphoma (n=8), non-HIV viral infections (n=9), first presentation of HIV/AIDS with opportunistic infections (n=4), Adult-onset Still’s disease (n=4), miliary tuberculosis (n=1), M. falciparum infection (n=1), meningococcal meningitis (n=1), checkpoint inhibitor therapy-related (n=1), and no diagnosis (n=1) - Table 1.

Table 1.

§ = Mann Whitney U test, τ = unpaired t-test, φ = Fisher exact

Total (n=30)Survived (n=18)Died (n=12)p-valueDemographicsMale2010100.78§Female1082Mean age4341470.348§Median H-score2402302540.059 τFerritin (ng/ml)4027734690484040.0949Trilineage cytopenia, n (%)9 (33%)5 (31%)4 (36%)0.28§Subgroup (not mutually exclusive)1 yr survivalLymphoma81712.5% (p=0.0025 φ)HIV/AIDS440100%AOSD440100%Transplant recipient41325%Other viral infection95444%  HSV330100%  CMV110100%  EBV1010%  Yellow fever2020%  Influenza A110100%Tuberculosis32166% with HIV220100%

Non-HIV viral infections were the most common cause overall. 6 of 9 were caused by Herpes virus family and all were primary infections. Two followed yellow fever viraemia following live vaccination and both patients died.

Mortality varied with aetiology. All four patients with AOSD survived, while 7 of 8 with lymphoma died, as per previous reports3. There was a strong association between lymphoma and mortality vs non-lymphoma sHLH (p=0.0025). Four patients post-solid organ transplantation were identified (three liver, one kidney), three with post-transplant lymphoproliferative disorder and one with CMV viraemia (50% mortality).

There was no significant difference between age, ferritin or H-score between surviving and deceased patients (Figure 1), but H-score trended higher in the deceased (p=0.059). Number of treatments given for HLH was higher in the deceased group vs survival (mean 3.41 deceased, mean 2.44 in survived). Anakinra was used in all 30 patients as treatment, including as monotherapy in one patient with HSV viraemia who survived.

Figure 1.

Conclusion

Ferritin, H-score at diagnosis or age do not appear to correlate with mortality in sHLH. Lymphoma is associated with a significantly worse outcome. Poor response to treatment and increasing numbers of treatment options is associated with increased mortality. Causes are varied and often co-exist.

References

[1]Jordan MB et al. An animal model of hemophagocytic lymphohistiocytosis (HLH): CD8+ T cells and interferon gamma are essential for the disorder. Blood. 2004.

[2]Carter SJ et al. Macrophage activation syndrome in adults: recent advances in pathophysiology, diagnosis and treatments. Rheumatology. 2019.

[3]Parikh SA et al. Prognostic Factors and Outcomes of Adults with Hemophagocytic Lymphohistiocytosis. Mayo Clin Proc. 2014.

Disclosure of Interests

None declared

213 Utility of Botox Injection in Early Laparostomy Closure for Abdominal Compartment Syndrome in Acute Severe Pancreatitis – a Case Report

Acute pancreatitis can cause significant visceral oedema due to fluid resuscitation, paralytic ileus and ascites with raised intra-abdominal pressure(IAP) and abdominal compartment syndrome (ACS >20mmHg). Failure of conservative management is an indication for decompressive laparostomy. Early fascial closure is the priority following laparostomy to reduce morbidity, mortality, and the risk of enteric fistulation. Chemical component separation with Botulinum toxin injection is proven to be of benefit prior to elective complex ventral hernia repairs and has been reported in laparostomy closure. We report our use of Botox to assist with vacuum and mesh-assisted early closure of laparostomy in a patient with acute severe pancreatitis.

A 29-year-old male was admitted with severe alcohol induced pancreatitis. He developed acute respiratory distress and was intubated and ventilated. On day 14 of admission, he developed raised IAP of >40mmHg with multiorgan dysfunction and underwent laparostomy and application of Abthera© vacuum assisted negative pressure dressing. 3 days later, the dressing was replaced and a prolene mesh was sutured to the fascial margins to allow approximation of the wound to prevent retraction of the rectus sheath. He underwent further dressing change with trimming of mesh on day 6 and received 300U of Botulinum toxin injection into the abdominal musculature bilaterally. On day 7 following botox injection, the mesh was excised, and the midline wound was closed without tension. He remained stable with normal IAP and no wound related complications. Chemical component separation with Botulinum toxin may be a valuable adjunct in early closure of laparostomy.

Development of a heterogeneous phantom to measure range in clinical proton therapy beams

PURPOSE

In particle therapy, determination of range by measurement or calculation can be a significant source of uncertainty. This work investigates the development of a bespoke Range Length Phantom (RaLPh) to allow independent determination of proton range in tissue. This phantom is intended to be used as an audit device.

METHOD

RaLPh was designed to be compact and allows different configurations of tissue substitute slabs, to facilitate measurement of range using radiochromic film. Fourteen RaLPh configurations were tested, using two types of proton fluence optimised water substitutes, two types of bone substitute, and one lung substitute slabs. These were designed to mimic different complex tissue interfaces. Experiments were performed using a 115 MeV mono-energetic scanning proton beam to investigate the proton range for each configuration. Validation of the measured film ranges was performed via Monte Carlo simulations and ionisation chamber measurements. The phantom was then assessed as an audit device, by comparing film measurements with Treatment Planning System (TPS) predicted ranges.

RESULTS

Varying the phantom slab configurations allowed for measurable range differences, and the best combinations of heterogeneous material gave agreement between film and Monte Carlo on average within 0.2% and on average within 0.3% of ionisation chamber measurements. Results against the TPS suggest a material density override is currently required to enable the phantom to be an audit device.

CONCLUSION

This study found that a heterogeneous phantom with radiochromic film can provide range verification as part of a dedicated audit for clinical proton therapy beams.

An updated report on the incidence and epidemiological trends of keratinocyte cancers in the United Kingdom 2013-2018

Introduction

The most common cancers in the UK are keratinocyte cancers (KCs): the combined term for basal cell carcinomas (BCCs) and cutaneous squamous cell carcinomas (cSCCs). Registration of KC is challenging due to high numbers and multiplicity of tumours per person.

Methods

We provide an updated report on the descriptive epidemiology of trends in KC incidence for the resident populations of UK countries (England, Northern Ireland, Scotland and Wales) using population-based cancer registry and pathology report data, 2013-18.

Results

Substantial increases in cSCC incidence in England, Scotland and Northern Ireland can be detected for the period of 2013-18, and the incidence of cSCC also increased in Wales from 2016 to 2018. In contrast, however, the pattern of annual change in the incidence of BCC across the nations differs. In England, the incidence of BCC declined slightly from 2016 to 2018, however, the overall trend across 2013-18 is not statistically significant. In Scotland, the incidence of BCC shows some variability, declining in 2017 before increasing in 2018, and the overall trend across 2013-18 was also not statistically significant. In Northern Ireland, the incidence of BCC increased significantly over the study period, and in Wales, the incidence of BCC increased from 2016 to 2018. One in five people will develop non-melanoma skin cancers (NMSC) in their lifetime in England. This estimate is much higher than the lifetime risk of melanoma (1 in 36 males and 1 in 47 females born after 1960 in the UK), which further highlights the burden of the disease and importance of early prevention strategies.

Conclusions

We highlight how common these tumours are by publishing the first ever lifetime incidence of NMSC. Additionally, the first time reporting of the age standardised incidence of KC in Wales further confirms the scale of the disease burden posed by these cancers in the UK. With approximately one in five people developing NMSC in their lifetime, optimisation of skin cancer prevention, management and research are essential.

1630 Laparoscopic Repair of Linea Arcuata Hernia Presenting as Generalised Abdominal Pain - a Case Report

Background

Arcuate line hernia (LAH) is an abnormal ascending herniation of intraperitoneal structures over the linea arcuate, between the rectus abdominus muscle and the posterior layer of its sheath. It is a rare clinical entity often associated with non-specific abdominal pain, posing a significant diagnostic challenge. The true prevalence is unknown, and diagnosis is almost always radiological.

Case Report

We report the case of a 57-year-old lady investigated extensively for frequent episodes of generalised abdominal pain. No palpable hernial defect or other pathology was identified on clinical examination. Subsequent computed tomography(CT) of the abdomen and pelvis revealed a 95 x 74 mm arcuate line hernia(LAH) anterior to the transversalis fascia, containing small bowel loops. She underwent an elective laparoscopic repair involving closure of the hernial defect with 2-0 knotless barbed sutures and reinforcement with a 20 x 15 cm underlay mesh. Postoperative recovery was uneventful, with complete resolution of her symptoms. One year after the repair there were no signs of recurrence.

Discussion

To our knowledge, only eleven prior cases of symptomatic LAH have been reported in the literature. There is no conclusive evidence regarding most appropriate diagnostic imaging, treatment approach and follow up regimen. Clinical diagnosis is difficult. Existing literature suggests use of CT scan as the primary imaging modality for diagnosis. The laparoscopic approach is safe, feasible and has certain advantages. This includes confirmation of diagnosis, excludes the presence of concomitant hernias and enables inspection of herniated viscera. Prosthetic mesh reinforcement is considered to minimise recurrence. Long term follow-up of these patients is required

A summary of the updated report on the incidence and epidemiological trends of keratinocyte cancers in the United Kingdom 2013-2018

Skin cancer is the commonest cancer in the UK. Skin cancer referrals via the two-week wait (urgent suspected cancer) pathway outnumber any other suspected malignancy.^{1, 2} The commonest skin cancers are keratinocyte cancers (KCs) which represents Basal Cell Carcinomas (BCC) and Cutaneous Squamous Cell Carcinomas (cSCC). Accurate KC incidence reporting is crucial for healthcare planning.

Neutron calorimeter design for pulsed neutron experiment diagnostics

Neutron calorimeter for diagnostic support of both fission- and fusion-based pulsed neutron experiments is described. The calorimeter generates a voltage signal output via a pair of thermocouples contacting a sample material, which experiences a temperature increase due to interactions with an incident neutron fluence. Advantages of the calorimeter include the versatility derived from its small size, modularity, and the variety of employable neutron absorber materials and sizes. These characteristics permit use with neutron energies between the thermal and fast (up to 14 MeV) spectra. Design overview and requirements, Monte Carlo particle transport simulation results, test data, and possibilities for calorimeter development are provided and discussed.

6 Plantar plate repair – a single centre, single procedure case series

Aim

The plantar plate (PP) is an important structure that maintains stability of the metatarsophalangeal joints1 and is commonly injured in athletes such as sprinters and ballet dancers. However, clinical outcomes following plantar plate repair are limited due to the lack of studies and the heterogeneity of surgical procedures.2 This retrospective case series reviews the pre- and post-operative outcomes of a single-procedure PP repair series.

Methods

Patients who underwent PP repair using the Arthrex Complete Plantar Plate Repair System (CPR™) were identified in a single academic hospital centre. Pre- and post-operative outcomes were compared using clinical notes, radiological evaluation and the national podiatry surgery clinical outcomes database (PASCOM-10). Parameters measured included PP rupture grading, congruence, alignment, joint stability and Manchester-Oxford Foot Questionnaire (MOXFQ) scores.

Results

A total of 20 patients with confirmed PP rupture underwent CPR™ procedure with a team comprising 4 surgeons. Post-operative congruence correction was achieved in 95% of patients, whereas average alignment score (range 0–4) improved from 2.7 to 0.5 and joint stability score (range 0–4) from 2.6 to 0.25. MOXFQ functional outcome scores were available for 65% of patients, showing a 42%, 53% and 42% improvement for weightbearing (W/S), pain and social interaction (SI) domains respectively.

Conclusions

This is the first single-centre, single procedure PP repair case series. Objective radiological and clinical measures showed good improvement in the majority of patients. Functional outcome scores were more heterogeneous and limited by incomplete data collection. Our results appear replicable with no difference between surgeons performing the same procedure.

References

Nery C, Coughlin M, Baumfeld D, Raduan F, Mann TS, Catena F. How to classify plantar plate injuries: parameters from history and physical examination. Rev Bras Ortop 2015; 50(6):720–728.

Elmajee M, Shen Z, A’Court J, Pillai A. A Systematic Review of Plantar Plate Repair in the Management of Lesser Metatarsophalangeal Joint Instability. The Journal of Foot & Ankle Surgery 2017; 56(6):1244–1248.

OP0286 CHARACTERISTICS ASSOCIATED WITH SEVERE COVID-19 OUTCOMES IN SYSTEMIC LUPUS ERYTHEMATOSUS (SLE): RESULTS FROM THE COVID-19 GLOBAL RHEUMATOLOGY ALLIANCE (COVID-19 GRA)

Background:

An increased risk of severe COVID-19 outcomes may be seen in patients with autoimmune diseases on moderate to high daily doses of glucocorticoids, as well as in those with comorbidities. However, specific information about COVID-19 outcomes in SLE is scarce.

Objectives:

To determine the characteristics associated with severe COVID-19 outcomes in a multi-national cross-sectional registry of COVID-19 patients with SLE.

Methods:

SLE adult patients from a physician-reported registry of the COVID-19 GRA were studied. Variables collected at COVID-19 diagnosis included age, sex, race/ethnicity, region, comorbidities, disease activity, time period of COVID-19 diagnosis, glucocorticoid (GC) dose, and immunomodulatory therapy. Immunomodulatory therapy was categorized as: antimalarials only, no SLE therapy, traditional immunosuppressive (IS) drug monotherapy, biologics/targeted synthetic IS drug monotherapy, and biologic and traditional IS drug combination therapy. We used an ordinal COVID-19 severity outcome defined as: not hospitalized/hospitalized without supplementary oxygen; hospitalized with non-invasive ventilation; hospitalized with mechanical ventilation/extracorporeal membrane oxygenation; and death. An ordinal logistic regression model was constructed to assess the association between demographic characteristics, comorbidities, medications, disease activity and COVID-19 severity. This assumed that the relationship between each pair of outcome groups is of the same direction and magnitude.

Results:

Of 1069 SLE patients included, 1047 (89.6%) were female, with a mean age of 44.5 (SD: 14.1) years. Patient outcomes included 815 (78.8%) not hospitalized/hospitalized without supplementary oxygen; 116 (11.2) hospitalized with non-invasive ventilation, 25 (2.4%) hospitalized with mechanical ventilation/extracorporeal membrane oxygenation and 78 (7.5%) died. In a multivariate model (n=804), increased age [OR=1.03 (1.01, 1.04)], male sex [OR =1.93 (1.21, 3.08)], COVID-19 diagnosis between June 2020 and January 2021 (OR =1.87 (1.17, 3.00)), no IS drug use [OR =2.29 (1.34, 3.91)], chronic renal disease [OR =2.34 (1.48, 3.70)], cardiovascular disease [OR =1.93 (1.34, 3.91)] and moderate/high disease activity [OR =2.24 (1.46, 3.43)] were associated with more severe COVID-19 outcomes. Compared with no use of GC, patients using GC had a higher odds of poor outcome: 0-5 mg/d, OR =1.98 (1.33, 2.96); 5-10 mg/d, OR =2.88 (1.27, 6.56); >10 mg/d, OR =2.01 (1.26, 3.21) (Table 1).

Table 1.

Characteristics associated with more severe COVID-19 outcomes in SLE. (N=804)

OR (95% CI)Age, years1.03 (1.01, 1.04)Sex, Male1.93 (1.21, 3.08)Race/Ethnicity, Non-White vs White1.47 (0.87, 2.50)RegionEuropeRef.North America0.67 (0.29, 1.54)South America0.67 (0.29, 1.54)Other1.93 (0.85, 4.39)Season, June 16th 2020-January 8th 2021 vs January-June 15th 20201.87 (1.17, 3.00)Glucocorticoids0 mg/dayRef.0-5 mg/day1.98 (1.33, 2.96)5-10 mg/day2.88 (1.27, 6.56)=>10 mg/day2.01 (1.26, 3.21)Medication CategoryAntimalarial onlyRef.No IS drugs2.29 (1.34, 3.91)Traditional IS drugs as monotherapy1.17 (0.77, 1.77)b/ts IS drugs as monotherapy1.00 (0.37, 2.71)Combination of traditional and b/ts IS1.00 (0.55, 1.82)Comorbidity BurdenNumber of Comorbidities (excluding renal and cardiovascular disease)1.39 (0.97, 1.99)Chronic renal disease2.34 (1.48, 3.70)Cardiovascular disease1.93 (1.34, 3.91)Disease Activity, Moderate/ high vs Remission/ low 2.24 (1.46, 3.43)

IS: immunosuppressive. b/ts: biologics/targeted synthetics

Conclusion:

Increased age, male sex, glucocorticoid use, chronic renal disease, cardiovascular disease and moderate/high disease activity at time of COVID-19 diagnosis were associated with more severe COVID-19 outcomes in SLE. Potential limitations include possible selection bias (physician reporting), the cross-sectional nature of the data, and the assumptions underlying the outcomes modelling.

Acknowledgements:

The views expressed here are those of the authors and participating members of the COVID-19 Global Rheumatology Alliance and do not necessarily represent the views of the ACR, EULAR) the UK National Health Service, the National Institute for Health Research (NIHR), or the UK Department of Health, or any other organization.

Disclosure of Interests:

Manuel F. Ugarte-Gil Grant/research support from: Pfizer, Janssen, Graciela S Alarcon: None declared, Andrea Seet: None declared, Zara Izadi: None declared, Cristina Reategui Sokolova: None declared, Ann E Clarke Consultant of: AstraZeneca, BristolMyersSquibb, GlaxoSmithKline, Exagen Diagnostics, Leanna Wise: None declared, Guillermo Pons-Estel: None declared, Maria Jose Santos: None declared, Sasha Bernatsky: None declared, Lauren Mathias: None declared, Nathan Lim: None declared, Jeffrey Sparks Consultant of: Bristol-Myers Squibb, Gilead, Inova, Janssen, and Optum unrelated to this work., Grant/research support from: Amgen and Bristol-Myers Squibb, Zachary Wallace Consultant of: Viela Bio and MedPace, Grant/research support from: Bristol-Myers Squibb and Principia/Sanofi, Kimme Hyrich Speakers bureau: Abbvie, Grant/research support from: MS, UCB, and Pfizer, Anja Strangfeld Speakers bureau: AbbVie, MSD, Roche, BMS, Pfizer, Grant/research support from: AbbVie, BMS, Celltrion, Fresenius Kabi, Lilly, Mylan, Hexal, MSD, Pfizer, Roche, Samsung, Sanofi-Aventis, and UCB, Laure Gossec Consultant of: Abbvie, Biogen, Celgene, Janssen, Lilly, Novartis, Pfizer, Sanofi-Aventis, UCB, Grant/research support from: Lilly, Mylan, Pfizer, Loreto Carmona: None declared, Elsa Mateus Grant/research support from: Pfizer, Abbvie, Novartis, Janssen-Cilag, Lilly Portugal, Sanofi, Grünenthal S.A., MSD, Celgene, Medac, Pharmakern, GAfPA, Saskia Lawson-Tovey: None declared, Laura Trupin: None declared, Stephanie Rush: None declared, Gabriela Schmajuk: None declared, Patti Katz: None declared, Lindsay Jacobsohn: None declared, Samar Al Emadi: None declared, Emily Gilbert: None declared, Ali Duarte-Garcia: None declared, Maria Valenzuela-Almada: None declared, Tiffany Hsu: None declared, Kristin D’Silva: None declared, Naomi Serling-Boyd: None declared, Philippe Dieudé Consultant of: Boerhinger Ingelheim, Bristol-Myers Squibb, Lilly, Sanofi, Pfizer, Chugai, Roche, Janssen unrelated to this work, Grant/research support from: Bristol-Myers Squibb, Chugaii, Pfizer, unrelated to this work, Elena Nikiphorou: None declared, Vanessa Kronzer: None declared, Namrata Singh: None declared, Beth Wallace: None declared, Akpabio Akpabio: None declared, Ranjeny Thomas: None declared, Suleman Bhana Consultant of: AbbVie, Horizon, Novartis, and Pfizer (all <$10,000) unrelated to this work, Wendy Costello: None declared, Rebecca Grainger Speakers bureau: Abbvie, Janssen, Novartis, Pfizer, Cornerstones, Jonathan Hausmann Consultant of: Novartis, Sobi, Biogen, all unrelated to this work (<$10,000), Jean Liew Grant/research support from: Pfizer outside the submitted work, Emily Sirotich Grant/research support from: Board Member of the Canadian Arthritis Patient Alliance, a patient run, volunteer based organization whose activities are largely supported by independent grants from pharmaceutical companies, Paul Sufka: None declared, Philip Robinson Speakers bureau: Abbvie, Eli Lilly, Janssen, Novartis, Pfizer and UCB (all < $10,000), Consultant of: Abbvie, Eli Lilly, Janssen, Novartis, Pfizer and UCB (all < $10,000), Pedro Machado Speakers bureau: Abbvie, BMS, Celgene, Eli Lilly, Janssen, MSD, Novartis, Pfizer, Roche and UCB, all unrelated to this study (all < $10,000)., Consultant of: Abbvie, BMS, Celgene, Eli Lilly, Janssen, MSD, Novartis, Pfizer, Roche and UCB, all unrelated to this study (all < $10,000), Milena Gianfrancesco: None declared, Jinoos Yazdany Consultant of: Eli Lilly and AstraZeneca unrelated to this project

How good is operator opinion at predicting high ventricular pacing burden among patients receiving device therapy for bradycardia?

Funding Acknowledgements

Type of funding sources: None.

Introduction

Current guidelines indicate that pacing methods that maintain physiologic ventricular activation (biventricular pacing or His-bundle pacing) should be chosen over right ventricular pacing (Vp) among patients with EF 36-50% who are expected to Vp &gt;40% of the time. There are no guidelines to help predict which patients will receive a high burden of Vp and this is left to operator

opinion. We sought to ascertain whether operator opinion is an accurate predictor of high burden of Vp.

Methods

This was a single-centre single-blinded observational study of patients who received pacemaker implant for treatment of bradycardia between April 2015 and 2019 and had at least 12 month follow-up data on record. Patients’ demographic, clinical, electrocardiographic and echocardiographic data were reviewed in a blinded fashion by a senior implanting physician, who estimated whether the Vp at 12 months would exceed 40%. The Vp at approximately 12 months was obtained from the pacing records and compared with the prediction.

Results

Some 982 patients underwent pacemaker implantation during the study period, 698 for conduction system disease (CSD), 267 for sinus node disease (SND) and 17 for other conditions. Overall, 856 had valid follow-up data. Of these, 543 (63.4%) were predicted to Vp &gt;40% , and 527(61.6%) were documented as having Vp &gt;40%. The sensitivity and specificity of operator prediction were 93.2% and 84.2%, with positive and negative predictive values of 90.4% and 88.5%. Table 1 illustrates analyses of different populations by clinical parameter. In sub-group analysis, complete heart block and PR &gt; 300ms were significant factors for accurate prediction of Vp &gt; 40%, however clinical features, such as syncope, were poor discriminators.

Conclusion

In this single-centre study, among patients receiving pacemaker implant for treatment of bradycardia, operator prediction of the burden of Vp &gt;40% has an acceptable degree of accuracy. Sub-group analysis suggests that certain clinical parameters could make this prediction easier. Table 1. Comparison of operator opinion SND CSD CHB SND+PR &lt; 160 PR &gt; 300 Syncope Non-syncope n 698 267 216 84 60 409 344 Sensitivity 44.4% 97.7% 100% 6.3% 100% 86.4% 87.9% Specificity 98.3% 62.0% 45.2% 97.1% 0%* 89.9% 79.6% PPV 87.0% 90.6% 91.6% 33.3% 98.3% 94.2% 92.2% NPV 87.9% 87.9% 100% 81.5% - 77.6% 70.5% * only 1 patient did not RV pace &gt;40% - this was not predicted. SND – sinus node disease; CSD – conduction system disease; CHB – complete heart block, PPV – positive predictive value; NPV – negative predictive value

How many patients treated for bradycardia may be eligible for His bundle pacing?

Funding Acknowledgements

Type of funding sources: None.

Introduction

Pacing-Induced Cardiomyopathy (PICM) can lead to significant morbidity, requiring treatment by device upgrade procedures. The risk of occurrence is directly related to the burden of right ventricular pacing, which can be reduced by careful device programming. When frequent ventricular stimulation cannot be avoided, pacing the conduction system may offer an alternative to myocardial pacing and reduce the risk of PICM. The most recent international pacing guidelines recommend that His-bundle pacing should be considered among 1) patients with EF 36-50% and expected to require &gt;40% ventricular pacing (Vp &gt; 40%) (class IIa); and 2) patients requiring pacing who have block at the level of the AV node (class IIb).

Purpose

This study sought to determine how many patients undergoing bradycardia pacing would have fulfilled those criteria.

Methods

This was a single-centre retrospective study over a 5 year period to the end of April 2020. Demographic and clinical details of patients receiving device implants were obtained from the Pacing Service Database, along with the indication for pacing, electrocardiographic and echocardiographic data. A cardiology consultant with a special interest in pacing reviewed each case with regards to the likelihood of requiring &gt;40% ventricular pacing. Heart block at the level of the AV node was considered present if patients presented with a narrow QRS in conjunction with second or third degree heart block.

Results

1,265 patients underwent pacemaker implant for bradycardia during the study period, 888 for conduction system disease (198 second degree block, 333 complete heart block), 349 for sinus node disease and 28 for other indication. Figure 1 gives a breakdown of patients with conduction system block according to i) level of block; ii) ejection fraction; iii) expectation or not of Vp &gt; 40%.  In total, 166 patients had a class IIa indication for His-bundle pacing. 227 patients had block at the level of the AV node, of whom 36 also fulfilled the class IIa criteria for His-bundle pacing; 191 patients (16% of the total) had a sole class IIb indication for His-bundle pacing. Adjusting for the 176 patients who did not undergo echocardiography, up to an additional 45 patients may be expected to have an indication for His-bundle pacing

Conclusion

As many as 32% of patients in a bradycardia pacing population may be eligible for His-bundle pacing. This has significant implications for training and service provision. Abstract Figure 1. Flowsheet showing distribution

OP0006 ASSOCIATIONS OF BASELINE USE OF BIOLOGIC OR TARGETED SYNTHETIC DMARDS WITH COVID-19 SEVERITY IN RHEUMATOID ARTHRITIS: RESULTS FROM THE COVID-19 GLOBAL RHEUMATOLOGY ALLIANCE

Background:

Targeted DMARDs may dampen the inflammatory response in COVID-19, perhaps leading to a less severe clinical course. However, some DMARD targets may impair viral immune defenses. Due to sample size limitations, previous studies of DMARD use and COVID-19 outcomes have combined several heterogeneous rheumatic diseases and medications, investigating a single outcome (e.g., hospitalization).

Objectives:

To investigate the associations of baseline use of biologic or targeted synthetic (b/ts) DMARDs with a range of poor COVID-19 outcomes in rheumatoid arthritis (RA).

Methods:

We analyzed voluntarily reported cases of COVID-19 in patients with rheumatic diseases in the COVID-19 Global Rheumatology Alliance physician registry (March 12, 2020 - January 6, 2021). We investigated RA treated with b/tsDMARD at the clinical onset of COVID-19 (baseline): abatacept (ABA), rituximab (RTX), Janus kinase inhibitors (JAK), interleukin-6 inhibitors (IL6i), or tumor necrosis factor inhibitors (TNFi). The outcome was an ordinal scale (1-4) for COVID-19 severity: 1) no hospitalization, 2) hospitalization without oxygen need, 3) hospitalization with any oxygen need or ventilation, or 4) death. Baseline covariates including age, sex, smoking, obesity, comorbidities (e.g., cardiovascular disease, cancer, interstitial lung disease [ILD]), concomitant non-biologic DMARD use, glucocorticoid use/dose, RA disease activity, country, and calendar time were used to estimate propensity scores (PS) for b/tsDMARD. The primary analysis used PS matching to compare each drug class to TNFi. Ordinal logistic regression estimated ORs for the COVID-19 severity outcome. In a sensitivity analysis, we used traditional multivariable ordinal logistic regression adjusting for covariates without matching.

Results:

Of the 1,673 patients with RA on b/tsDMARDs at the onset of COVID-19, (mean age 56.7 years, 79.6% female) there were n=154 on ABA, n=224 on RTX, n=306 on JAK, n=180 on IL6i, and n=809 on TNFi. Overall, 498 (34.3%) were hospitalized and 112 (6.7%) died. Among all patients, 353 (25.3%) were ever smokers, 197 (11.8%) were obese, 462 (27.6%) were on glucocorticoids, 1,002 (59.8%) were on concomitant DMARDs, and 299 (21.7%) had moderate/high RA disease activity. RTX users were more likely than TNFi users to have ILD (11.6% vs. 1.7%) and history of cancer (7.1% vs. 2.0%); JAK users were more likely than TNFi users to be obese (17.3% vs. 9.0%). After propensity score matching, RTX was strongly associated with greater odds of having a worse outcome compared to TNFi (OR 3.80, 95% CI 2.47, 5.85; Figure). Among RTX users, 42 (18.8%) died compared to 27 (3.3%) of TNFi users (Table). JAK use was also associated with greater odds of having a worse COVID-19 severity (OR 1.52, 95%CI 1.02, 2.28). ABA or IL6i use were not associated with COVID-19 severity compared to TNFi. Results were similar in the sensitivity analysis and after excluding cancer or ILD.

Table 1.

Frequencies for the ordinal COVID-19 severity outcome for patients with RA on biologic or targeted synthetic DMARDs (n=1673).

COVID-19 outcomes by severity scale (n,%)ABAn=154RTXn=224JAKn=306IL6in=180TNFi n=8091)Not hospitalized113 (73.3%)121 (54.0%)220 (71.9%)150 (83.3%)666 (82.3%)2)Hospitalization without oxygenation10 (6.5%)14 (6.2%)11 (3.6%)9 (5.0%)53 (6.5%)3)Hospitalization with any oxygenation or ventilation16 (10.4%)47 (21.0%)52 (17.0%)16 (8.9%)63 (7.8%)4)Death15 (9.7%)42 (18.8%)23 (7.5%)5 (2.8%)27 (3.3%)

Conclusion:

In this large global registry of patients with RA and COVID-19, baseline use of RTX or JAK was associated with worse severity of COVID-19 compared to TNFi use. The very elevated odds for poor COVID-19 outcomes in RTX users highlights the urgent need for risk-mitigation strategies, such as the optimal timing of vaccination. The novel association of JAK with poor COVID-19 outcomes requires replication.

Acknowledgements:

The views expressed here are those of the authors and participating members of the COVID-19 Global Rheumatology Alliance and do not necessarily represent the views of the ACR, EULAR, the UK National Health Service, the National Institute for Health Research, the UK Department of Health, or any other organization.

Disclosure of Interests:

Jeffrey Sparks Consultant of: Bristol-Myers Squibb, Gilead, Inova, Janssen, and Optum, unrelated to this work, Grant/research support from: Amgen and Bristol-Myers Squibb, unrelated to this work, Zachary Wallace Consultant of: Viela Bio and MedPace, outside the submitted work., Grant/research support from: Bristol-Myers Squibb and Principia/Sanofi, Andrea Seet: None declared, Milena Gianfrancesco: None declared, Zara Izadi: None declared, Kimme Hyrich Speakers bureau: Abbvie unrelated to this study, Grant/research support from: BMS, UCB, and Pfizer, all unrelated to this study, Anja Strangfeld Paid instructor for: AbbVie, MSD, Roche, BMS, Pfizer, outside the submitted work, Grant/research support from: grants from a consortium of 13 companies (among them AbbVie, BMS, Celltrion, Fresenius Kabi, Lilly, Mylan, Hexal, MSD, Pfizer, Roche, Samsung, Sanofi-Aventis, and UCB) supporting the German RABBIT register, outside the submitted work, Laure Gossec Consultant of: Abbvie, Biogen, Celgene, Janssen, Lilly, Novartis, Pfizer, Sanofi-Aventis, UCB, unrelated to this study, Grant/research support from: Lilly, Mylan, Pfizer, all unrelated to this study, Loreto Carmona: None declared, Elsa Mateus Grant/research support from: grants from Abbvie, Novartis, Janssen-Cilag, Lilly Portugal, Sanofi, Grünenthal S.A., MSD, Celgene, Medac, Pharmakern, GAfPA; grants and non-financial support from Pfizer, outside the submitted work, Saskia Lawson-Tovey: None declared, Laura Trupin: None declared, Stephanie Rush: None declared, Gabriela Schmajuk: None declared, Patti Katz: None declared, Lindsay Jacobsohn: None declared, Samar Al Emadi: None declared, Leanna Wise: None declared, Emily Gilbert: None declared, Ali Duarte-Garcia: None declared, Maria Valenzuela-Almada: None declared, Tiffany Hsu: None declared, Kristin D’Silva: None declared, Naomi Serling-Boyd: None declared, Philippe Dieudé Consultant of: Boerhinger Ingelheim, Bristol-Myers Squibb, Lilly, Sanofi, Pfizer, Chugai, Roche, Janssen unrelated to this work, Grant/research support from: Bristol-Myers Squibb, Chugaii, Pfizer, unrelated to this work, Elena Nikiphorou: None declared, Vanessa Kronzer: None declared, Namrata Singh: None declared, Manuel F. Ugarte-Gil Grant/research support from: Janssen and Pfizer, Beth Wallace: None declared, Akpabio Akpabio: None declared, Ranjeny Thomas: None declared, Suleman Bhana Consultant of: AbbVie, Horizon, Novartis, and Pfizer (all <$10,000) unrelated to this work, Wendy Costello: None declared, Rebecca Grainger Speakers bureau: Abbvie, Janssen, Novartis, Pfizer, Cornerstones, Jonathan Hausmann Consultant of: Novartis, Sobi, Biogen, all unrelated to this work (<$10,000), Jean Liew Grant/research support from: Yes, I have received research funding from Pfizer outside the submitted work., Emily Sirotich Grant/research support from: Board Member of the Canadian Arthritis Patient Alliance, a patient run, volunteer based organization whose activities are largely supported by independent grants from pharmaceutical companies, Paul Sufka: None declared, Philip Robinson Speakers bureau: Abbvie, Eli Lilly, Janssen, Novartis, Pfizer and UCB (all < $10,000), Consultant of: Abbvie, Eli Lilly, Janssen, Novartis, Pfizer and UCB (all < $10,000), Pedro Machado Speakers bureau: Yes, I have received consulting/speaker’s fees from Abbvie, BMS, Celgene, Eli Lilly, Janssen, MSD, Novartis, Pfizer, Roche and UCB, all unrelated to this study (all < $10,000)., Consultant of: Yes, I have received consulting/speaker’s fees from Abbvie, BMS, Celgene, Eli Lilly, Janssen, MSD, Novartis, Pfizer, Roche and UCB, all unrelated to this study (all < $10,000)., Jinoos Yazdany Consultant of: Eli Lilly and AstraZeneca unrelated to this project

O45: DEFINING CELL-ENRICHED MICRORNAS TO SUPPORT RATIONAL BIOMARKER SELECTION IN HUMAN RENAL TRANSPLANTATION

Introduction

MicroRNAs are promising biomarkers of renal disease, however the cellular origin of their expression is usually unclear limiting their interpretation when measured in renal biopsies and urine. We hypothesised that by first defining renal cell-enriched microRNAs, we could select biomarkers based on the expected histopathological profile.

Method

Small RNA-sequencing of cortical, proximal tubular (LTL), macrophage (F480), endothelial (CD31) and fibroblast (PDGFRb) populations from the reversible unilateral ureteric obstruction (rUUO) murine model was performed. Hierarchical clustering was used to identify clusters. Findings were translated into an ischaemia reperfusion injury (IRI) model and then into urine samples from renal transplant recipients (n=16) with delayed graft function (DGF) vs. those with primary function.

Result

Kidney injury resulted in significant macrophage infiltration and tubular injury which improved upon reversal. We characterised novel microRNA clusters enriched for each cell type. With injury there was a significant increase in macrophage (p&lt;0.0001), fibroblast (p&lt;0.01) and decrease in proximal tubule (p&lt;0.0001) enriched microRNAs vs. non-enriched microRNAs. We validated macrophage enriched miR-18a, miR-16 and tubular enriched miR-194 in the IRI model, demonstrating that microRNA expression reflected the histological profile. In humans, urinary miR-16 (FC 16.9; p&lt;0.05) and miR-18a (FC 10: p=0.06) were upregulated at day 2 in patients with DGF; outperforming the traditional injury marker KIM1.

Conclusion

This is the first study to characterise cell-enriched microRNAs during renal injury and repair. By defining the source of microRNA expression we were able to rationally select miR-16 and miR-18a as promising urinary biomarkers of renal injury.

Take-home message

We have found that microRNAs have differences in expression between cell types and renal injury states which is important when considering microRNA expression in samples composed of varying cellular composition. By defining the cellular origins of microRNA expression we were able to rationally select microRNA biomarkers of human renal injury.

Results on Low-Mass Weakly Interacting Massive Particles from an 11 kg d Target Exposure of DAMIC at SNOLAB

We present constraints on the existence of weakly interacting massive particles (WIMPs) from an 11 kg d target exposure of the DAMIC experiment at the SNOLAB underground laboratory. The observed energy spectrum and spatial distribution of ionization events with electron-equivalent energies >200  eV_{ee} in the DAMIC CCDs are consistent with backgrounds from natural radioactivity. An excess of ionization events is observed above the analysis threshold of 50  eV_{ee}. While the origin of this low-energy excess requires further investigation, our data exclude spin-independent WIMP-nucleon scattering cross sections σ_{χ-n} as low as 3×10^{-41}  cm^{2} for WIMPs with masses m_{χ} from 7 to 10  GeV c^{-2}. These results are the strongest constraints from a silicon target on the existence of WIMPs with m_{χ}<9  GeV c^{-2} and are directly relevant to any dark matter interpretation of the excess of nuclear-recoil events observed by the CDMS silicon experiment in 2013.

Predictors for a dementia gene mutation based on gene-panel next-generation sequencing of a large dementia referral series

Next-generation genetic sequencing (NGS) technologies facilitate the screening of multiple genes linked to neurodegenerative dementia, but there are few reports about their use in clinical practice. Which patients would most profit from testing, and information on the likelihood of discovery of a causal variant in a clinical syndrome, are conspicuously absent from the literature, mostly for a lack of large-scale studies. We applied a validated NGS dementia panel to 3241 patients with dementia and healthy aged controls; 13,152 variants were classified by likelihood of pathogenicity. We identified 354 deleterious variants (DV, 12.6% of patients); 39 were novel DVs. Age at clinical onset, clinical syndrome and family history each strongly predict the likelihood of finding a DV, but healthcare setting and gender did not. DVs were frequently found in genes not usually associated with the clinical syndrome. Patients recruited from primary referral centres were compared with those seen at higher-level research centres and a national clinical neurogenetic laboratory; rates of discovery were comparable, making selection bias unlikely and the results generalisable to clinical practice. We estimated penetrance of DVs using large-scale online genomic population databases and found 71 with evidence of reduced penetrance. Two DVs in the same patient were found more frequently than expected. These data should provide a basis for more informed counselling and clinical decision making.

Optic pathway tumor in children: Toward a new classification for neurosurgical use

OBJECT

Optic pathway tumors (OPT) represent a challenge for pediatric neurosurgeons. Role of surgery is debated due to the high risk of iatrogenic damage, and in lasts decades it lost its importance in favor of chemotherapy. However, in some cases surgery is necessary to make biomolecular and histological diagnosis, to manage intracranial hypertension (IH) and to cooperate with medical therapies in controlling tumor relapse. With the aim to standardize selection of surgical OPT cases, we propose a simple, practical and reproducible classification.

METHODS

We retrospectively analyzed data of 38 patients with OPT treated at our institution (1990-2018). After careful analysis of MRI images, we describe a new classification system. Group 1: lesion limited to one or both optic nerve(s). Group 2: chiasmatic lesions extending minimally to hypothalamus. Group 3: hypothalamo-chiasmatic exophitic lesions invading the third ventricle; they can be further divided on the base of concomitant hydrocephalus. Group 4: hypothalamo-chiasmatic lesions extending widely in lateral direction, toward the temporal or the frontal lobes. Patients' data and adopted treatment are reported and analyzed, also depending on this classification.

RESULTS

Twenty children were operated on for treatment of OPT during the study period. Permanent clinical impairment was noted in 5 (25%) of operated patients, while visual improvement was noted in 1 patient. OS rate was 100% at 5 years, with a median follow up of 9 years (ranging from 2 to 23). Prevalence of intracranial hypertension and proportion of first-line surgical treatment decision were significantly higher in groups 3-4 compared to groups 1-2 (P<0.001 for both tests).

CONCLUSION

Surgery can offer a valuable therapeutic complement for OPT without major risk of iatrogenic damage. Surgery is indispensable in cases presenting with IH, as in groups 3 and 4 lesions. Eligibility of patients to surgery can be based on this new classification system.

Isolated truncal contrapulsion as a rare presentation of acute thalamic infarct

Infarcts involving the thalamus can yield many deficits, including sensory syndromes, altered consciousness, and cognitive disturbances, depending on the thalamic vascular territory involved. Isolated truncal contrapulsion due to pure thalamic infarct has been rarely reported. Truncal lateropulsion is a compelling sensation of being pulled toward one side that cannot be explained by weakness or limb ataxia. It is commonly reported in lateral medullary infarcts. It may occur with lesions that involve the peripheral vestibular system, brainstem, cerebellum, basal ganglia, ponto-mesencephalic, and thalamic lesions. We hereby report a 64-year-old woman who presented with truncal contrapulsion as the sole manifestation of an acute right lateral thalamic infarct.

226Ra, 210Po and lead isotopes in a pit lake water profile in Sweden

A pit lake arises as a consequence of anthropogenic activities in opencast mining areas. These water bodies may be enriched in hazardous stable contaminants and/or in naturally occurring radionuclides depending on the local geological conditions. Mining legacy in Sweden produced hundreds of these pit lakes and most of them are used for recreational purposes in the southern part of the country. In this paper, one pit lake was selected for having enhanced levels of natural radionuclides. Physico-chemical parameters (temperature, pH, oxidation-reduction potential, dissolved oxygen and depth), elemental composition (via Inductive Coupled Plasma Mass Spectrometry) and radiometric characterization (via alpha spectrometry of ²²⁶Ra, ²¹⁰Po and ²¹⁰Pb) were carried along the depth of a 60 m depth pit lake, with the main aim to describe how natural radionuclides and elements behaves with depth in a non-uraniferous pit lake. Based on observed changes in physico-chemical parameters, a thermocline and a chemocline region were identified at around 10 and 30 m depth respectively. Concerning radionuclides, ²²⁶Ra ranged from 75 ± 3 up to 360 ± 12 mBq/kg while ²¹⁰Po ranged from 11 ± 1 up to 71 ± 3 mBq/kg. ²¹⁰Pb distribution with depth was also determined via secular equilibrium with ²¹⁰Po after 2 years and also stable Pb was measured. Disequilibrium ²²⁶Ra-²¹⁰Pb was found and the residence time of ²¹⁰Pb in the water column was assessed. Additionally, different vertical distributions between ²¹⁰Pb and Pb were found which points out different sources for different lead isotopes in the water body.

Is obligation the proper policy to increase immunization coverage? A comparison of 16 OECD countries

Issue

Globally, between 2016 and 2018, low vaccination coverage rates led to an increase of measles cases and related deaths. The WHO European Region reported a total of 83540 measles cases and 74 deaths in 2018, versus the 5273 cases and 13 deaths in 2016, with WHO global estimates reporting 333445 cases. In order to contrast these outbreaks, the European Vaccine Action Plan 2015-2020 states that the ideal immunization coverage for measles must be 95%. Although, this rate is not reached and maintained everywhere, thus one debated solution is to adopt compulsory vaccination plans rather than recommended. Our aim is to analyse if compulsory policies may increase coverage.

Description

Between 2014 and 2018 3 countries (Italy, France and California) changed their measles vaccination policies from recommended to compulsory to fight low immunization. In order to describe the effects of this action, we compared their measles coverage rates in 2014 and 2018 together with other 12 OECD countries rates who adopt both recommendation and obligation, evaluating the trend variations. Data were collected from OECD's, WHO's and Ministries of Health's documents.

Results

After the introduction of obligation, California (91% in 2014; 95% in 2018) and Italy (87% to 94%) coverage rates increased, while France's reduced (91% to 90%). Of other mandatory countries, only Australia showed an increase (94% to 95%); totally, 37.5% mandatory countries showed an increase among the analysed ones. Through the same period, 50% of analysed countries with recommendation maintained rates over 95%, 10% increased, while 40% remained below 95%.

Lessons

Even if mandatory vaccinations can lead to a sharp increase of coverage in a short time in response to emergency situations, the causes and solutions of hesitancy are more complex than law enforcement. Some countries without obligation show rates constantly above 95% throughout the years, demonstrating that other measures can be taken to fight low immunization.

Key messages

Apart from estimates coming from WHO and OECD, it is difficult to find extensive and official information about the application and the effectiveness of vaccination policies in different countries. Low immunization coverage rates rely on different causes (information, religion, personal beliefs, trust), thus the application of mandatory vaccination alone is not sufficient to fight hesitancy.

Plus-minus lid syndrome with ataxia and severe apathy-A rare manifestation of midbrain infarct

Plus-minus lid syndrome is a rare manifestation of midbrain infarct, characterized by ptosis of one eye and lid retraction in the other eye. It has also been described in ocular myasthenia gravis, orbital myositis, or after lesions of the oculomotor nerve. Our patient was a 55-year-old man with hypertension and atrial fibrillation, who presented to us with acute onset left-sided ptosis and right-sided eyelid retraction. He was apathic and had right-sided ataxia. His MRI of the brain showed acute infarct involving the paramedian midbrain. To our knowledge, severe apathy and resultant executive function disorder have not been described previously in a patient having plus-minus lid syndrome with ataxia.

FRI0297 COMPARISON OF EFFICACY OF SECUKINUMAB VS ANTI-TNF AS SECOND LINE BIOLOGIC THERAPY IN AXIAL SPONDYLOARTHROPATHY BASED ON BASDAI RESPONSE IN AN OBSERVATIONAL STUDY

Background:

Modern biologic therapies have demonstrated encouraging results in the treatment of axial spondylarthropathy (AxSpA). The benefits of interleukin-17 inhibitors (IL-17i), as first and second line therapies, are well established [1, 2]. A systematic literature review by Navarro-Compán has shown some benefit of second line therapies using both anti-tumour necrosis factor (anti-TNF) and IL-17i [3]. To our knowledge, there are currently no studies that have directly compared which pathway has a better overall outcome. This is therefore the first observational study directly comparing both treatment arms after anti-TNF had been administered as first line therapy.

Objectives:

To investigate which second line therapy is superior, anti TNF or IL-17i (secukinumab), in patients with AxSpA, that have failed first line anti-TNF therapy.

Methods:

Patient data was extracted from the Whipps Cross Hospital Rheumatology biologics registry database. All patients selected were required to have a diagnosis of AxSpA on magnetic resonance imaging (MRI). The patient cohort that was selected had previously been treated with anti-TNF as a first line therapy and were being considered for second line therapy with either anti-TNF or IL-17i. Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) scores were recorded at 3, 6 and 12 months to assess treatment response. The unpaired t-test was used to assess the significance between the treatment groups and were analysed using the R statistical package.

Results:

Seventy patients were identified for this study of which, 57% (46/70) were male and 37% (26/70) were female. The age ranged from 30-97 years, with an average age of 72. The HLA-B27 gene association in this cohort was 71% (50/70). Three patients out of the cohort had psoriatic spondylarthropathy and the remaining had isolated AxSpA. There were an equal number of secukinumab and anti-TNF patients. The anti-TNF patients were subdivided into their respective anti-TNF drug (listed in Table 1).

Table 1.

Frequency of individual anti-TNF drugs used in this cohort.

Anti-TNF drugFrequency usedAdalimumab9/35Certolizumab8/35Etanercept17/35Golimumab1/35

This study revealed that the patients experienced an average of a 52% reduction in the BASDAI score after 6 months of anti-TNF treatment compared to only a 6% reduction in patients on secukinumab (P 0.009). However, the disease activity improvement at 12 months was not sustained in the anti-TNF group and at this stage there was no difference between the groups. Overall both treatment groups showed an average reduction in the BASDAI score by more than 30% at each 3 monthly interval.

Figure 1.

BASDAI percentage reduction at 3 monthly intervals between the two second line treatment groups using anti-TNF and Secukinumab.

Conclusion:

A significant difference could not be demonstrated between the anti-TNF and secukinumab groups in this observational cohort. Interestingly, at 6 months, anti-TNF demonstrated better outcomes according to BASDAI scores than Secukinumab but this efficacy was lost at 12 months. It was difficult to interpret these isolated results without further testing, as this is a small non-randomised study. We observed similar outcomes to the Navarro-Compán review where there was a low percentage change in the BASDAI improvement in patients on second line therapy when compared to first line treatment BASDAI scores. Therefore, exploring the mechanism for the reduction in the BASDAI response would be an interesting future study. Moreover, to fully understand these results, randomised controlled studies would need to be conducted.

References:

[1]Baeten el al. NEJM 2015.

[2]van der Heijde et al. ARD 2018.

[3]Navarro-Compán et al. RMD Open 2017.

Disclosure of Interests:

None declared

0348 Sleep EEG-Based Brain Age Index is Reduced Under Continuous Positive Airway Pressure Treatment

Introduction

Continuous positive airway pressure (CPAP) is a treatment for apnea. With long-term CPAP, changes in electroencephalogram (EEG) include increased delta power (1 - 4Hz) and sigma power (11 - 15Hz, spindle). However, the short-term EEG response to CPAP in a split-night study is less quantified. We recently developed a “brain age” model using sleep EEG features. The brain age index (BAI) is defined as the difference between chronological age and brain age (BA - CA). Here we first quantify how BAI changes during CPAP in the same patient, and then investigate how much brain age features during the diagnostic part can predict the reduction in apnea-hypopnea index (AHI) during CPAP.

Methods

The dataset consisted of 160 subjects. The average age was 59 years with 53% male, 24% female and 23% unknown. We extracted 480 features including band powers, and then computed the BAIs for both diagnostic and CPAP parts. To predict the reduction in AHI during CPAP, we fit a Bayesian regression model using the brain age features, demographics, and sleep parameters during the diagnostic part, and assessed the feature importance using dominance analysis.

Results

The BAI from the diagnostic part is significantly reduced compared to BAI during CPAP for the same subject (paired t-test, p &lt; 0.01). The diagnostic part has an average BAI 2.24 years; and the CPAP part -4.75 years. The brain age features that are increased during CPAP include sigma powers in N2 and N3. The prediction of AHI reduction has Pearson’s correlation 0.85. The features predictive of reduced AHI are the diagnostic AHI (explained variance 69%), followed by high/low waveforms during N2 (e.g. K-complex, measured by kurtosis) (8.6%), delta power during REM (4.5%) and N1 (2%). The feature predictive of increased AHI is frontal alpha power during quiet awake (2.6%).

Conclusion

The average BAI is reduced during CPAP. BAI provides a novel view of the acute response to CPAP in sleep EEG. Future study with more CPAP failure patients has the potential of predicting CPAP failure.

Support

MBW is supported by Glenn Foundation for Medical Research. RJT is supported by Category I AASM Foundation.

0661 Comparison Between Ventilator Detected Apnea Hypopnea Index and Manual Scored Results

Introduction

The apnea hypopnea index and percentage of periodic breathing detected by the ventilator machine are often used by sleep doctors to evaluate whether sleep apnea has been adequately treated or need further interventions. There are concerns about the accuracy of this autodetection.

Methods

Patients with sleep apnea who were treated with positive airway pressure at the Beth Israel Deaconess Medical Center (Boston) and tracked by the EncoreAnywhere system were included. The machine detected AHI(AHIm) and PB(PBm) were extracted from the first week data in every month from the start of use. The manual scored AHI(AHIs) and PB(PBs) were calculated from the last waveform graph during every month. The apnea hypopnea index as well as periodic breathing in 1st, 2nd, 3rd,6th month AHIm, AHIs, PBm and PBs were compared respectively.

Results

A total of 128 patients were included. The mean age was 56.5 and 66% of them were male. In the first month, the mean AHIs was significantly higher than AHIm, 16.27 vs. 5.36, p&lt;0.001. There was also a large difference between percentage of PBs and PBm, 15.55% vs. 1.96, p&lt;0.001. 78% patients whose AHIm &lt;5 were actually has AHIs &gt;5. The Kappa value for the AHIm and AHIs were 0.074, p=0.069; the value of PBm and PBs was 0.216, p=0.015. In the 2nd, 3rd and 6th months, the mean difference between AHIs and AHIm was 10.58, 10.68, 10.12, respectively. The mean difference between PBs and PBm was 12.32%,11.53%,and 9.18%.

Conclusion

Autodetection of respiratory events consistently under-estimates the severity of residual events. Mean differences remained stable over 6 months. Caution is recommended when attributing non-apnea reasons for residual symptoms in patients with apparently low machine estimated AHI and PB.

Support

This study is supported by American Academy of Sleep Medicine Foundation, category-I award to RJT