Lymphedema in Inflammatory Breast Cancer Patients Following Trimodal Treatment

BACKGROUND

Breast cancer-related lymphedema (BCRL) is a debilitating sequela of breast cancer treatment and is becoming a greater concern in light of improved long-term survival. Inflammatory breast cancer (IBC) is a rare and aggressive malignancy for which systemic therapy, surgery, and radiotherapy remain the standard of care, thereby making IBC patients highly susceptible to developing BCRL. This study evaluated BCRL in IBC following trimodal therapy.

METHODS

IBC patients treated from 2016 to 2019 were identified from an institutional database. Patients were excluded if they presented with recurrent disease, underwent bilateral axillary surgery, did not complete trimodal therapy, or were lost to follow-up. Demographic, clinicopathologic factors, oncologic outcomes, and perometer measurements were recorded. BCRL was defined by clinician diagnosis and/or objective perometer measurements when available. Time to development of BCRL and treatment received were captured.

RESULTS

Eighty-three patients were included. Median follow-up was 33 months. The incidence of BCRL was 50.6% (n = 42). Mean time to BCRL from surgery was 13 (range 2-24) months. Demographic and clinicopathologic features were similar between patients with and without BCRL with exception of higher proportion receiving delayed reconstruction in the BCRL group (38.1% vs. 14.6%, p = 0.03). Forty patients (95.2%) underwent BCRL treatment, which included physical therapy (n = 39), compression (n = 38), therapeutic lymphovenous bypass (n = 13), and/or vascularized lymph node transfer (n = 12).

CONCLUSIONS

IBC patients are at high-risk for BCRL after treatment, impacting 51% of patients in this cohort. Strategies to reduce or prevent BCRL and improve real-time diagnosis should be implemented to better direct early management in this patient population.

AB1121 HOW FEARS AND HOPES HAVE EVOLVED IN PATIENTS WITH RMDs THROUGHOUT THE COVID-19 PANDEMIC? RESULTS FROM THE REUMAVID STUDY (PHASE 1 AND 2)

Background

The COVID-19 pandemic has generated uncertainties and concerns along with expectations and hopes that may be of relevance to patients with rheumatic diseases.

Objectives

The aim of this study is to assess changes in the fears and hopes of patients with rheumatic diseases throughout the two phases of REUMAVID.

Methods

REUMAVID is an international cross-sectional study collecting data through an online survey in seven European countries led by the Health & Territory Research group of the University of Seville, together with a multidisciplinary team including patient representatives, rheumatologists, and health researchers. Data were collected in two phases: Phase 1 (P1) between April-July 2020 and Phase 2 (P2) between February-April 2021. Demographics, health behaviours, employment status, access to healthcare services, disease characteristics, WHO-5 Well-Being Index and Hospital Anxiety and Depression Scale (HADS). Participants rated a series of fears (infection, medication consequences, lack of medication, impact on healthcare, lost job, civil disorder) on a scale from zero (“no concern at all”) to five (“extremely concerned”) and hopes (treatment/vaccine availability, going outside, travel, economic situation, treatment continuation, health status) on a scale from zero (“no hopeful at all”) to five (“extremely hopeful”). Descriptive analysis and Mann-Whitney test were used to explore fears and hopes in both phases of REUMAVID.

Results

A total of 3,802 participants were recruited across both phases in REUMAVID with comparable demographic characteristics: mean age 52.6 (P1) vs. 55.0 years (P2), 80.2% female (P1) vs. 83.7% (P2), 69.6% married (P1) vs. 68.3% (P2), and 48.6% university educated (P1) vs. 47.8% (P2). Most prevalent RMD was axial spondyloarthritis in P1 (37.2%), and rheumatoid arthritis in P2 (53.1%).

In P1 and P2 the major concern was the impact on healthcare in the future (3.1 and 3.2 out of 5, p=0.051). Compared to P1, patients in P2 had less fears about RMD medications not reaching the country (2.4 vs. 1.9, p<0.001), civil disorders (2.0 vs. 1.8, p=0.001), or losing their jobs (1.4 vs. 1.5, p=0.003). Comparing hopes with P1, patients in P2 had greater hopes about availability of treatments or vaccines suitable for COVID-19 (3.2 vs. 3.9, p<0.001), to be able to go out as before the pandemic (3.1 vs. 3.5, p<0.001), to be able to travel as before the pandemic (2.8 vs. 3.3, p<0.001), maintain and even improve the current economic situation after the pandemic (2.6 vs. 3.0, p<0.001), and to be able to continue their treatment as usual (3.8 vs. 3.8, p=0.049; Table 1)

Table 1.

Bivariate analysis of patients’ fears and hopes in both phases of REUMAVID (N= 3,802, unless specify)

Mean ± SDP-valueFirst Phasen= 1,800Second phasen= 2,002FearsImpact on healthcare in the future, n= 3,6533.1 ± 1.63.2 ± 1.60.051Treatment taken could make you more likely to get serious illness from COVID-19 infection, n= 3,6512.8 ± 1.82.9 ± 1.80.160More likely to be infected due to the condition, n= 3,6492.8 ± 1.72.9 ± 1.70.040Lack of medication, n= 3,6562.4 ± 1.81.9 ± 1.8<0.001Civil disorder, n= 3,6342.0 ± 1.61.8 ± 1.70.001Lost job, n= 3,5661.5 ± 1.91.4 ± 1.90.003HopesAvailability of a treatment or vaccine suitable for COVID-19, n= 3,3183.2 ± 1.53.9 ± 1.3<0.001*Continue treatment as usual, n= 3,3063.7 ± 1.43.8 ± 1.30.049*Go out as before the COVID-19 pandemic, n= 3,3183.1 ± 1.53.5 ± 1.4<0.001*Don’t get infected with COVID-19 and continue in the same health, n= 3,2803.5 ± 1.53.5 ± 1.50.696Travel as before the COVID-19 pandemic, n= 3,3112.8 ± 1.63.3 ± 1.5<0.001*Maintain or improve economic situation after the COVID-19 pandemic, n= 3,3102.6 ± 1.73.0 ± 1.7<0.001*

Conclusion

During the first phase of REUMAVID at the beginning of the pandemic, patients with RMDs were more fearful and less hopeful compared to the second phase. These fears were notable in terms of lack of medication for their RMD, while during the second phase, patients were hopeful of a treatment or vaccine against COVID-19, and of being able to go out and travel as before.

Acknowledgements

This study was supported by Novartis Pharma AG. We would like to thank all patients that completed the survey as well as all of the patient organisations that participated in the REUMAVID study including: the Cyprus League for People with Rheumatism (CYLPER) from Cyprus, the Association Française de Lutte Anti-Rhumatismale (AFLAR) from France, the Hellenic League Against Rheumatism (ELEANA) from Greece, the Associazione Nazionale Persone con Malattie Reumatologiche e Rare (APMARR) from Italy, the Portuguese League Against Rheumatic Diseases (LPCDR), from Portugal, the Spanish Federation of Spondyloarthritis Associations (CEADE), the Spanish Patients’ Forum (FEP), UNiMiD, Spanish Rheumatology League (LIRE), Andalusian Rheumatology League (LIRA), Catalonia Rheumatology League and Galician Rheumatology League from Spain, and the National Axial Spondyloarthritis Society (NASS), National Rheumatoid Arthritis (NRAS) and Arthritis Action from the United Kingdom.

Disclosure of Interests

Marco Garrido-Cumbrera Grant/research support from: has a research collaboration with and provides services to Novartis Pharma AG, Helena Marzo-Ortega Speakers bureau: AbbVie, Biogen, Celgene, Janssen, Lilly, Novartis, Pfizer, Takeda and UCB, Consultant of: AbbVie, Celgene, Janssen, Lilly, Novartis, Pfizer and UCB, Laura Christen Employee of: Novartis Pharma AG, José Correa-Fernández: None declared, Elsa Mateus Grant/research support from: Pfizer, grants from Lilly Portugal, Sanofi, AbbVie, Novartis, Grünenthal S.A., MSD, Celgene, Medac, Janssen-Cilag, Pharmakern and GAfPA, LAURENT GRANGE: None declared, Dale Webb Grant/research support from: AbbVie, Biogen, Janssen, Lilly, Novartis and UCB, Clare Jacklin Grant/research support from: Abbvie, Amgen, Biogen, Eli Lilly, Gilead, Janssen, Pfizer, Roche, Sanofi and UCB, Shantel Irwin: None declared, Serena Mingolla: None declared, KATY ANTONOPOULOU: None declared, Souzi Makri Grant/research support from: Novartis, GSK and Bayer, Victoria Navarro-Compán Grant/research support from: Abbvie, BMS, Janssen, Lilly, MSD, Novartis, Pfizer, Roche and UCB

Contemporary surgical management of inflammatory breast cancer: a narrative review

OBJECTIVE

The purpose of this review is to outline the surgical management of inflammatory breast cancer (IBC) including the clinical decision making, operative approach and current controversies.

BACKGROUND

IBC is a rare and aggressive form of breast cancer. Trimodality therapy consisting of neoadjuvant therapy, modified radical mastectomy (MRM) and radiation therapy improves survival and is the recommended course of treatment. Advancements in systemic therapy and de-escalation strategies in non-IBC have accelerated discussions regarding several aspects of care in IBC including feasibility of de-escalation of surgical care, timing of reconstruction and the role of surgery in de novo stage IV disease. We discuss the evidence to support the surgical approach and decision-making in this rare disease.

METHODS

We reviewed existing literature using multiple electronic databases and clinical consensus guidelines to identify historical and current publications addressing current management recommendations and clinical controversies in IBC.

CONCLUSIONS

Breast conserving surgery (BCS), skin- or nipple-sparing mastectomy should not be performed in IBC as surgical resection to negative margins results in improved locoregional recurrence rates. Level I and II axillary lymph node dissection should be performed regardless of response to therapy and initial nodal status. Reconstruction should be delayed and contralateral prophylactic mastectomy (CPM) is discouraged in IBC. Surgery may be considered for de novo stage IV IBC patients who demonstrate durable response to neoadjuvant therapy to improve local-regional control.

30-Day postoperative COVID-19 outcomes in 398 patients from regional hospitals utilising a designated COVID-19 minimal surgical site pathway

INTRODUCTION

Postoperative pulmonary complications and mortality rates during the COVID-19 pandemic have been higher than expected, leading to mass cancellation of elective operating in the UK. To minimise this, the Guy's and St Thomas' Hospital NHS Foundation Trust elective surgery hub and the executive team at London Bridge Hospital (LBH) created an elective operating framework at LBH, a COVID-19 minimal site, in which patients self-isolated for two weeks and proceeded with surgery only following a negative preoperative SARS-CoV-2 polymerase chain reaction swab. The aim was to determine the rates of rates of postoperative COVID-19 infection.

METHODS

The collaboration involved three large hospital trusts, covering the geographic area of south-east London. All patients were referred to LBH for elective surgery. Patients were followed up by telephone interview at four weeks postoperatively.

RESULTS

Three hundred and ninety-eight patients from 13 surgical specialties were included in the analysis. The median age was 60 (IQR 29-71) years. Sixty-three per cent (252/398) were female. In total, 78.4% of patients had an American Society of Anesthesiologists grade of 1-2 and the average BMI was 27.2 (IQR 23.7-31.8) kg/m2. Some 83.6% (336/402) were 'major' operations. The rate of COVID-19-related death in our cohort was 0.25% (1/398). Overall, there was a 1.26% (5/398) 30-day postoperative all-cause mortality rate. Seven patients (1.76%) reported COVID-19 symptoms, but none attended the emergency department or were readmitted to hospital as a result.

CONCLUSION

The risk of contracting COVID-19 in our elective operating framework was very low. We demonstrate that high-volume major surgery is safe, even at the peak of the pandemic, if patients are screened appropriately preoperatively.

AB0677 GENDER DIFFERENCES ON THE IMPACT OF THE COVID-19 PANDEMIC AND LOCKDOWN IN PATIENTS WITH RHEUMATIC DISEASES. RESULTS FROM THE REUMAVID STUDY (PHASE 1)

Background:

The COVID-19 pandemic has impacted health, lifestyle, treatment and healthcare of European patients with rheumatic and musculoskeletal diseases (RMDs).

Objectives:

The aim is to evaluate gender differences on the impact of the first wave of the COVID-19 pandemic in the wellbeing, life habits, treatment, and healthcare access of European patients with RMDs.

Methods:

REUMAVID is an international collaboration led by the Health & Territory Research at the University of Seville, together with a multidisciplinary team including patient organisations and rheumatologists. This cross-sectional study consisting of an online survey gathering data from 1,800 patients with a diagnosis of 15 RMDs, recruited by patient organisations in Cyprus, France, Greece, Italy, Portugal, Spain, and the United Kingdom during the first phase of the pandemic (April-July 2020). Mann-Whitney and χ2 tests were used to analyse differences between gender regarding sociodemographic characteristics, life style, treatment, healthcare, and patient-reported outcomes.

Results:

1,797 patients were included in this analysis. 80.2% were female and a mean age of 52.6 years. The most common diagnosis was inflammatory arthritis (81.7% male vs 73.8% female). There was a higher prevalence of fibromyalgia among females (20% vs 7.0% male). Overall, females reported worse self-perceived health (67.0% vs 51.4%, p<0.001), higher risk of anxiety (59.5% vs 48.1%, p<0.001), and depression (48.0% vs 37.2%, p<0.001). Females reported a greater increase in smoking (26.5% vs 17.5%, p=0.001), although they were less likely to drink alcohol (34.5% vs 25.4%, p=0.013), and also engaged less in physical activity (53.0% vs 60.3%, p=0.045). Overall, females were more likely to keep their scheduled rheumatology appointment (43.3% vs 34.1% of males (p=0.049; Table 1) with a higher proportion of females having their rheumatic treatment changed (17.0% vs 10.7%, p=0.005).

Conclusion:

The first wave of the COVID-19 pandemic and the containment measures have worsened self-perceived health status of patients with RMDs, affecting genders differently. Females reported worse psychological health and life habits such as increased smoking and reduced physical activity, while males increased their alcohol consumption and were less likely to attend their rheumatology appointments.

Table 1.

Bivariate analysis by gender (N= 1,797 unless specify)

Mean ± SD or n (%)P- valueMale(N= 355)Female(N= 1,442)Sociodemographic characteristicsDiseaseInflammatory arthritis1290 (81.7)1,064 (73.8)Fibromyalgia25 (7.0)287 (19.9)Connective tissue disease218 (5.1)195 (13.5)Osteoarthritis52 (14.6)255 (17.7)Osteoporosis10 (2.8)104 (7.2)Vasculitis37 (2.0)29 (2.0)SAPHO1 (0.3)14 (1.0)Age, years52.8 ± 14.252.5 ± 12.90.896Educational levelUniversity162 (45.6)711 (49.3)0.215Marital statusMarried or in relationship269 (75.8)983 (68.2)0.002*Member of a Patient organisation, N=1,795Yes188 (53.0)559 (38.8)<0.001*Patient-reported outcomesHADS Anxiety, N=1,766Risk168 (48.1)843 (59.5)<0.001*HADS Depression, N=1,766Risk130 (37.2)680 (48.0)<0.001*Wellbeing, N=1,774WHO-5 ≤ 50188 (53.4)681 (47.9)0.064Self-perceived health, N=1,783Fair or bad182 (51.4)958 (67.0)<0.001*Change in health status during COVID-19 pandemic, N=1,783Worse333 (94.1)1,339 (93.7)0.799Life style during COVID-19 pandemicSmoking, N=555More than before20 (17.5)117 (26.5)0.001*Alcohol consumption, N=1,083Quit drinking71 (25.4)277 (34.5)0.013Physical activity, N=1,126Yes144 (60.3)470 (53.0)0.045*Treatment and healthcareAble to meet rheumatologist, N= 721No89 (65.9)332 (56.7)0.049*Access to GP, N=688No43 (39.4)248 (42.8)0.512

1Including: Axial Spondyloarthritis, Rheumatoid Arthritis, Psoriatic Arthritis, Juvenile Idiopathic Arthritis, Gout and Peripheral Spondyloarthritis; 2Including: Systemic Lupus Erythematosus, Sjögren’s Syndrome, Systemic Sclerosis and Myositis; 3Including: Polymyalgia Rheumatic and Vasculitis or Arteritis.

Acknowledgements:

This study was supported by Novartis Pharma AG. We would like to thank all patients that completed the survey as well as all of the patient organisations that participated in the REUMAVID study including: the Cyprus League Against Rheumatism (CYPLAR) from Cyprus, the Association Française de Lutte Anti-Rhumatismale (AFLAR) from France, the Hellenic League Against Rheumatism (ELEANA) from Greece, the Associazione Nazionale Persone con Malattie Reumatologiche e Rare (APMARR) from Italy, the Portuguese League Against Rheumatic Diseases (LPCDR), from Portugal, the Spanish Federation of Spondyloarthritis Associations (CEADE), the Spanish Patients’ Forum (FEP), UNiMiD, Spanish Rheumatology League (LIRE), Andalusian Rheumatology League (LIRA), Catalonia Rheumatology League and Galician Rheumatology League from Spain, and the National Axial Spondyloarthritis Society (NASS), National Rheumatoid Arthritis (NRAS) and Arthritis Action from the United Kingdom.

Disclosure of Interests:

Marco Garrido-Cumbrera: None declared, Helena Marzo-Ortega Speakers bureau: AbbVie, Biogen, Celgene, Janssen, Lilly, Novartis, Pfizer, Takeda and UCB, Consultant of: AbbVie, Celgene, Janssen, Lilly, Novartis, Pfizer and UCB, Grant/research support from: Janssen and Novartis, Laura Christen Employee of: Novartis Pharma AG, Loreto Carmona: None declared, José Correa-Fernández: None declared, Sergio Sanz-Gómez: None declared, Pedro Plazuelo-Ramos: None declared, Souzi Makri Grant/research support from: Novartis, GSK and Bayer, Elsa Mateus Grant/research support from: Pfizer, grants from Lilly Portugal, Sanofi, AbbVie, Novartis, Grünenthal S.A., MSD, Celgene, Medac, Janssen-Cilag, Pharmakern, GAfPA., Serena Mingolla: None declared, KATY ANTONOPOULOU: None declared, LAURENT GRANGE: None declared, Clare Jacklin Grant/research support from: Abbvie, Amgen, Biogen, Eli Lilly, Gilead, Janssen, Pfizer, Roche, Sanofi & UCB., Dale Webb Grant/research support from: AbbVie, Biogen, Janssen, Lilly, Novartis and UCB., Shantel Irwin: None declared, Victoria Navarro-Compán Grant/research support from: Abbvie, BMS, Janssen, Lilly, MSD, Novartis, Pfizer, Roche, and UCB

POS1213 IMPACT OF THE COVID-19 PANDEMIC AND LOCKDOWN ON WELLBEING ON PATIENTS WITH RHEUMATIC DISEASES. RESULTS FROM THE REUMAVID STUDY (PHASE 1)

Background:

The COVID-19 pandemic has impacted the wellbeing of patients with Rheumatic and Musculoskeletal Diseases (RMDs).

Objectives:

The aim is to assess emotional well-being and its associated factors in patients with RMDs during the first wave of the COVID-19 pandemic.

Methods:

REUMAVID is an international collaboration led by the Health & Territory Research group at the University of Seville, together with a multidisciplinary team including patient organisations and rheumatologists. This cross-sectional study consisting of an online survey gathering data from patients with a diagnosis of 15 RMDs in Cyprus, France, Greece, Italy, Portugal, Spain, and the United Kingdom. 1,800 participants were recruited by patient organisations. Data was collected between April and July 2020. Participants were divided into two groups: 1) Participants with poor wellbeing (World Health Organization-Five Wellbeing Index (WHO-5) ≤ 50), 2) Participants with good wellbeing (WHO-5 >50). The Mann-Whitney and χ2 tests were used to analyse possible relations between sociodemographic characteristics, lifestyle, and outdoor contact with wellbeing during the first wave of the COVID-19 pandemic. Univariate and multivariate binary logistic regression was used to determine the impact of the independent variables associated with poor wellbeing.

Results:

1,777 patients with 15 different RMDs were included. The mean age was 52.7, 80.2% female, 48.7% had a university degree, and 69.7% were married or in a relationship. The most frequent diagnoses were inflammatory arthritis (75.4%). 49.0% reported poor wellbeing. 57.7% of patients who belonged to a patient organisation reported good wellbeing (vs 46.3% who did not, p<0.001). Those who reported poor wellbeing had higher disease activity (51.4% vs 41.3%, p<0.001), a higher risk of anxiety (54.3% vs 41.7%, p<0.001) and depression (57.0% vs 42.1%, p<0.001), and poorer self-perceived health (53.0% vs 41.8%, p<0.001), compared to those who did not. A higher proportion of those who engaged in physical activity presented good wellbeing (54.0% vs 46.5%, p=0.012). 57.4% of the patients who were unable to attend their appointment with their rheumatologist reported poor wellbeing, compared to 48.2% who did attend (p=0.027). Patients who did not walk outside (56.2%) or who lacked elements in their home to facilitate outside contact (63.3%) experienced poor wellbeing (p<0.001). The factors associated with poor wellbeing were lack of elements in the home enabling contact with the outside world (OR=2.10), not belonging to a patient organisation (OR=1.51), risk of depression (OR=1.49), and not walking outside (OR=1.36) during the COVID-19 pandemic (Table 1).

Conclusion:

Almost half of the patients with RMDs reported poor emotional wellbeing during the first wave of the COVID-19 pandemic. The lack of elements in the home that facilitate outdoor contact, not belonging to a patient organisation, the presence of anxiety, and not walking outside during the pandemic increase the probability of poor emotional well-being. These results highlight the importance of environmental factors and the role of patient organisations in addressing the effects of the pandemic and its containment measures.

Table 1.

Logistic regression for poor wellbeing WHO-5 (N=1,104)

Univariate logistic analysisMultivariate logistic analysisOR95% CI1OR95% CI1Patient organisation. Non-member1.571.30, 1.891.511.18, 1.93Disease activity (VAS ≥ 4)1.501.21, 1.861.160.85, 1.56Risk of anxiety (HADs, 0-21)1.671.38, 2.021.200.92, 1.58Risk of depression (HADs, 0-21)1.831.51, 2.211.491.12, 1.99Self-reported health. Fair to very bad1.581.30, 1.911.260.94, 1.68Change in health status. Worse1.271.06, 1.531.050.80, 1.38Physical activity. No1.351.07, 1.711.080.83, 1.40Talked with rheumatologist during the pandemic. No1.451.04, 2.031.040.68, 1.61Walk outside during COVID-19 pandemic. No1.471.19, 1.831.361.02, 1.81Element in home with outdoor contact. No1.931.42, 2.622.101.41, 3.15

195% CI for test H0: OR = 1

Acknowledgements:

This study was supported by Novartis Pharma AG. We would like to thank all patients that completed the survey as well as all of the patient organisations that participated in the REUMAVID study including: the Cyprus League Against Rheumatism (CYPLAR) from Cyprus, the Association Française de Lutte Anti-Rhumatismale (AFLAR) from France, the Hellenic League Against Rheumatism (ELEANA) from Greece, the Associazione Nazionale Persone con Malattie Reumatologiche e Rare (APMARR) from Italy, the Portuguese League Against Rheumatic Diseases (LPCDR), from Portugal, the Spanish Federation of Spondyloarthritis Associations (CEADE), the Spanish Patients’ Forum (FEP), UNiMiD, Spanish Rheumatology League (LIRE), Andalusian Rheumatology League (LIRA), Catalonia Rheumatology League and Galician Rheumatology League from Spain, and the National Axial Spondyloarthritis Society (NASS), National Rheumatoid Arthritis (NRAS) and Arthritis Action from the United Kingdom.

Disclosure of Interests:

Marco Garrido-Cumbrera: None declared, Helena Marzo-Ortega Speakers bureau: AbbVie, Biogen, Celgene, Janssen, Lilly, Novartis, Pfizer, Takeda and UCB., Consultant of: AbbVie, Celgene, Janssen, Lilly, Novartis, Pfizer and UCB, Laura Christen Employee of: Novartis Pharma AG, Loreto Carmona: None declared, José Correa-Fernández: None declared, Sergio Sanz-Gómez: None declared, Pedro Plazuelo-Ramos: None declared, LAURENT GRANGE: None declared, Dale Webb Grant/research support from: AbbVie, Biogen, Janssen, Lilly, Novartis and UCB., Shantel Irwin: None declared, Clare Jacklin Grant/research support from: has received grant funding from Abbvie, Amgen, Biogen, Eli Lilly, Gilead, Janssen, Pfizer, Roche, Sanofi & UCB, Souzi Makri Grant/research support from: Novartis, GSK and Bayer., Elsa Mateus Grant/research support from: Lilly Portugal, Sanofi, AbbVie, Novartis, Grünenthal S.A., MSD, Celgene, Medac, Janssen-Cilag, Pharmakern, GAfPA., Serena Mingolla: None declared, KATY ANTONOPOULOU: None declared, Victoria Navarro-Compán Grant/research support from: Abbvie, BMS, Janssen, Lilly, MSD, Novartis, Pfizer, Roche, and UCB.

AB0676 FEARS AND HOPES DURING THE COVID-19 PANDEMIC IN PATIENTS WITH RHEUMATIC DISEASES. RESULTS FROM THE REUMAVID STUDY (PHASE 1)

Background:

The first wave of the COVID-19 pandemic led to a rapidly evolving global crisis characterized by major uncertainty.

Objectives:

The objective is to assess COVID-19-related fears and hopes in patients with rheumatic and musculoskeletal diseases (RMDs) during the first wave of the pandemic.

Methods:

REUMAVID is an international collaboration led by the Health & Territory Research group at the University of Seville, together with a multidisciplinary team including patient organisations and rheumatologists. This cross-sectional study consisting of an online survey gathering data from 1,800 patients with a diagnosis of 15 RMDs recruited by patient organisations in Cyprus, France, Greece, Italy, Portugal, Spain and, the United Kingdom. Data are collected in two phases, the first phase between April and July 2020, the second in 2021. Participants rated a series of fears (infection, medication consequences, lack of medication, impact on healthcare, job loss, civil disorder) on a Likert scale from zero (“no concern at all”) to five (“extremely concerned”) and their hopes (treatment/vaccine availability, going outside, travel, economic situation, treatment continuation, health status) on a Likert scale from zero (“not hopeful at all”) to five (“extremely hopeful”). The Mann-Whitney and Kruskal-Wallis tests were used to analyse the different fears and hopes according to socio-demographics characteristics, disease and health status.

Results:

1,800 patients participated in the first phase of REUMAVID. The most frequent RMDs group was inflammatory arthritis (75.4%), the mean age was 52.6 years and 80.1% were female. The most important fear for patients was the impact of the COVID-19 pandemic on healthcare (3.1 out of 5), particularly for those younger in age (3.0 vs 3.2, p=0.004), female gender (3.2 vs 2. 9 of men, p=0.003), experiencing greater pain (3.1 vs 2.8, p=0.007), with higher risk of anxiety (3.3 vs 2.9 of without anxiety, p<0.001) and depression (3.3 vs 2.9 without depression, p<0.001). The possible impact of anti-rheumatic medication and the development of severe disease if they became infected with COVID-19,was mostly feared (2.8 out of 5), by those receiving biological therapy (3.1 vs 2.5 not biological therapy, p<0.001) or those with underlying anxiety (2.9 vs 2.6 without anxiety, p=0.007). The risk of contracting COVID-19 due to their condition (2.8 out of 5), was especially feared by those with vasculitis (3.2 out of 5), who were female (2.9 vs 2.5, p<0.001), using biologics (2. 9 vs 2.7 of no use, p=0.003), in greater pain (2.8 vs 2.4, p<0.001), with a risk of anxiety (3.0 vs 2.6 without anxiety, p=0.004), and risk of depression (3.0 vs 2.6 without depression, p<0.001). The major hopes were to be able to continue with their treatment as usual (3.7 out of 5), particularly for those taking biologics (3.8 vs 3.6 not taking, p=0.026), those with a better well-being (3.8 vs 3.6 with worse well-being, p=0.021), without anxiety (3.8 vs 3.6 at risk, p=0.004) and without depression (3.8 vs 3.6 at risk, p=0.007). Hoping not to become infected with COVID-19 and to maintain the same health status, were especially those who were older (3.6 vs 3.4 p=0.018) without anxiety (3.4 vs 3.6 at risk, p=0.005), and without depression (3.6 vs 3.4 at risk, p=0.006). Another important hope was the availability of a treatment or vaccine for COVID-19, which was important for patients experiencing better well-being (3.3 vs 3.0 with worse well-being, p<0.001; Figure 1).

Conclusion:

The outstanding COVID-19-related fear expressed by European patients with RMDs was its impact on healthcare, while the greatest hope was to be able to continue treatment. Younger patients reported more fears while older patients were more hopeful. Those receiving biologics had greater fears and hopes associated with their treatment. In addition, patients at risk of mental disorders presented greater fears and less hopes.

Figure 1.

Fears and Hopes of REUMAVID participants

Acknowledgements:

This study was supported by Novartis Pharma AG. We would like to thank all patients that completed the survey as well as all of the patient organisations that participated in the REUMAVID study including: the Cyprus League Against Rheumatism (CYPLAR) from Cyprus, the Association Française de Lutte Anti-Rhumatismale (AFLAR) from France, the Hellenic League Against Rheumatism (ELEANA) from Greece, the Associazione Nazionale Persone con Malattie Reumatologiche e Rare (APMARR) from Italy, the Portuguese League Against Rheumatic Diseases (LPCDR), from Portugal, the Spanish Federation of Spondyloarthritis Associations (CEADE), the Spanish Patients’ Forum (FEP), UNiMiD, Spanish Rheumatology League (LIRE), Andalusian Rheumatology League (LIRA), Catalonia Rheumatology League and Galician Rheumatology League from Spain, and the National Axial Spondyloarthritis Society (NASS), National Rheumatoid Arthritis (NRAS) and Arthritis Action from the United Kingdom.

Disclosure of Interests:

Marco Garrido-Cumbrera: None declared, Helena Marzo-Ortega Speakers bureau: AbbVie, Biogen, Celgene, Janssen, Lilly, Novartis, Pfizer, Takeda and UCB, Consultant of: AbbVie, Celgene, Janssen, Lilly, Novartis, Pfizer and UCB, Grant/research support from: Janssen and Novartis, Laura Christen Employee of: Novartis Pharma AG, Loreto Carmona: None declared, José Correa-Fernández: None declared, Sergio Sanz-Gómez: None declared, Pedro Plazuelo-Ramos: None declared, Dale Webb Grant/research support from: AbbVie, Biogen, Janssen, Lilly, Novartis and UCB., Clare Jacklin Grant/research support from: Abbvie, Amgen, Biogen, Eli Lilly, Gilead, Janssen, Pfizer, Roche, Sanofi & UCB, Shantel Irwin: None declared, LAURENT GRANGE: None declared, Souzi Makri Grant/research support from: Novartis, GSK and Bayer., Elsa Mateus Grant/research support from: Lilly Portugal, Sanofi, AbbVie, Novartis, Grünenthal S.A., MSD, Celgene, Medac, Janssen-Cilag, Pharmakern, GAfPA., Serena Mingolla: None declared, KATY ANTONOPOULOU: None declared, Victoria Navarro-Compán Grant/research support from: Abbvie, BMS, Janssen, Lilly, MSD, Novartis, Pfizer, Roche, and UCB

AB0675 COUNTRY COMPARISON ON THE IMPACT OF THE COVID-19 PANDEMIC ON PATIENTS WITH RHEUMATIC DISEASES. RESULTS FROM THE REUMAVID STUDY (PHASE 1)

Background:

The COVID-19 pandemic has impacted every aspect of life of European patients with rheumatic and musculoskeletal diseases (RMDs).

Objectives:

The aim is to evaluate country differences on the impact of the first wave of the COVID-19 pandemic on life habits, healthcare access, health status, mental health and wellbeing in European patients with RMDs.

Methods:

REUMAVID is an international collaboration led by the Health & Territory Research group at the University of Seville, together with a multidisciplinary team including patient organisations and rheumatologists. This cross-sectional study consisting of an online survey gathering data from patients with a diagnosis of 15 RMDs in Cyprus, France, Greece, Italy, Portugal, Spain, and the United Kingdom. Participants were recruited by patient organisations (April-July 2020). The Kruskal-Wallis and χ2 tests were used to analyse differences between countries and independent variables.

Results:

1,800 patients participated in the first wave of the COVID-19 pandemic (REUMAVID). 37.8% of Spanish patients increased their smoking consumption during the pandemic followed by Cyprus (32.1%) and Portugal (31.0%), while alcohol consumption was higher in the UK (36.3%) and France (27.0%). 82.3% of patients in Spain unable to attend their appointment with their rheumatologist, either due to cancellations or other personal reasons. Access to primary care was most limited in Portugal and Italy, where only 45.0% and 51.6% got access. 61.9% in Italy and 53.3% in Spain experienced a worsening of their health during the pandemic. 68.5% in Spain and 67.8% in Portugal were at risk of anxiety. The highest proportion at risk of depression was found in Greece (55.4%), Cyprus (55.1%), and Italy (54.8%). 66.9% of patients in Spain reported poor wellbeing, compared to 23.8% in Italy and 30.1% in Portugal (Table 1).

Conclusion:

The first wave of the pandemic and the related containment measures heterogeneously affected patients with RMDs across European countries, who overall increased harmful habits, experienced more difficulties in accessing healthcare and, reported poor mental health and well-being.

Table 1.

Bivariate analysis between European countries (N=1,800, unless specified)

Mean ± SD or n (%)UKn: 558Spainn: 464Francen: 229Greecen: 57Cyprusn: 101Italyn: 127Portugaln: 264- Inflammatory arthritis1509 (91.2)402 (86.6)147 (64.2)33 (57.9)57 (56.4)89 (70.1)120 (45.5)- Fibromyalgia53 (9.5)14 (3.0)26 (11.4)14 (24.6)28 (27.7)53 (41.7)124 (47.0)- Connective tissue disease236 (6.5)15 (3.2)13 (5.7)25 (43.9)33 (32.7)30 (23.6)61 (23.1)- Osteoarthritis140 (25.1)29 (6.3)102 (44.5)0 (0.0)8 (7.9)15 (11.8)13 (4.9)- Osteoporosis50 (9.0)3 (0.6)20 (8.7)2 (3.5)9 (8.9)18 (14.2)12 (4.5)- Vasculitis39 (1.6)1 (0.2)6 (2.6)3 (5.3)3 (3.0)5 (3.9)9 (3.4)- Sapho (only France)15 (6.6)Smoking, More than before.N= 55616 (10.3)48 (37.8)22 (24.7)8 (23.5)9 (32.1)8 (20.5)26 (31.0)Alcohol consumption, More than before. N= 1,08599 (36.3)48 (10.3)27 (27.0)4 (7.0)4 (4.0)4 (13.3)11 (18.3)Unable to meet rheumatologist. N= 72283 (48.8)186 (82.3)27 (30.3)18 (64.3)22 (51.2)9 (31.0)77 (56.2)Access to primary care. N= 68987 (76.3)65 (67.7)32 (76.2)14 (60.9)17 (60.7)65 (51.6)117 (45.0)Change in health status, Much worse or worse. N=1,786214 (38.4)245 (53.3)98 (43.0)24 (42.9)38 (38.4)78 (61.9)135 (51.9)WHO-5. Poor well-being (≤50).N= 1,777292 (52.5)303 (66.9)100 (43.9)21 (37.5)46 (46.5)30 (23.8)78 (30.1)Risk of anxiety. N= 1,769241 (43.6)309 (68.5)118 (52.0)31 (55.4)61 (62.2)78 (61.9)175 (67.8)Risk of depression. N= 1,769186 (33.6)232 (51.4)101 (44.5)31 (55.4)54 (55.1)69 (54.8)138 (53.8)

Note: all relations were significant at the 0.001 level. 1Including: Axial Spondyloarthritis, Rheumatoid Arthritis, Psoriatic Arthritis, Juvenile Idiopathic Arthritis, Gout and Peripheral Spondyloarthritis; 2Including: Systemic Lupus Erythematosus, Sjögren’s Syndrome, Systemic Sclerosis and Myositis; 3Including: Polymyalgia Rheumatic and Vasculitis or Arteritis.

Acknowledgements:

This study was supported by Novartis Pharma AG. We would like to thank all patients that completed the survey as well as all of the patient organisations that participated in the REUMAVID study including: the Cyprus League Against Rheumatism (CYPLAR) from Cyprus, the Association Française de Lutte Anti-Rhumatismale (AFLAR) from France, the Hellenic League Against Rheumatism (ELEANA) from Greece, the Associazione Nazionale Persone con Malattie Reumatologiche e Rare (APMARR) from Italy, the Portuguese League Against Rheumatic Diseases (LPCDR), from Portugal, the Spanish Federation of Spondyloarthritis Associations (CEADE), the Spanish Patients’ Forum (FEP), UNiMiD, Spanish Rheumatology League (LIRE), Andalusian Rheumatology League (LIRA), Catalonia Rheumatology League and Galician Rheumatology League from Spain, and the National Axial Spondyloarthritis Society (NASS), National Rheumatoid Arthritis (NRAS) and Arthritis Action from the United Kingdom.

Disclosure of Interests:

Marco Garrido-Cumbrera: None declared, Helena Marzo-Ortega Speakers bureau: AbbVie, Biogen, Celgene, Janssen, Lilly, Novartis, Pfizer, Takeda and UCB, Consultant of: AbbVie, Celgene, Janssen, Lilly, Novartis, Pfizer and UCB, Grant/research support from: Janssen and Novartis, Laura Christen Employee of: Novartis Pharma AG, Loreto Carmona: None declared, José Correa-Fernández: None declared, Sergio Sanz-Gómez: None declared, Elsa Mateus Grant/research support from: Lilly Portugal, Sanofi, AbbVie, Novartis, Grünenthal S.A., MSD, Celgene, Medac, Janssen-Cilag, Pharmakern, GAfPA., Souzi Makri Grant/research support from: Novartis, GSK and Bayer., Pedro Plazuelo-Ramos: None declared, LAURENT GRANGE: None declared, Serena Mingolla: None declared, KATY ANTONOPOULOU: None declared, Dale Webb Grant/research support from: AbbVie, Biogen, Janssen, Lilly, Novartis and UCB, Clare Jacklin Grant/research support from: Abbvie, Amgen, Biogen, Eli Lilly, Gilead, Janssen, Pfizer, Roche, Sanofi & UCB, Shantel Irwin: None declared, Victoria Navarro-Compán Grant/research support from: Abbvie, BMS, Lilly, MSD, Novartis, Pfizer, Roche, and UCB

Abstract P1-10-08: Development of a first-in-class oral selective ERα covalent antagonist (SERCA) for the treatment of ERαWT and ERαMUT breast cancer

Mutations in estrogen receptor alpha (ERα) are detected in up to 30% of breast cancer patients who have relapsed during endocrine therapy. ERα mutations functionally confer resistance to existing classes of endocrine therapies, likely through gaining constitutive activity. The fact that current ER-directed therapies are only partially effective in the ERα mutant setting, and that a significant proportion of resistant breast cancer metastases continue to remain dependent on ERα signaling for growth/survival, highlights the critical need to develop the next generation of ERα antagonists that can overcome aberrant ERα activity. Using structure-based drug design approaches we have identified a novel class of ERα antagonist referred to as Selective ERα Covalent Antagonist (SERCA) that inactivate both wild-type and mutant ERα by targeting a unique cysteine residue that is not conserved among other steroid hormone receptors. Biophysical, biochemical and cellular analyses confirm the covalent mechanism of action, specific binding to ER and selective inhibition of ERα-dependent transcription of SERCAs. H3B-6545 is a highly selective SERCA that potently antagonizes wild-type and mutant ERα in biochemical and cell based assays demonstrating increased potency over standard of care and other experimental agents. In vivo, H3B-6545 shows superior efficacy to fulvestrant in the MCF-7 xenograft model with once daily oral dosing, achieving maximal antitumor activity at doses &gt;10x below the maximum tolerated dose in mice. In addition, H3B-6545 shows superior antitumor activity to both tamoxifen and fulvestrant in patient derived xenograft models of breast cancer carrying estrogen receptor mutations. In summary, H3B-6545 is a first-in-class, orally available and selective ER covalent antagonist with a compelling pre-clinical profile that is being developed for the treatment of ERα positive breast cancer.

Citation Format: Korpal M, Puyang X, Furman C, Zheng GZ, Banka D, Wu J, Zhang Z, Thomas M, Mackenzie C, Yao H, Rimkunas V, Kumar P, Caleb B, Karr C, Subramanian V, Irwin S, Larsen N, Vaillancourt F, Nguyen T-V, Davis A, Chan B, Hao MH, O'Shea M, Prajapati S, Agoulnik S, Kuznetsov G, Kumar N, Yu Y, Lai G, Hart A, Eckley S, Fekkes P, Bowser T, Joshi JJ, Selvaraj A, Wardell S, Norris J, Smith S, Reynolds D, Mitchell L, Wang J, Yu L, Kim A, Rioux N, Sahmoud T, Warmuth M, Smith PG, Zhu P. Development of a first-in-class oral selective ERα covalent antagonist (SERCA) for the treatment of ERαWT and ERαMUT breast cancer [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P1-10-08.

Taking culture seriously: Can we improve the developmental health and well-being of Australian Aboriginal children in out-of-home care?

BACKGROUND

Children in out-of-home care have well-documented health and developmental needs. Research suggests that Aboriginal children in care have unmet health and intervention needs. In metropolitan Sydney, Kari Aboriginal Resources Inc. (KARI), an Aboriginal organization, provides support to indigenous children in care, including clinical assessment and intervention. We wanted to determine the health and developmental needs of a subset of children in out-of-home care with KARI, who had been in stable care for at least a year. We wanted to identify child, carer, and intervention characteristics that contributed to children doing well. We also wanted to identify enablers and barriers to providing culturally competent intervention.

METHODS

We used mixed methods. From the KARI clinic database over the past 3 years, we identified children who had been in stable care with KARI for >12 months. We compared clinical measures and outcomes for these children with results from previous audits. We carried out a group discussion and key informant interviews with therapists and caseworkers to identify risk and resilience factors for each child, as well as enablers and barriers to culturally competent intervention.

RESULTS

The health and developmental profile of the 26 children identified as being in stable care was similar to that of previous audits. Most (88%) were getting speech pathology intervention; one third were getting occupational therapy and psychological intervention; most children and their carers attended cultural programmes. The majority of children (25/26) improved in their developmental health. Caseworkers and therapists identified risk and resilience factors related to child, carer, and home characteristics. They also identified elements of good practice; systemic issues prevented some interventions from being carried out.

CONCLUSIONS

There are challenges delivering a trauma-informed, culturally respectful service to Aboriginal children in out-of-home care in an urban setting, but it can be done if attention is paid to culture and the enablers and barriers are identified.

Hearing in school-aged children with trisomy 21 - results of a longitudinal cohort study in children identified at birth

OBJECTIVES

To report the prevalence of hearing problems and the hearing sequelae in school-aged children with trisomy 21 in a longitudinal study.

DESIGN

All children with trisomy 21 were identified via schools, community-based child development centres, general practitioners, or the universal newborn hearing screen. Audiological data and otorhinolaryngological problems were prospectively entered in to the Audiological Surveillance Programme database from each visit.

SETTING

Retrospective review of the Audiological Surveillance Programme database in the Glasgow area (United Kingdom) of all children reviewed between 2004 and 2012.

PARTICIPANTS

All pre-teenaged children with trisomy 21 of school age (aged 5-12 years old).

MAIN OUTCOME MEASURES

Hearing thresholds, aetiology of hearing loss and management of hearing loss was determined for the cohort of children.

RESULTS

A total of 102 children were included. Fifty-four had normal hearing. Twenty-six had fluctuating otitis media with effusion; five had hearing in normal limits, six were managed with hearing aids, fourteen were managed conservatively, and one had ventilation tube insertion. Fifteen had persistent otitis media with effusion; four had ventilation tube insertion; and nine were managed with hearing aids. Seven had mixed hearing loss with four required hearing aids.

CONCLUSIONS

Otitis media with effusion was the commonest cause of hearing impairment; effusions may fluctuate through the pre-teenaged years, and thus, hearing aids are beneficial. Ventilation tube insertion and bone-conducting hearing aids were useful when ear-level hearing aids were not tolerated. Mixed hearing loss occurred in later years as sensorineural hearing loss developed on a background of otitis media with effusion.

Cytosine-phosphate-guanine motifs fail to promote T-helper type 1-polarized responses in human neonatal mononuclear cells

BACKGROUND

The T-helper type 1 (Th1) trophic properties of bacterial cytosine-phosphate-guanine (CpG) motifs have made them logical adjuvants both for the suppression of Th2-mediated allergic disease in early life and for promoting vaccine responses in neonates who have relatively immature Th1 function. However, little is known about their effects on immature immune responses in this period.

OBJECTIVES

To compare the effects of CpG on adult and neonatal cellular immune responses to various stimuli.

METHODS

The immune responses of mononuclear cells (MC) derived from neonates (n=25) and their mothers (n=25) were compared in vitro. These were stimulated with house dust mite (HDM), CpG B, CpG C, non-CpG oligodeoxynucleotides (ODN) or diphtheria toxoid (DT) in optimized conditions. In parallel cultures, CpGs were combined with HDM or DT antigens to assess the effect of the various ODN on these antigen-specific responses. Lymphoproliferation and cytokine responses IL-13, IFN-gamma, IL-6, IL-10, TNF-alpha) were measured for all of the cultures described above.

RESULTS

Although neonates showed attenuated lymphoproliferation to CpG, the production of antigen-presenting cell-derived cytokines such as IL-6 and IL-10 and the up-regulation of major histocompatibility complex class II (HLA-DR) were detected at adult levels. T cell-derived cytokines (IL-13 and IFN-gamma) were not detectable in response to CpG alone. Most neonates also failed to produce detectable IFN-gamma to HDM or DT (unlike adults), but readily produced IL-13 to these stimuli. The addition of CpG resulted in an increase in neonatal IFN-gamma production in response to HDM (P=0.011) and a similar but non-significant trend with DT. However, rather than inhibiting Th2 IL-13 responses, the addition of CpGs was associated with a significant increase in the IL-13 responses to HDM (P=0.016) and DT (P=0.03), effects not seen in adults.

CONCLUSIONS

This study provides further evidence that neonatal MC responses to CpG are functionally different from adults, and do not show clear Th1 polarization. The CpG associated increase in Th2 responses may reflect a potentiation of the normal neonatal Th2 propensity, or non-specific activation of neonatal MC.

Clinical experience with the MicroMed DeBakey ventricular assist device

BACKGROUND

The MicroMed DeBakey ventricular assist device (VAD) (MicroMed Technology, Inc, Houston, TX) is the first long-term axial flow circulatory assist device to be introduced into clinical trials as a bridge to transplantation. Clinical trials began in Europe in November 1998 and in the United States in June 2000.

METHODS

To qualify for the study, the patients must be listed for cardiac transplantation and must have demonstrated profound cardiac failure. There were no exclusions to the MicroMed DeBakey VAD implant other than those patients who would typically be excluded from cardiac transplantation.

RESULTS

As of September 2000, 51 patients have been implanted with the MicroMed DeBakey VAD. A detailed evaluation of the first 32 patients has been completed. With current data, the probability of survival at 30 days after VAD implant is 81%.

CONCLUSIONS

The clinical trial demonstrated that the MicroMed DeBakey VAD is capable of providing adequate circulatory support in patients with severe heart failure, sufficient to recover and return to normal activities while awaiting a heart transplantation. Much has been learned about the function of the device and its continuous flow in humans.

Turbine blood pumps

After years of development and preclinical testing, clinical trials of the MicroMed DeBakey VAD began in November 1998 in Europe and in June 2000 in the United States. As of August 2000, 44 patients in Europe and 3 patients in the United States have undergone implantation with the MicroMed DeBakey VAD. In conclusion, data from the European clinical trial of the MicroMed DeBakey VAD support the safety and performance of the device. Results show that the device provides adequate left ventricular and circulatory support in patients with end-stage heart failure without unduly jeopardizing patient safety. Moreover, the device provides advantages not inherent to commercially available pulsatile devices: (1) miniature size, enabling implantation in smaller patients; (2) ease of implantation; (3) reduced surgical bleeding; and (4) a low incidence of postoperative infections, often a limiting factor with other devices. The MicroMed DeBakey VAD European clinical trial is the first demonstration of the compatibility of continuous blood flow with adequate tissue perfusion and overall maintenance of life for up to 4.5 months. This initial experience with the MicroMed DeBakey VAD suggests that the pump can provide circulatory support to bridge patients to cardiac transplantation and may provide an improved quality of life for the patient with end-stage heart failure.

Market returns? Gender and theories of change in employment relations

This paper explores recent arguments about the marketization of female labour, in the context of a wider analysis of the role of concepts like 'the market' and 'individualization' in sociological accounts of change in employment relations. It will be argued that within sociology there has been a tendency for rapid, large-scale changes in employment relations to be characterized as the breakdown of social influences or structures and as the emergence of atomized, individuated market forces. In the most recent models, change in the nature of gendered positions within employment are presented in terms of a decline of social structuring and social constraint. These emergent accounts hold similarities to classical economics, and to Marx's and Weber's accounts of employment, which also characterized new forms of employment relations in terms of the emptying of their social content and their replacement by market forms. We offer an alternative, moral economy, perspective which foregrounds the continued significance of social relations in the structuring of employment and employment change. We develop the argument through an analysis of gendered patterns of employment and change in family form.

Development and clinical application of the MicroMed DeBakey VAD

A miniaturized axial flow pump to provide left ventricular assistance has been developed. Such a device has the potential to address limitations of the larger pulsatile devices. Clinical trials of the MicroMed DeBakey VAD (ventricular assist device) began in Europe in November 1998. As of December 1, 1999, 18 patients have been implanted with the MicroMed DeBakey VAD. Hemodynamic evaluations along with blood chemistry analysis were recorded routinely. Exercise tolerance was observed. In most patients, end-organ function has improved and has not deteriorated in any patient. Patients have been able to perform normal low-level activity and have tolerated positional changes without evidence of postural hemodynamic changes. Select patients have taken supervised out-of-hospital excursions. This initial clinical experience with the MicroMed DeBakey VAD suggests that the miniaturized axial flow pump can provide ventricular support to bridge patients to cardiac transplant and may provide an improved quality of life for the end-stage heart failure recipient.

Adaptation and validation of a radioimmunoassay kit for measuring plasma cortisol in turbot

Levels of cortisol in fish blood provide quantitative information on the degree of stress induced by a variety of stressors. It is also useful in describing the social status of individual fish within groups. The commercial production of radioimmunoassay (RIA) kits, such as the DPC Coat-A-Count radioimmunoassay kit, has considerably reduced the effort required for cortisol measurement. These kits employ human plasma based cortisol standards which are not compatible for use with non mammalian species such as fish e.g. turbot, Scophthalmus maximus (Rafinesque), blood due to the interference effect of lipids and steroid binding proteins present in the plasma. In this study the DPC kit was used following the removal of these lipids and steroid binding proteins from the plasma using an ethanol-hexane extraction. Excessive variability in the cortisol values obtained using this method deemed it unsatisfactory in overcoming the problem of incompatibility. A second modification of this technique that was tested involved the preparation of turbot specific standards for use in the preparation of modified standard curves. Using this method, an accuracy of 93.4% was achieved, as opposed to 79.6% using the kit human plasma based standards, and 47.1% using samples following lipid removal using an ethanol-hexane extraction. Based on analysis of accuracy, precision and reproducibility it is concluded that commercially available cortisol kits are suitable for use with turbot plasma, but a number of minor modifications are necessary.

Acute and temporary ventricular support with BioMedicus centrifugal pump

BACKGROUND

Short-term ventricular and pulmonary support can be provided by the Medtronic BioMedicus (Eden Prairie, MN) centrifugal pump, which is available in most cardiovascular surgery centers. This versatile pump can provide support during cardiopulmonary resuscitation, cardiopulmonary bypass, extracorporeal membrane oxygenation, and ventricular assistance. A common use of the pump is to provide ventricular assistance for patients after cardiotomy or cardiogenic shock.

METHODS

From January 1986 to September 1995, 141 patients at The Methodist Hospital in Houston, Texas were placed on the BioMedicus centrifugal pump after postcardiotomy cardiac failure. Patient treatment and postimplant complications are discussed.

RESULTS

Fifty-four percent of the patients were weaned; however, only 22% survived to discharge. There was a very high mortality rate in the early stage after support was discontinued, after weaning, and after device removal.

CONCLUSIONS

A high incidence of complications and death is likely related to the period of attempted weaning from cardiopulmonary bypass before the initiation of ventricular support. When weaning a patient from the pump during cardiopulmonary bypass or during ventricular assistance, it is important to optimize preload, after-load, ventricular function, and cardiac rhythm. In patients who have had postcardiotomy support, avoiding fluid overload, low colloid oncotic pressure, hypoperfusion, and use of excessive inotropic and vasoactive medications improve results.

Age related distributive justice and claims on resources

The ageing population structure, and claims on resources by non-working groups, are seen by many to be contributing to a growing welfare crisis. In their arguments, relations between age groups and generations will become increasingly fraught, and welfare arrangements will be undermined, as 'unacceptable' levels of taxation blight the experience of a contracting workforce, required to resource a growing welfare population. However, more seems to be known about researchers' views on distributive justice than is known about the perceptions of their subject populations. It has not been demonstrated that members of age groups share interests which are consonant with their cohort experience, or perceive their interests to be in conflict with those members of other age groups or generations. This paper analyses empirical evidence on people's perceptions of who should get, and do, what, in developing an argument that standard processes do not place age groups or generations in antagonistic relationship. Understanding the relations between age groups and generations is essential to explaining change in patterns of inequality, but the interdependence of these relations suggest that they are part of a coherent social structure, and not likely to give rise to crisis in the ways predicted.

DNA specificity of the Cre recombinase resides in the 25 kDa carboxyl domain of the protein

The Cre protein of bacteriophage P1 is a 38.5 kDa site-specific recombinase that belongs to the Int family of recombination proteins. Cre acts by binding specifically to a 34 base-pair sequence, lox, where it carries out recombination. A limited chymotryptic digest of Cre resulted in two fragments of sizes 25 and 13.5 kDa, respectively. The sequence of the amino terminus of the purified 25 kDa peptide demonstrates that this peptide represents the carboxyl-terminal portion of the Cre protein. A truncated version of the cre gene was constructed which produces only the 25 kDa peptide. The 25 kDa peptide is capable of specific binding to the lox site, but binds at lower affinity than does wild-type Cre. Footprinting with Fe-EDTA indicates that the 25 kDa peptide protects the inverted repeats of the lox site but shows only partial protection of the spacer region. This is in contrast to the footprint obtained with wild-type Cre which protects the entire spacer region.

Compliance and the patient's perspective: controlling symptoms in everyday life

Non-compliance with medical advice is poorly understood. Most of the existing literature considers the problem only from the doctor's point of view. We undertook a diachronic, qualitative study of the illness experiences of 19 women to try to understand non-compliance from the patient's perspective. Three-fourths of our study group had ceased to follow their doctor's recommendations by four months post-diagnosis. Their non-compliance could not be explained by the fact that the women held understandings of their illnesses which were incongruent with their physician's; nor were they unable to understand the diagnosis they received. A consideration of the roles that their diagnosis and treatments played in their daily lives proved more useful in explaining their failure to follow physicians' recommendations. Patients' use of treatments reflected their desire to control symptoms within the constraints of their daily routines.

Views of what's wrong: diagnosis and patients' concepts of illness

A group of women were interviewed about their construction of their illness experiences before they saw a physician and subsequently over a period of several months following consultation. It was found that the physician's input was one of many components of their post-consultation understanding of their illnesses. The women built up their understandings in an interactive process, drawing significantly on their prior histories, ongoing experiences and social worlds. They continually tried out, adjusted and reworked the construction of their illnesses to adapt them to the exigencies of everyday life. We conclude that illness explanations are dynamic entities whose adequacy is determined by their usefulness within the extra-medical social environment.

Clinical manifestations and assessment of ischemic heart disease

This article reviews five clinical techniques for measuring and assessing the manifestations of ischemic heart disease. These measurements are heart rate, blood pressure, electrocardiogram, symptoms, and changes in heart sounds. The data obtained from these measurements are discussed in relation to measurement accuracy and to their clinical significance and relationship with the patient's diagnosis, prognosis, and disease manifestations. These clinical measures provide information that is critical to the decision-making processes for patient programming and safety.