Implementation of sonopartogram: multicenter feasibility study

OBJECTIVES

Well-established clinical practice to assess progress in labor involves routine abdominal palpation and vaginal examination (VE). However, VE is subjective, poorly reproducible and painful for women. In this study, our aim is to evaluate the feasibility of systematically integrating transabdominal and transperineal ultrasound assessment of fetal position, psAOP, HPD and SCD to monitor labor progress in women undergoing induction of labor (IOL). We also aim at determining if ultrasound can reduce women's pain during examinations.

METHODS

Women were recruited as they presented for IOL in three maternity units. Ultrasound assessments were performed in 100 women between 37+0 and 41+6 weeks' gestation. A baseline combined transabdominal and transperineal scan was performed, including the assessment of fetal biometry, umbilical artery and middle cerebral artery Dopplers, amniotic fluid index (AFI), fetal spine and occiput positions, psAOP, HPD, SCD, and cervical length. Intrapartum scans were performed instead of VEs according to protocol. Participants were asked to indicate their level of pain by verbally giving a pain score from 0 - 10 (with 0 representing no pain) during assessment. The repeated measures data were analyzed by mixed effect models to identify the significant factors that affected the relationship between psAOP, HPD, SCD and mode of delivery.

RESULTS

223 intrapartum ultrasound scans with a median of 2 scans per participant (interquartile range (IQR) = 1 - 3), and 151 VEs were performed with a median of 1 per participant (IQR = 0 - 2). There were no adverse fetal or maternal outcomes. After excluding those with epidural anesthesia during examination, median pain score for intrapartum scan was 0 (IQR = 0 - 1) and 3 for VE (IQR = 0 - 6). Cesarean delivery and epidural anesthesia were significantly associated with slower rate of change in psAOP, HPD and SCD. Maternal height, parity and neonatal birth weight did not affect ultrasound measurements of labor progress.

CONCLUSIONS

Comprehensive transabdominal and transperineal ultrasound assessment can be successfully used to assess progress in labor and can reduce the level of pain experienced during examination. Ultrasound assessment may be able to replace some transabdominal and VE examinations during labor. This article is protected by copyright. All rights reserved.

Long-term trends in the incidence and management of shoulder dystocia in a tertiary obstetric unit in Hong Kong

INTRODUCTION

Because there have been changes in the management of macrosomic pregnancies and shoulder dystocia in the past decade, this study was conducted to compare the incidences of shoulder dystocia and perinatal outcomes between the periods of 2000-2009 and 2010-2019.

METHODS

This retrospective study was conducted in a tertiary obstetric unit. All cases of shoulder dystocia were identified using the hospital's electronic database. The incidences, maternal and fetal characteristics, obstetric management methods, and perinatal outcomes were compared between the two study periods.

RESULTS

The overall incidence of shoulder dystocia decreased from 0.23% (134/58 326) in 2000-2009 to 0.16% (108/65 683) in 2010-2019 (P=0.009), mainly because of the overall decline in the proportion of babies with macrosomia (from 3.3% to 2.3%; P<0.001). The improved success rates of the McRoberts' manoeuvre (from 31.3% to 47.2%; P=0.012) and posterior arm extraction (from 52.9% to 92.3%; P=0.042) allowed a greater proportion of affected babies to be delivered within 2 minutes (from 59.0% to 79.6%; P=0.003). These changes led to a significant reduction in the proportion of fetuses with low Apgar scores: <5 at 1 minute of life (from 13.4% to 5.6%; P=0.042) and <7 at 5 minutes of life (from 11.9% to 4.6%; P=0.045).

CONCLUSION

More proactive management of macrosomic pregnancies and enhanced training in the acute management of shoulder dystocia led to significant improvements in shoulder dystocia incidence and perinatal outcomes from 2000-2009 to 2010-2019.

A point-of care urine test to predict preeclampsia development in Asian women with suspected preeclampsia

OBJECTIVES

To evaluate the diagnostic performance and clinical utility of the urine Congo red dot test (CRDT) in predicting preeclampsia (PE) within 7 days, 14 days and 28 days of assessment.

STUDY DESIGN

A prospective single center double blind non-intervention study conducted from January 2020 to March 2022. Urine congophilia has been proposed as a point-of-care test for the prediction and rapid identification of PE. In our study, urine CRDT and pregnancy outcomes were assessed in women presenting with clinical features of suspected PE after 20 weeks of gestation.

RESULTS

Among the 216 women analyzed, 78 (36.1 %) women developed PE, in which only 7 (9.0 %) of them had a positive urine CRDT test. The median (IQR) interval between the initial test and the diagnosis of PE was significantly shorter for women with a positive urine CRDT compared with women with a negative urine CRDT (1 day (0-5 days) vs 8 days (1-19 days), P = 0.027). The negative predictive value of a negative urine CRDT test for PE within 7 days, 14 days and 28 days of assessment were 83.73 % (95 %CI 81.75 %- 85.54 %), 78.92 % (95 % confidence interval [CI] 77.07 %- 80.71 %) and 71.77 % (95 %CI 70.06 %- 73.42 %) respectively. The sensitivity of the urine CRDT in ruling in PE within 7 days, 14 days and 28 days of assessment were 17.07 % (95 %CI 7.15 %- 32.06 %), 13.73 % (95 %CI 5.70 %- 26.26 %) and 10.61 % (95 %CI 4.37 %- 20.64 %), respectively.

CONCLUSIONS

Urine CRDT alone has high specificity yet low sensitivity in the short-term prediction of PE in women with suspected PE. Further studies are required to evaluate its clinical utility.

Neonatal mortality in singleton pregnancies: a 20-year retrospective study from a tertiary perinatal unit in Hong Kong

INTRODUCTION

The global neonatal death (NND) rate has been declining in recent decades, but there are no comprehensive data concerning the characteristics of NNDs in Hong Kong. This study investigated the trends and aetiologies of NNDs among singleton pregnancies in Hong Kong.

METHODS

This study included all cases of NND from singleton pregnancies in a tertiary hospital in Hong Kong between 2000 and 2019. The rates, clinical characteristics, and aetiologies of NND were compared between the first (2000-2009) and the second (2010-2019) decades.

RESULTS

The NND rate decreased from 1.66/1000 livebirths (97 cases) in the first decade to 1.32/1000 livebirths (87 cases) in the second decade. Congenital or genetic abnormalities (82 cases) caused 44.6% of all NNDs. There was a significant reduction from 0.82/1000 livebirths in the first decade to 0.52/1000 livebirths in the second decade (P=0.037). Other causes of NND were prematurity (69 cases; 37.5%), sepsis (16 cases; 8.7%), hypoxic-ischaemic encephalopathy (15 cases; 8.2%), and sudden infant death syndrome (2 cases; 1.1%). Gestational age-specific neonatal mortality for moderately preterm neonates (31-33 weeks of gestation) significantly decreased from 34.73/1000 in 2000-2009 to 8.63/1000 in 2010-2019 (P=0.001), but there were no significant changes in neonatal mortality for other gestations.

CONCLUSION

The NND rate in Hong Kong is among the lowest worldwide. Neonatal deaths in our centre declined over the past two decades, mainly because of improvements in the prenatal diagnosis and treatment of congenital or genetic abnormalities, as well as an improved survival rate among moderately preterm neonates.

Perinatal mortality rate in multiple pregnancies: a 20-year retrospective study from a tertiary obstetric unit in Hong Kong

INTRODUCTION

Multiple pregnancies have become more common, but their perinatal mortality rate remains higher than the rate among singleton pregnancies. This retrospective study investigated the prevalence and causes of perinatal mortality among multiple pregnancies in Hong Kong.

METHODS

All multiple pregnancies in a university tertiary obstetric unit between 2000 and 2019 were reviewed, and the medical records of cases complicated by stillbirth and neonatal death were identified. The causes of perinatal mortality were determined based on clinical assessment and laboratory results, then compared between the first (2000-2009) and second (2010-2019) decades.

RESULTS

The prevalence of multiple pregnancies increased from 1.41% in the first decade to 1.91% in the second decade (P<0.001). Compared with the first decade, the second decade had a lower stillbirth rate (14.72 vs 7.68 [both per 1000 births]; P=0.026), late neonatal death rate (4.78 vs 1.16 [both per 1000 livebirths]; P=0.030), and total mortality rate (25.32 vs 13.82 [both per 1000 births]; P=0.006). The decline in stillbirth rate was related to improvements in antenatal care and treatment. The decline in the late neonatal death rate was related to a reduction in preterm birth before 34 weeks (18.5% vs 15.2%; P=0.006), as well as an improvement in the mortality rate in the subgroup of 31-33 weeks (19.23 vs 0 [both per 1000 livebirths]; P=0.035).

CONCLUSION

Although the prevalence of multiple pregnancies increased during the study period, the corresponding total perinatal mortality rate improved by 45.4%.

POS0372 USE OF TELEMEDICINE FOR FOLLOW-UP OF LUPUS NEPHRITIS IN THE COVID-19 OUTBREAK: ONE-YEAR, PRAGMATIC RANDOMISED CONTROLLED TRIAL

Background

Patients with systemic lupus erythematosus (SLE) are at increased risk of severe COVID-19 due to the underlying disease, comorbidities and use of immunosuppressants (IS). An alternative option would be to adopt telemedicine (TM) to maintain medical care while minimizing exposure. Despite being widely adopted during the pandemic, the evidence supporting the use of TM in rheumatology has been limited.

Objectives

We primarily aimed to evaluate the effectiveness to maintain disease activity control using TM delivered care compared to conventional in-person follow-up in patients with lupus nephritis (LN). The secondary objectives were to compare the patient reported outcomes, safety and cost-of-illness from the patient’s perspective between the 2 modes of health care delivery.

Methods

This was a 1-year, single-center, RCT conducted at a regional hospital in Hong Kong. From May 2020, consecutive adult patients with a SLE according to the 2019 EULAR/ACR classification criteria followed up at the LN clinic were invited to participate in the study. Participants were randomized 1:1 to either TM (TM group) or standard FU (SF group). Patients randomized to receive TM FU were scheduled for a video consultation via a commerical software ZOOM. Patients in the SF group received standard in-person outpatient care. SLE disease activity at each consultation was assessed by SLEDAI-2k and physician global assessment (PGA).

Results

A total of 144 patients with LN were randomized and 3 patients self-withdrew from the study. The mean age was 44.5±11.4 years and the median time from diagnosis to randomization was 168 months (range: 1-528). Most of the patients had class III, IV or V LN (87.2%) and were on prednisolone (89.4%, median dose 5mg daily). Many of them (68.1%) were on IS. While 66.0% of the patients were in lupus low disease activity state (LLDAS), none had disease remission. There were no baseline differences, including demographics, SLEDAI-2k (TM: 3.8±2.3, SF: 3.2±2.2, p=0.13, PGA (TM: 6.2±6.5, SF: 4.6±5.9, p=0.13) and SLE damage index (TM: 1.1±1.3, SF: 0.8±1.1, p=0.10), between the 2 groups.

At one year, 80.0% and 80.2% of the patients in the TM group and SF group were in LLDAS or remission respectively. SLE disease activity indices including SLEDAI-2k, PGA, proteinuria amount and serum anti-ds-DNA level remained similar between the 2 groups. Within the study period, 28 (40%) patients in the TM group and 21 (29.6%) patients in the SF group had disease flare (p=0.20). There were no differences in the SF-36, lupusQoL and HADS scores between the 2 groups at the end of the study. The overall patient satisfaction score was higher in the TM group with a significantly shorter waiting time before seeing doctors. At the end of the study, 67.9% of the overall participants agreed to (versus 15.0% who did not agree to) use TM as a mode of future FU.

The mean indirect costs of illness (HKD26,681 vs HKD12,016, p=0.20) and the out-of-pocket costs for health care services were similar between the 2 groups (TM: HKD13,547 vs SF: HKD12,297, p=0.83) in one year. The total number of FU was similar (TM: 6.0±2.0, SF: 5.7±1.7, p=0.40). However, significantly more patients in the TM group (29/70, 41.4% vs 4/71, 5.6%; p<0.01) requested change mode of FU. The proportion of patients requiring hospitalization during the study period was also higher in the TM group (TM: 23/70, 32.9% vs 11/71, 15.5%; p=0.02). After adjusting for age and prednisolone dosage, not being in LLDAS at baseline was the predictor of hospitalization (OR 3.4, 95%CI 1.20-9.65). None of the participants was tested positive for COVID-19.

Conclusion

TM FU resulted in similar 1-year disease activity control and better satisfaction in patients with LN compared to standard care. However, a significant proportion of patients cared by TM required in-person visits or were hospitalized. The results of the study suggest that TM delivered care could help minimizing exposure to COVID-19, but it needs to be complemented by physical visits, particularly in those with unstable disease.

Acknowledgements

We would also like to thank the University of Central Lancashire & East Lancashire Hospitals NHS Trust for granting us permission to use the LupusQoL questionnaire.

Disclosure of Interests

None declared

OP0241 BONE MICROARCHITECTURE ASSESSED BY HIGH-RESOLUTION PERIPHERAL QUANTITATIVE COMPUTED TOMOGRAPHY (HR-pQCT) PREDICTS FRACTURE RISK IN PATIENTS WITH RHEUMATIC DISEASES ON GLUCOCORTICOIDS

Background

Peripheral bone micro-architectural parameters assessed by high-resolution peripheral quantitative computer tomography (HR-pQCT) were able to discriminate vertebral fracture in patients with rheumatic diseases on glucocorticoid (GC) independent of areal bone mineral density aBMD. Whether these parameters could predict future fracture remained to be determined.

Objectives

The aim of this study was to compare the differences in baseline vBMD, bone microarchitecture and estimated bone strength in these patients with and without incident fragility fracture over a period of 5 years.

Methods

This was a multi-centered, retrospective, case-controlled study. Patients with rheumatic diseases on long term GC from 7 regional hospitals who had dual-energy X-ray absorptiometry (DXA) and HR-pQCT done were invited to have a 5th year follow-up assessment. X-rays were repeated. The occurrence of new fragility fracture after 5 years was documented. The baseline clinical characteristics, aBMD, FRAX and HR-pQCT parameters in patients who experienced a new fragility fracture during the 5-year follow-up period (incident fracture group) were compared with patients who did not experience a fragility fracture (control group).

Results

A total of 140 patients were recruited. The mean age of the patients, who were mostly female (80.7%), was 58.7 ± 12.5 years at baseline. SLE and RA were the commonest diagnoses. At baseline, 45.0% and 28.6% of the patients had osteopenia or osteoporosis respectively. The baseline 10-year major osteoporotic and hip fracture risks by FRAX were 13.3% and 6.0% respectively. After 5 years, 47 (33.6%) of the patients developed new fractures. The baseline clinical characteristics of incident facture group and the control group are shown in Table 1. Patients with incident fracture were older. They also had more prevalent fracture and worse mobility. The aBMD and FRAX scores were significantly higher in the incident fracture group. When comparing the HR-pQCT parameters, the incident fracture group had significantly worse vBMD, microarchitecture and bone strength particularly over the tibia at baseline. However, the changes in these parameters were not different between the 2 groups. Multivariate regression confirmed that the baseline vBMD, microarchitectural parameters and estimated bone strength over distal tibia were independent predictors of new fractures after adjusting for age, gender as well as baseline fracture, mobility and osteoporosis status.

Table 1.

Demographic and clinical characteristics at baseline

Control groupn=93Incident fracture groupn=47pAge (years)57 ± 1262 ± 120.015Gender, n (%)Female74 (79.6%)39 (83%)0.629Disease typeSLE40 (43.5%)21 (44.7%)0.711RA19 (20.7%)12 (25.5%)Others33 (35.9%)14 (29.8%)Mobility class, n (%)Ambulatory82 (88.2%)34 (72.3%)0.046Stick-walking9 (9.7%)12 (25.5%)Chair-bound2 (2.2%)1 (2.1%)Previous fracture, n (%)10 (10.8%)12 (25.5%)0.023MedicationsCumulative prednisolone dose (g)20.4 ± 18.722.0 ± 15.50.604Ever or current anti-osteoporotic treatment, n (%)15 (16.1%)11 (23.4%)0.310aBMD (g/cm2) atFemoral neck0.66 ± 0.120.60 ± 0.120.009Lumbar spine0.86 ± 0.150.80 ± 0.160.025FRAX score (%)Major osteoporotic fracture9.9 ± 9.420.6 ± 17.3<0.001Hip fracture3.7 ± 5.610.8 ± 13.20.001HR-pQCT parameters*Distal radius:mTb.vBMD82.0 ± 45.262.6 ± 42.40.016Distal tibia:Average vBMD258 ± 70225 ± 700.010Tb. vBMD144 ± 42122 ± 400.003pTb. vBMD221 ± 52197 ± 460.010mTb.vBMD91.3 ± 37.770.0 ± 40.00.002Tb. number1.50 ± 0.281.36 ± 0.340.010Stiffness162139 ± 42623142054 ± 353750.004Est. failure load-8173 ± 2083-7200 ± 17440.004

*Only statististically significant parameters are shown

Conclusion

A significant proportion (33.6%) of patients with rheumatic diseases on long-term GC developed new fragility fracture in 5 years, which could be predicted by the worse vBMD, microarchitecture and bone strength over tibia at baseline on HR-pQCT independent of aBMD.

Disclosure of Interests

None declared

POS1164 USE OF TELEMEDICINE FOR FOLLOW-UP OF SLE PATIENTS WITH NEPHRITIS IN THE COVID-19 OUTBREAK (“TeleSLE”): THE 6-MONTH RESULTS OF A RANDOMIZED CONTROLLED TRIAL

Background:

Patients with lupus nephritis (LN) might be more susceptible to COVID-19 due to the underlying disease, co-morbidities and use of immunosuppressants. We hypothesized that telemedicine (TM) could be a well-accepted mode of health-care delivery minimizing the risk of exposure to the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), while maintaining disease control in these patients.

Objectives:

To evaluate the short-term patient satisfaction, compliance, disease control and infection risk of TM compared with standard in-person follow-up (FU) for patients with LN during COVID-19.

Methods:

This was a single-center randomized-controlled study. Consecutive patients followed at the LN clinic were randomized to either TM (TM group) or standard FU (SF group) in a 1:1 ratio. Patients in the TM group received scheduled follow-ups via videoconferencing. SF group patients continued conventional in-person outpatient care. The 6-month data were compared.

Results:

From June to December 2020, 122 patients were randomized (TM: 60, SF: 62) and had attended at least 2 FU visits. There were no baseline differences, including SLEDAI-2k and proportion of patients in lupus low disease activity state (LLDAS), between the 2 groups except a higher physician global assessment score (PGA) in the TM group (mean 0.67±0.69 vs 0.45±0.60, p=0.003) (Table 1). The mean FU duration was 19.8±4.5 weeks. When comparing the most recent visit, the mean waiting time between entering the clinic waiting room (virtual or real) and seeing a rheumatologist (virtual or in-person) was significantly shorter in the TM group (22.5±28.6 vs 68.9±40.7 minutes, p< 0.001) (Figure 1A). The mean overall patient satisfaction score was higher in the TM group (mean 2.19±0.61 vs 1.89±0.78, p=0.042). The results of the post-consultation satisfaction questionnaire are shown in Figure 1B. The number of visits was similar in the two groups (TM: 3.1±1.3 vs SF: 3.0±1.2, p=0.981). However, there was a trend suggesting that alternative mode of FU was requested more frequently in the TM group than the SF group (TM: 12/60, 20.0% and SF: 5/62, 8.1%; p=0.057). More patients in the TM group had hospitalization (15/60, 25.0% vs 7/62, 11.3%; p=0.049) within the FU period, which was no longer statistically significant after adjusting for the baseline PGA. The proportions of patients remained in LLDAS were similar in the 2 groups (TM: 75.0% vs SF: 74.2%, p=0.919). None of the patients had COVID-19.

Conclusion:

TM resulted in better patient satisfaction and could achieve similar disease control in patients with LN in the short-term when compared to standard care.

Table 1.

Baseline clinical data of the recruited patients and comparison between the telemedicine/standard follow-up groups

Overall (n=122)Telemedicine group (n=60)Standard follow-up group (n=62)P-valueAge in years44.4±11.544.1±11.744.7±11.50.779Gender: Female111 (91.0)55 (91.7)56 (90.3)0.796Disease duration in years15.1±9.016.2±8.714.0±9.10.115Nephritis class III, IV or V108 (88.5)54 (90.0)54 (87.1)0.42724 hour urine proteinuria in gram0.51±0.630.53±0.600.50±0.650.712Current use of prednisolone112 (91.8)57 (95.0)55 (88.7)0.323Daily prednisolone dose in mg5.51±4.215.69±4.175.34±4.290.570Use of immunosuppressant90 (73.8)46 (76.7)44 (71.0)0.474SLEDAI-2K3.65±2.334.00±2.343.30±2.290.097PGA0.56±0.650.67±0.690.45±0.600.003LLDAS78 (63.9)36 (60.0)42(67.7)0.251Remission0 (0)0 (0)0 (0)n/aPresence of comorbidity87 (71.3)40 (66.7)47 (75.8)0.264SDI0.93±1.151.08±1.280.78±0.980.243HAQ-DI0.23±0.460.25±0.470.21±0.440.571HADS:Anxiety scaleDepression scale6.07±4.125.72±4.316.20±4.195.73±3.935.93±4.095.70±4.680.7200.724

Data are reported as mean ± SD or number (%). LLDAS: lupus low disease activity state; SDI: Systemic Lupus International Collaborating Clinics/American College of Rheumatology (SLICC/ACR) Damage Index; HAQ-DI: Health Assessment Questionnaire Disability Index; and HADS: Hospital Anxiety and Depression Scale.

Disclosure of Interests:

Ho SO: None declared, Evelyn Chow: None declared, Tena K. Li: None declared, Sze-Lok Lau: None declared, Isaac T. Cheng: None declared, Cheuk-Chun Szeto: None declared, Lai-Shan Tam Grant/research support from: Grants from Novartis and Pfizer.

POS1222 FACTORS ASSOCIATED WITH USE OF TELEMEDICINE FOR FOLLOW-UP OF LUPUS NEPHRITIS IN THE COVID-19 OUTBREAK

Background:

It is important to weigh the potential risk of exposure to the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) during a doctor visits against the risk of missing disease controls in patients with lupus nephritis during the COVID-19. Telemedicine (TM) follow-up is a reasonable option. Despite the recent exponential increase in application worldwide, there is no study examining the clinical factors associated with the patients‘ choice of TM use in lupus nephritis.

Objectives:

In this study, we aimed to examine the clinical variables associated with a higher preference for TM follow-up in patients with lupus nephritis.

Methods:

Consecutive patients followed at the lupus nephritis clinic were contacted for their preferred mode of follow-up. The demographic, socioeconomic and clinical data of the first 140 patients opted for TM and 140 patients preferred to continue standard in-person follow-up were collected and compared.

Results:

The mean age of the 280 recruited patients was 45.6 ± 11.8 years. The mean disease duration was 15.0 ± 9.2 years. The majority of them had lupus nephritis class III, IV or V (88.2%) and were on prednisolone (90%). Three quarters of the patients (67.1%) were on immunosuppressants. The mean SLEDAI-2k was 4.06 ± 2.54, physician global assessment (PGA) 0.46 ± 0.62 and SLICC/ACR damage index 1.11 ± 1.36. A significant proportion of the patients (72.1%) had one or more comorbidities. It was found that patients with higher PGA and family monthly income (> USD3,800) preferred TM, while fulltime employees preferred in-person follow-up (Table 1). These predictors remained significant after controlling for age in the multivariate analysis with odd ratios for PGA 1.05 (95% CI 1.01-1.09), family income >USD3,800 1.90 (95% CI 1.24-3.79) and fulltime employment 0.53 (95% CI 0.32-0.88). PGA was noted to be positively correlated with the perceptions that TM reduces (r=0.13, p=0.036) and routine visit increases (r=0.12, p=0.04) the risk of COVID-19 during the outbreak.

Conclusion:

When choosing the mode of care delivery between TM and clinic visit, the patient’s disease activity as well as employment and economic status appeared to be important.

Table 1.

Demographic, socio-economic and disease data of the recruited lupus nephritis patients with comparison between the telemedicine/standard follow-up groups

Overall (n=280)Telemedicine group (n=140)Standard follow-up group (n=140)P-valueAge in years45.6±11.844.6±11.446.6±12.10.159Gender: Female256 (91.4)127 (90.7)129 (92.1)0.669Ever presence of rash170 (60.8)87 (62.1)82 (58.6)0.527Ever presence of joint pain174 (62.1)92 (65.7)82 (58.6)0.247Disease duration in months15.8±9.515.0±9.316.5±9.60.17624 hour urine proteinuria in gram0.45±0.600.50±0.630.40±0.570.176Daily prednisolone dose in mg8.82±6.15.28±4.466.35±7.370.143Use of immunosuppressant188 (67.1)96 (68.6)92 (65.7)0.611SLEDAI-2K3.39±2.353.51±2.283.26±2.410.366PGA0.46±0.620.54±0.630.38±0.590.025LLDAS196 (70)92 (0.66)104 (74.3)0.160Presence of comorbidity202 (72.1)100 (71.4)102 (72.9)0.790SDI0.97±1.230.95±1.211.00±1.260.732HAQ-DI0.20±0.400.23±0.450.18±0.340.300HADS: Anxiety scale5.93±3.985.86±4.066.00±3.910.776 Depression scale5.57±3.915.56±4.255.59±3.540.954Education level: tertiary or above122 (43.6)63 (45.0)59 (42.1)0.746Fulltime employment127 (45.4)56 (40.0)71 (50.7)0.041Occupation: professionals36 (12.9)22 (15.7)14 (10.0)0.181Monthly family income > USD3,80084 (30.0)51 (36.4)33 (23.6)0.028

Data are reported as mean ± SD or number (%). HAQ-DI: Health Assessment Questionnaire Disability Index; HADS: Hospital Anxiety and Depression Scale; PGA: physician global assessment; LLDAS: lupus low disease activity state and SDI: Systemic Lupus International Collaborating Clinics/American College of Rheumatology (SLICC/ACR) Damage Index.

Disclosure of Interests:

Ho SO: None declared, Evelyn Chow: None declared, Tena K. Li: None declared, Isaac T. Cheng: None declared, Sze-Lok Lau: None declared, Cheuk-Chun Szeto: None declared, Lai-Shan Tam Grant/research support from: Grants from Novartis and Pfizer

POS0094 EFFECTS OF RANKL INHIBITION ON PROMOTING HEALING OF BONE EROSION IN RHEUMATOID ARTHRITIS USING HR-pQCT: A 2-YEAR, RANDOMIZED, DOUBLE-BLIND, PLACEBO-CONTROLLED TRIAL

Background:

Partial repair of bone erosions in rheumatoid arthritis (RA) is known from high-resolution peripheral quantitative computer tomography (HR-pQCT) studies in patients with moderate to high disease activity using biologics [1]. Whether RANKL inhibition by denosumab is efficacious in healing existing erosions in RA patients with low disease activity or in remission on conventional synthetic DMARDs is uncertain.

Objectives:

To evaluate the effects of denosumab on erosion healing at 2-4 metacarpophalangeal head as determined by HR-pQCT in patients with RA with stable disease.

Methods:

This was a randomized, placebo-controlled, double-blind study. RA patients with disease activity score 28 joints (DAS28) ≤5.1 were randomized (1:1) to subcutaneous denosumab 60 mg or placebo once every six months for 24 months. The primary outcome was erosion healing at MCP 2-4 on HR-pQCT at 12 months. The effects of denosumab on erosion and joint space parameters on HR-pQCT and radiographs, disease activity and health assessment questionnaire-disability index (HAQ-DI) were also examined.

Results:

At 24 months, HR-pQCT images were analyzed in 98 patients. Baseline demographic, clinical characteristics and imaging parameters were comparable between the two treatment groups (table 1). Seventeen patients in each group (placebo group: 17/52, 32.6%; denosumab group: 17/50, 34.0%) achieved sustained low disease activity (DAS28 ≤ 3.2) throughout the 24 months. At 12 months, changes in erosion parameters on HR-pQCT were similar between the two groups. At 24 months, new erosions (19% vs 9%, p=0.009) and erosion progression (34% vs 16%, p<0.001) were more common in the placebo group than the denosumab group. Erosion healing was seen in a significantly higher proportion of patients in the denosumab group (20% vs 6%, p=0.045) at 24 months. The details of the changes in HR-pQCT erosion parameters are shown in figure 1. No significant differences in the changes in joint space parameters on HR-pQCT, van der Heijde-Sharp erosion score, DAS28 and HAQ-DI were observed between the two groups at 12 and 24 months.

Table 1.

Baseline clinical, demographic, disease activity parameters and medications

Placebo (n=55)Denosumab (n=55)Total (n=110)Age56.5 ± 7.157.2 ± 8.556.8 ± 7.8Gender (Female)47 (86)41 (75)88 (80)Disease duration (years)8.5 ± 6.87.3 ± 6.97.9 ± 6.8Rheumatoid factor positive40 (72)38 (69)78 (71)ACPA positive43 (78)44 (80)87 (79)DAS28-CRP2.43 ± 0.832.6 ± 0.922.51 ± 0.88DAS28-CRP>3.28 (15)13 (24)21 (19)HAQ-DI (0-3)0.31 ± 0.380.46 ± 0.470.39 ± 0.43csDMARDs49 (89)52 (95)101 (92)Combination csDMARDs26 (47)33 (60)59 (54)Glucocorticoids5 (10)5 (9)10 (9)vdH- Sharp erosion score10.4 ± 18.48.9 ± 13.89.6 ± 16.2vdH- Sharp JSN score12.4 ± 17.711.5 ± 17.211.9 ± 17.4Lumbar spine aBMD, g/cm20.914 ± 0.1470.930 ± 0.1430.922 ± 0.145Total hip aBMD, g/cm20.837 ± 0.1020.847 ± 0.1460.841 ± 0.125Femoral neck aBMD, g/cm20.681 ± 0.0990.695 ± 0.1280.687 ± 0.114

Data are reported as mean ± SD or number (%). ACPA: Anti-cyclic citrullinated peptide antibody; DAS28: disease activity score 28; csDMARDs: conventional synthetic disease modifying anti-rheumatic drug. HAQ-DI: health assessment questionnaire disability index; vdH- Sharp score: Van der Heijde- Sharp score; aBMD: areal bone mineral density

Conclusion:

Although no differences in erosion parameters were observed at 12 months, denosumab was more efficacious than placebo in erosion repair on HR-pQCT after 24 months.

References:

[1]Finzel S, Rech J, Schmidt S, et al. Interleukin-6 receptor blockade induces limited repair of bone erosions in rheumatoid arthritis: a micro CT study. Ann Rheum Dis 2013;72:396-400.

Figure 1.

Changes in erosion parameters by HR-pQCT. (A) Percentage of patients with overall erosion healing; (B) Outcome of individual erosion with healing, progression and new erosion detected across study period; change in (C) mean erosion volume; (D) total erosion volume; (E) erosion width; (F) erosion depth and (G) marginal osteosclerosis per patient.

Disclosure of Interests:

Ho SO: None declared, Isaac T. Cheng: None declared, Sze-Lok Lau: None declared, Evelyn Chow: None declared, Tommy Lam: None declared, Vivian W Hung: None declared, Edmund Li: None declared, James F Griffith: None declared, Vivian WY Lee: None declared, Lin Shi: None declared, Junbin Huang: None declared, Yan Kitty Kwok: None declared, Isaac C Yim: None declared, Tena K. Li: None declared, Vincent Lo: None declared, Jolly M Lee: None declared, Jack Jock Wai Lee: None declared, Ling Qin: None declared, Lai-Shan Tam Grant/research support from: Grants from Novartis and Pfizer

Ethnicity influences cardiovascular outcomes and complications in patients with type 2 diabetes

AIM

To determine whether cardiovascular outcomes in type 2 diabetes (T2D) differ according to ethnicity, and whether ethnicity influences the effect of gender on these outcomes in Caucasians, East-Southeast-Asians, Middle-Easterners, South-Asians and Pacific-Islanders.

METHODS

We compared demographics, HbA1c, lipid profile, renal function markers, and prevalence of macrovascular and microvascular complications between ethnic groups. Cross-sectional data was prospectively collected from 204 consecutive patients at Westmead Hospital's T2D clinic from April-October 2015. Univariate analysis was performed using chi-squared test for categorical data, and Mann-Whitney-U or Kruskal-Wallis test for continuous data.

RESULTS

Compared to Caucasians, South-Asians were diagnosed younger, were currently younger, had lower body-mass-index (BMI) and better renal function but higher rates of non-ST-elevation myocardial infarction (STEMI, 21.7% versus 3.5%, p<0.05). East-Southeast-Asians had lower BMI but more nephropathy than Caucasians (59% versus 39%, p<0.05). East-Southeast-Asian males had fewer CVD than Caucasians, but this protection was absent in East-Southeast-Asian females. Middle-Easterners had more non-STEMI than Caucasians (5.3% vs 3.5%, p<0.05). Middle-Eastern females were not at lower CVD risk than males. Caucasians had most PVD (20% versus 6%, p<0.05).

CONCLUSIONS

Ethnicity influences rates of diabetes-related complications. Female CVD protection is altered in some groups. Ethnicity should be considered in assessing CVD and complications risk.

Size fractionation of metals present in highway runoff: beyond the six commonly reported species

Highway runoff is an important non-point source of pollutants, especially metals. This study reports monitoring results from 17 storm events at three highway sites for six commonly sampled metals: cadmium, chromium, copper, lead, nickel, and zinc. The study also reports the results of eight additional metals: aluminum, arsenic, cobalt, iron, manganese, selenium, strontium, and vanadium. Soluble phase, defined as passing a 0.45 microm filter, and particulate phase concentrations on four size fractions from 0.45 to larger than 100 microm are reported. The greatest metal masses were typically observed in the 8 to 20 microm fraction. The size distribution shows that sedimentation as a treatment process typically found in stormwater management can remove only 65% of the mass of most particulate phase metal species. Additional processes, such as coagulation or filtration, are needed to obtain greater removal rates. The results indicate the need to study particle size distribution (PSD) in order to better select treatment alternatives or assess environmental impacts.

Pre-emptive ibuprofen arginate in third molar surgery: a double-blind randomized controlled crossover clinical trial

BACKGROUND

This study evaluated the effectiveness of 400 mg ibuprofen arginate either as a pre-emptive (PRE group) or postoperative (POST group) analgesic using a common dental pain model.

METHODS

A randomized double-blind crossover clinical trial involving a series of consecutive patients admitted for bilateral third molar surgery. Results were analysed according to the self-reported pain score and the pattern of rescue medication taken.

RESULTS

The mean pain score ranged from 0.73 to 1.60 for the PRE group and 0.47 to 1.41 for the POST group among 30 included subjects. The mean time point when first rescue medication taken was 7.3 hours and 8.3 hours postoperative, respectively. Nine patients (30 per cent) in the PRE group and 12 patients (40 per cent) in the POST group took no rescue medication. There was no statistically significant difference for all parameters between groups, while a majority (53 per cent) found the drug "good" to "excellent" in both groups.

CONCLUSIONS

Ibuprofen arginate may be considered effective in reducing surgically induced moderate to severe pain when administered either pre-operatively or postoperatively due to the reported relatively low pain score, less consumption of rescue medication, delayed onset of pain, good number of pain-free patients and a high rating in the global assessment score.

Clinical and biochemical improvement in acromegaly during pregnancy

Numerous case reports of pregnancy in acromegaly exist, however detailed descriptions of changes in placental and pituitary GH and IGF-I throughout gestation are rare. A 19-yr-old female presented to this institution with signs and symptoms of a GH-secreting pituitary adenoma. Following transphenoidal hypophysectomy, she had 3 unplanned pregnancies, despite ongoing active disease. No pregnancy was complicated by glucose intolerance or hypertension and 3 healthy newborns were delivered near or at term. Clinical improvement was observed during each pregnancy, accompanied by IGF-I levels lower than in the non-pregnant state, the majority lying within the normal range. This was despite increasing placental GH levels, and was not consistent with previous reports in the literature. Further surgical and medical therapies for acromegaly failed to normalize nonpregnant GH or IGF-I levels in this woman. Estrogen is known to alter GH signaling via its interaction with Janus kinase/signal transducers and activators of transcription (JAK-STAT) pathways. We hypothesize that increasing concentrations of estrogen or other pregnancy-related hormones resulted in her clinical and biochemical improvement during pregnancy. This may be used for future therapeutic benefit.

Levels of evidence and journal impact factor in oral and maxillofacial surgery

The aim of this study was to identify the relationship between quality of research, in terms of levels of evidence, and journal impact factor (IF), and to describe the pattern of publications in oral and maxillofacial surgery. All four major journals in this subject area only, and with a published IF, were included in the study. Latest published IF dated 2004 was chosen, and all articles related to its calculation were accessed and classified into four levels of evidence. Correlation between levels of evidence and IF was investigated and the pattern of publications was described. All eligible 932 published articles were analysed. None (0%) were level I evidence, 20 (2%) were Level II, 70 (8%) level III and 337 (40%) level IV; 465 (50%) articles were classified as non-evidence. IF ranged from 0.689 to 1.154. There were statistically significant correlations between levels of evidence and IF (rho=1.0, P<0.01). Among the 465 non-evidence articles, there were 219 (47%) case reports, 91 (20%) animal studies, 52 (11%) laboratory studies, 35 (8%) technical notes, 24 (5%) tutorial articles, and 16 (3%) reviews articles.

Recurrence related to treatment modalities of unicystic ameloblastoma: a systematic review

This systematic review aims to identify all studies pertinent to the clinical question, 'which treatment for unicystic ameloblastoma results in the lowest recurrence rate?' A structured systematic search of the literature, with predefined inclusion and exclusion criteria, using computer and manual searches as well as personal communication, was performed. Evaluations and critical appraisal were done separately in 3 rounds. All searches were performed by 2 independent judges and any disagreement was settled by discussion with a third party. Four treatment modalities for unicystic ameloblastomas were identified. The recurrence rates were 3.6% for resection, 30.5% for enucleation alone, 16% for enucleation followed by application of Carnoy's solution and 18% for marsupialization with/without other treatment in a second phase. It was concluded that there is only weak evidence showing that jaw resection resulted in the lowest recurrence rate, followed by enucleation with application of Carnoy's solution. Enucleation alone resulted in the highest recurrence rate and treatment by marsupialization cannot be sufficiently evaluated since most cases were followed by a second stage surgery of some kind.

First flush and natural aggregation of particles in highway runoff

Particle Size Distribution (PSD) in highway runoff was monitored in the 2004-2005 rainy season at three highway sites in west Los Angeles, California. PSD was measured for 200 grab samples for 18 storm events. Particles and especially larger particles showed a strong first flush. On average, the initial 20% runoff volume transported approximately 28% total number of particles between 0.5 and 2 microm in diameter, more than 30% of particles between 2 and 30 microm and more than 40% of particles larger than 30 microm. A naturally occurring aggregation was observed with smaller particles and mixing experiments were performed to determine the possible benefits for sedimentation and filtration. Samples composited from grab samples manually collected over the first hour of runoff were gently mixed (G = 38) and small particle concentration decreased by more than 50%. After 24 hours the number of particles with diameter between 0.5 and 7 microm decreased by 51% with gentle mixing and the same size particles decreased by only 14% without mixing. Number of particles with diameter larger than 20 microm increased by 6 and 4.5 times with and without mixing, respectively. Slow mixing can improve sedimentation efficiency by more than 40% for particles less than 20 microm in diameter.

Correlation analysis among highway stormwater pollutants and characteristics

Stormwater runoff from highway land use is a common non-point source of pollutants. A large quantity of highway stormwater runoff characteristics were collected in California during the past three years. Correlations among various water quality parameters and constituents were performed using data sets collected over the 2000-2001, 2001-2002, and 2002-2003 wet seasons for 18, 21 and 23 storm events at three highway sites in west Los Angeles, California. In addition, statistical and graphical correlation analysis of the mass first flush ratio (MFF) with storm characteristics was made to determine if the first flush is related to site or storm characteristics. The results and analyses performed indicate that (1) TSS correlates well with most particulate-bound metals. However, TSS was poorly correlated with most other pollutants. (2) Strong correlations were also observed among dissolved and total metals; DOC, COD, TKN and oil and grease; conductivity and Cl. (3) Total metals, COD and DOC were generally well correlated with mass first flush, suggesting that BMPs that treat the early portion of runoff have an opportunity to remove high concentrations of these pollutants.

A new modeling approach for estimating first flush metal mass loading

The purpose of this study was to investigate pollutant mass loading from major highways in Southern California, with emphasis on interpretation of event mean concentrations and first flush effects. The results of monitoring eight sites during the 1999-2002 storm seasons found that metal contaminants had higher concentrations at the early stages of storm events compared with other stages of rain storms. A new washoff model was developed to predict the event mean concentrations of metal contaminants taking first flush effect into account. Model variable parameters included average daily traffic, antecedent dry period, rain intensity, total runoff volume, and runoff coefficient. The results obtained using the washoff model were compared with measured values and found to fit well for heavy metals with R2 ranging from 0.8 to 0.95.

Catch basin inserts to reduce pollution from stormwater

Stormwater contamination represents the largest source of contaminants to many receiving waters in the United States, such as Santa Monica Bay in Los Angeles, California. Point sources to these same waters generally receive secondary or better treatment before they are released, and they are usually discharged through outfalls that diffuse the wastewater plume to prevent it from contacting the shoreline. Stormwaters receive no treatment and reach the receiving waters through a variety of ways, but most enter through catch basins or inserts to storm drains that terminate at the beach or in shallow coastal areas. Under these conditions, the stormwater discharge may have greater impact on the quality and utility of the receiving water than the treated wastewater discharges. One method of reducing pollution is to equip catch basins with an insert that can capture pollutants. A number of commercially available devices exist but few have been evaluated by independent parties in full-scale applications. A series of tests using bench and full-scale devices under both laboratory and field conditions were conducted to evaluate their ability to remove trash and debris, suspended solids and oil and grease in stormwaters. The results presented in the paper should provide a basis for future insert development and application.

Marr's theory of the neocortex as a self-organizing neural network

Marr's proposal for the functioning of the neocortex (Marr, 1970) is the least known of his various theories for specific neural circuitries. He suggested that the neocortex learns by self-organization to extract the structure from the patterns of activity incident upon it. He proposed a feedforward neural network in which the connections to the output cells (identified with the pyramidal cells of the neocortex) are modified by a mechanism of competitive learning. It was intended that each output cell comes to be selective for the input patterns from a different class and is able to respond to new patterns from the same class that have not been seen before. The learning rule that Marr proposed was underspecified, but a logical extension of the basic idea results in a synaptic learning rule in which the total amount of synaptic strength of the connections from each input ("presynaptic") cell is kept at a constant level. In contrast, conventional competitive learning involves rules of the "postsynaptic" type. The network learns by exploiting the structure that Marr assumed to exist within the ensemble of input patterns. For this case, analysis is possible that extends that carried out by Marr, which was restricted to the binary classification task. This analysis is presented here, together with results from computer simulations of different types of competitive learning mechanisms. The presynaptic mechanism is best known in the computational neuroscience literature. In neural network applications, it may be a more suitable mechanism of competitive learning than those normally considered.