Ground-up approach to understanding the impacts of historical trauma in one reserve-dwelling first nations community

OBJECTIVE

First Nations peoples experience disproportionate health inequities compared to most non-Indigenous populations. Historical trauma is one factor that has received growing attention in relation to health inequities among First Nations populations. The goal of the present study was to improve understanding of the specific forms, impacts, and mechanisms of transmission of events that lead to historical trauma and the historical trauma response in First Nations peoples.

METHOD

Five focus groups were conducted among adult members of one First Nations community in Canada (N = 34; 70.4% female).

RESULTS

Conventional content analysis revealed the numerous forms that historical trauma take in this First Nations community; individual-, familial-, community-, and societal-level impacts of historical trauma; and ways in which historical trauma has been transmitted in this community. Loss of culture, alcohol use, and parenting were major themes identified across these domains.

CONCLUSIONS

Findings provide important information on the experience of historical trauma in one First Nations community, highlighting the roles of loss of culture; alcohol use; and parenting in the forms, impacts, and transmission of historical trauma. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Primary Socialization Theory and American Indian Adolescents' Intentions to Use Substances

Intentions to use substances are a robust risk factor for future substance use. Primary Socialization Theory (PST), with its focus on relational factors, is well-suited to provide insight into American Indian adolescents' intentions to use substances given the importance of relationships in American Indian communities. The goal of the present study was to examine the role of PST-related factors (i.e., parental monitoring, peer pressure, attitudes toward school) on likelihood of intending to use substances (i.e., alcohol, cigarettes, cannabis, other drugs) among American Indian adolescents.

American Indian participants (N = 8,950, 50.7% females) were recruited as a part of the Our Youth, Our Future survey, an ongoing surveillance of substance use among 7th-12th graders attending school on or near reservations.

Parental monitoring was found to be associated with decreased likelihood of intending to use alcohol (aOR = 0.97, 95%CI [0.96, 0.99]), cigarettes (aOR = 0.96, 95%CI [0.94, 0.98]), cannabis (aOR = 0.95, 95%CI [0.94, 0.96]), and other drugs (aOR = 0.94, 95%CI [0.92, 0.96]). Peer pressure was associated with increased likelihood of intending to use alcohol (aOR = 1.68, 95%CI [1.59, 1.78]), cigarettes (aOR = 1.73, 95%CI [1.60, 1.86]), cannabis (aOR = 1.81, 95%CI [1.71, 1.92]), and other drugs (aOR = 1.40, 95%CI [1.26, 1.56]). More positive attitudes toward school were associated with decreased likelihood of intending to use alcohol (aOR = 0.93, 95%CI [0.91, 0.94]), cigarettes (aOR = 0.92, 95%CI [0.90, 0.94]), cannabis (aOR = 0.90, 95%CI [0.88, 0.91]), and other drugs (aOR = 0.96, 95%CI [0.93, 0.99]).

Results support incorporating social relationships into interventions aiming to prevent substance use initiation, including promoting positive parental monitoring, peer interactions, and school attitudes.

The role of culture in the association between racial discrimination and alcohol use among North American Indigenous adolescents reporting recent drinking

BACKGROUND

North American Indigenous (NAI) communities have identified alcohol use as a primary health concern. Experiences of racial discrimination are associated with increased alcohol use, but findings are mixed regarding the role of culture. The goal of the present study is to examine the role of culture in the association between racial discrimination and alcohol use.

METHODS

Across two studies (Study 1: N = 52; Study 2: N = 1,743), NAI adolescents who reported recent alcohol use living on or near NAI reservations completed self-report measures of racial discrimination, cultural affiliation, and alcohol use (e.g., frequency).

RESULTS

Bivariate correlations revealed a significant positive correlation between racial discrimination and alcohol use (Study 1: r = .31, p = .029; Study 2: r = .14, p < .001), and no significant correlation between cultural affiliation and alcohol use. Racial discrimination and cultural affiliation were significantly positively correlated in Study 1 (r = .18, p < .001), but not in Study 2. Across both studies, the interactions between racial discrimination and cultural affiliation predicting alcohol use were significant in unadjusted models (Study 1: b = 0.70, SE = 0.32, p = .033, 95%CI [0.06, 1.33]; Study 2: b = 0.01, SE = 0.01, p = .041, 95%CI [0.001, 0.03]), such that the association between racial discrimination and alcohol use was stronger for adolescents reporting high (versus low) levels of cultural affiliation. However, in adjusted models controlling for age and sex, the interaction between racial discrimination and cultural affiliation remained significant in Study 2 (b = 0.01, SE = 0.01, p = .0496, 95%CI [0.00002, 0.03]) but was no longer significant in Study 1.

CONCLUSIONS

Findings speak to the need to reduce racial discrimination against NAI youth, and to consider youths' different needs based on level of cultural affiliation to reduce subsequent alcohol consumption.

12 VACCINATION UP-TAKE IN DERMATOLOGY PATIENTS OVER THE AGE OF 65 YEARS ON BIOLOGICAL TREATMENT

Background

Biologic and immunosuppressive therapies play important roles in the management of a wide variety of dermatologic diseases. However, immunotherapies can negatively affect normal immune functioning, placing these patients at high risk of infection. The strength of the immune system also declines with increasing age. Thus, in accordance with the British Association of Dermatology guidelines (August 2021), patients taking biologic therapy can and should have their covid, influenza and pneumococcal vaccinations.

Methods

We conducted a retrospective audit of all patients over the age of 65 years on biological therapy in the dermatology clinic between March 2021 to March 2022. Data on patients covid, influenza and pneumococcal vaccination status was obtained from Dermatology database and patients medical records.

Results

A total of 18 patients over the age of 65 years, were on biological therapy in the Dermatology Department, between March 2021 to March 2022. The mean age was found to be 71 years with a standard deviation of 5.2 and there was equal gender distribution. 94% (n=17) of patients had psoriasis and 6% (n=1) had eczema. With regards to biological treatments, 17% (n=3) of patients were on Adalimumab,11% (n=2) on Etanercept and 28% (n=5) on Cosntyx. 100% (n=18) had all three of their covid-19 vaccines. 50% (n=8) are awaiting their 4th covid vaccination. 94% (n=17) of patients had their influenza vaccine. 66% (n=12) had their pneumococcal vaccination, the patients who had not had their pneumococcal vaccination were recommended and advised to have it.

Conclusion

This audit confirms dermatology patients over the age of sixty-five years, are compliant on receiving their covid vaccinations, as recommended by the BAD. However, only 66% of patients had their pneumococcal vaccination and 94% had their influenza vaccine, illustrating the need for educational intervention on the importance of vaccination. This will then be followed by a reaudit next year to complete the audit cycle.

Cultural identity affiliation and alcohol use and related consequences among American Indian and White adolescents: A latent profile analysis

BACKGROUND

Adolescent alcohol use is a significant public health concern and rates of alcohol use are higher among American Indian (AI) adolescents than national samples of non-AI youth. A potential factor in understanding AI alcohol use is cultural identity, which can vary widely based on experiences of historical trauma. We used latent class analysis to examine cultural identity in AI and White adolescents and their alcohol use outcomes in relation to the latent class solutions.

METHODS

The samples included 3189 AI adolescents (M_age  = 14.76, 48.9% female) and 1579 White adolescents (M_age  = 15.56, 48.7% female) living on or near a reservation. Participants completed self-report measures of AI and White cultural identity affiliation, alcohol use, and alcohol-related problems. We examined (1) the best-fitting latent class solution with respect to American Indian (AI) and White cultural identity; (2) equivalence of the latent class solution; and (3) alcohol use outcomes across the optimal latent class solution.

RESULTS

Latent profile analyses indicated an optimal 3-class solution in both the AI and White samples, which differed by level of affiliation with AI and White cultural identity. While the optimal number of classes were similar across racial groups (configural profile similarity), the nature of the classes differed (structural profile dissimilarity). The three classes represented low overall scores on AI and White cultural identity (Marginalized), a mixture of high and low scores on AI and White cultural identity (Third Culture), and overall high scores on AI and White cultural identity (Bicultural). Alcohol-related problems predicted membership in the Third Culture class compared with the Marginalized class and the Bicultural class. Specifically, youth in the Third Culture class reported significantly fewer alcohol-related problems than youth in the Marginalized and Bicultural classes. Alcohol use did not predict latent class membership.

CONCLUSIONS

The future-oriented nature of the Third Culture class may provide protection against adverse alcohol-related outcomes. Research is needed to test interventions that target greater future orientation and future plans to integrate culture into adolescents' lives.

POS0246 SEQUENTIAL RITUXIMAB AND MEPOLIZUMAB IN EOSINOPHILIC GRANULOMATOSIS WITH POLYANGIITIS

Background

Rituximab (RTX) is an effective remission-induction treatment in ANCA-associated vasculitides (AAVs). Some reports have suggested that it might be effective also in Eosinophilic Granulomatosis with Polyangiitis (EGPA), to induce and maintain remission of vasculitic manifestations [1,2]. However, its effects for preventing respiratory relapses seem to be poor. Mepolizumab (Mepo) (both 100 and 300mg/month) is effective in improving respiratory manifestations and lung function, while partially controlling also systemic activity [3,4]. Isolated case reports further indicate that the sequential therapy with RTX and Mepo might be effective [5-7].

Objectives

The study aimed to investigate the efficacy and safety of a therapeutic regimen based on sequential RTX and Mepo for the control of EGPA.

Methods

A multicenter, retrospective, cohort study was conducted on adult patients diagnosed with EGPA according to the ACR classification criteria [8] or MIRRA trial criteria [3]. Only patients who received induction therapy with RTX (any dosage), and subsequent treatment with Mepo (100-300 mg/4 weeks) within 12 months from last RTX administration were included. Patients receiving other induction therapies between RTX and Mepo were excluded. The effectiveness of sequential RTX and Mepo was assessed in terms of disease activity (by the Birmingham Vasculitis Activity Score, BVAS) and daily corticosteroid dosage. Safety data were also collected.

Results

Thirty-four EGPA patients treated with sequential RTX and Mepo were included (59% females, median age of 51 years (IQR 40-58); 41% ANCA positive).

In most cases (26/34; 76%), RTX was started at the dosage of 1g q2w, and all except two patients had active disease at time of RTX beginning [median BVAS of 9 (IQR 6-14)]. Specifically, most patients started RTX for the control of systemic manifestations (19/34; 56%), or of both systemic and respiratory symptoms (11/34; 32%). All except one patient were receiving oral corticosteroids, at a median dosage of 25 mg/day (10-38).

Mepo was started after a median of 14 months (6-23) from RTX initiation and after a median of 5 months (IQR 3-11) from the last RTX administration. Mepo was used at the dosage of 100mg/4 weeks in 32/34 (94%), mostly for the control of respiratory manifestations (25/34, 74%). At the time of starting Mepo, the median BVAS was 4 (2-8), and median prednisolone dose 10 mg/day (7-15). After a median follow-up of 28 months (IQR 23-33) from starting Mepo, the median BVAS decreased to 1.5 (IQR 0-4) and the median corticosteroid dosage to 5 mg/day (2.5-5), with 7/34 (21%) patients being off steroids. At last follow-up, most patients were off-RTX (28/34), typically due to stable disease remission (20/34; 59%).

Both RTX and Mepo were well-tolerated; 5 patients had adverse events on RTX (none serious), and 5 on Mepo (including one serious infection).

Conclusion

Sequential use of RTX and Mepo seems to be effective for remission induction and maintenance in EGPA.

References

[1]Emmi, Ann Rheum Dis, 2018

[2]Teixeira, RMD Open, 2019 3. Wechsler, NEJM, 2017

[4]Bettiol, Arthritis Rheumatol, 2021

[5]Shiroshita, Respir Med Case Rep, 2018

[6]Higashitani, Mod Rheumatol Case Rep, 2021

[7]Afiari, Cureus 2020

[8]Masi, Arthritis Rheum, 1990

Table 1.

Effectiveness of sequential RTX and Mepo in the 34 patients included in the study

RTX beginningMepo beginningLast follow-upMedian time elapsed (IQR)-14 months (6-23) from RTX beginning28 months (23-33) from Mepo beginningDosage1g q2w (26/34);100mg/4 weeks (32/34)6 patients off Mepo; 28 patients off RTX375mg/m2 for 4 weeks (8/34)300mg/4 weeks (2/34)Reason for treatment beginning (manifestations)Systemic (19/34);Respiratory (25/34);-Systemic + respiratory (11/34);Systemic (4/34);Only respiratory (3/34);Remission maintenance (5/34)Other (1/34)BVAS (median, IQR)9 (6-14)4 (2-8)1.5 (0-4)Prednisolone dosage (median, IQR), mg/day25 (10-38)10 (7-15)5 (2.5-5)

Disclosure of Interests

Alessandra Bettiol: None declared, Maria Letizia Urban: None declared, Federica Bello: None declared, Davide Fiori: None declared, Irene Mattioli: None declared, Giuseppe Lopalco: None declared, Florenzo Iannone: None declared, Allyson Egan: None declared, Luca Moroni: None declared, Lorenzo Dagna Consultant of: Consultation honoraria from GSK outside the current work, Marco Caminati: None declared, Simone Negrini: None declared, Paolo Cameli: None declared, Marco Folci: None declared, Paola Toniati: None declared, Roberto Padoan: None declared, Oliver Flossmann: None declared, Roser Solans-Laqué: None declared, Laura Losappio: None declared, Jan Schroeder Consultant of: Advisory Board fees from AstraZeneca and GSK, Marc André: None declared, Laura Moi: None declared, paola parronchi Consultant of: Consultation honoraria from GSK and Novartis, Fabrizio Conti: None declared, Savino Sciascia: None declared, David Jayne Consultant of: Consultant for Astra-Zeneca, Aurinia, BMS, Boehringer-Ingelheim, Chemocentryx, Chugai, CSL, GSK, Infla-RX, Janssen, Novartis, Roche/Genentech, Takeda and Vifor, Augusto Vaglio Consultant of: Consultation honoraria from GSK outside the current work, Giacomo Emmi Consultant of: Consultation honoraria from GSK outside the current work

77 INCONTINENCE AND DECONDITIONING IN A NONFRAIL SAMPLE OF INPATIENTS AT A UNIVERSITY TEACHING HOSPITAL

Background

Incontinence occurs in 26% of hospitalised adults1. Deconditioning in hospitalised adults is common and contributes to increased hospital stay2. The #endpjparalysis movement motivates us to reduce harms of hospitalisation older adults.

Methods

We surveyed inpatients to capture the point prevalence of incontinence. We also collected information regarding functional status, continence status and use of continence wear. Local ethical review-board approval was obtained. All participants provided informed consent.

Results

There were 86 responses. Mean age of participants was 71.5 years. 45.4% were female, &gt;95% were admitted from home and were functionally independent. Mean length of stay for respondents was 7.4 days ±12. The median Clinical Frailty Scale, for respondents aged &gt;65 years, was 3, indicating this cohort is not frail.

17 respondents reported incontinence on the day of survey; 8 of these reported that incontinence was a new experience for them since their admission. 24 respondents wore incontinence wear at home, 31 were wearing incontinence wear on the day of survey.

Of 80 respondents who could toilet independently at home, 23 (26%) reported a new dependency to toilet. Of 83 respondents who mobilised independently at home (with or without an aid), 11 reported needing assistance of one-person to walk, 3 needed the assistance of two-people to walk or stand, five people required a hoist, while 3 were bedbound on the day of survey.

Conclusion

We describe increased dependency in mobility, toileting and increased use of continence wear in non-frail hospitalised older adults. Future work is needed to maintain function during admission to hospital.

References

1. Condon, M., et al. (2019). ‘Urinary and Faecal Incontinence: Point Prevalence and Predictors in a University Hospital.’ Int J Environ Res Public Health 16.

2. Guilcher, S., et al. (2021). ‘A qualitative study exploring the lived experiences of deconditioning in hospital in Ontario, Canada.’ BMC Geriatrics 21.

194 TIA IMAGING: ARE WE FOLLOWING NICE 2020 GUIDELINES?

Background

CT brain imaging is customary in clinical practice after Transient Ischemic Attack (TIA). However, NICE (2020) guidelines recommend MRI brain with diffusion weighted and blood-sensitive sequences; to be completed on the same day as the assessment. The purpose is to detect the ischemic territory, haemorrhage, or other pathology. The aim of this audit was to assess the diagnostic radiology investigations performed on patients, over the age of sixty-five years, presenting with TIA to a university teaching hospital.

Methods

We conducted a retrospective audit of all patients coded as TIA on the Hospital Inpatient-Enquiry (HIPE) system between July 2019 to July 2020. Data on brain imaging was accessed using the National Integrated Medical Imaging System (NIMIS) system. Hospital attendance records were accessed via the Emergency Department patient database. Data was analysed using Microsoft Excel.

Results

Eighty patients had brain imaging performed (n = 38 CT brain only; n = 1 MRI only; n = 41 CT and MRI). Of these patients, only three had an MRI brain completed within twenty-four hours where thirty-nine patients had an MRI scans outside of twenty-four hours. Forty-one patients had both a CT and MRI brain imaging performed. The median time to MRI brain was three days and one and a half hours and the median time to CT brain was two hours and forty-nine minutes.

Conclusion

This audit confirms duplication of TIA brain imaging and CT as the primary imaging tool for TIA which is not in keeping with best practice (NICE, 2020). This has implications for resources, radiation exposure and patient’s length of stay. Development of dedicated ambulatory care pathways for TIA must incorporate rapid MRI access as the primary imaging modality.

A systematic review on outcome reporting in randomised controlled trials assessing treatment interventions in pregnant women with pregestational diabetes

BACKGROUND

Pregestational diabetes mellitus (PGDM) is associated with adverse pregnancy outcomes. Studies assessing interventions to improve maternal and infant outcomes have increased exponentially over recent years. Several outcomes in this field of maternal diabetes are rare, making it difficult to synthesise evidence.

OBJECTIVES

To collect outcomes reported in studies assessing treatment interventions in pregnant women with PGDM.

SEARCH STRATEGY

CENTRAL, Web of Science, Medline, CINAHL, Embase and ClinicalTrials.gov from their inception until 27 January 2020.

SELECTION CRITERIA

Any randomised controlled trial assessing treatment interventions in pregnant women with PGDM reported in English.

DATA COLLECTION AND ANALYSIS

Two independent reviewers assessed the suitability of articles and retrieved the data. Outcomes extracted from the literature were broadly categorised into maternal, fetal/infant or other outcomes by the study advisory group.

MAIN RESULTS

Sixty-seven of the 1475 studies identified fulfilled the inclusion criteria. The median number of outcomes reported per study was 15 (range 1-46). The majority of studies were from North America and Europe. Insulin and metformin were the most commonly investigated pharmacological interventions. Glucose monitoring was the most assessed technological intervention. In all, 131 unique outcomes were extracted: maternal (n = 69), fetal/infant (n = 61) and other (n = 1).

CONCLUSIONS

Outcome reporting in treatment interventions trials of pregnant women with PGDM is varied, making it difficult to synthesise evidence, especially for rare outcomes. Systems are needed to standardise outcome reporting in future clinical trials and so facilitate evidence synthesis in this area of maternal diabetes.

REGISTRATION

The systematic review was registered prospectively with the International Prospective Register of Systematic Reviews (PROSPERO) database (Registration number CRD42020173549).

TWEETABLE ABSTRACT

Outcome reporting is heterogeneous in intervention trials of pregnant women with diabetes existing before pregnancy.

OP0148 MEPOLIZUMAB FOR EOSINOPHILIC GRANULOMATOSIS WITH POLYANGIITIS (EGPA): A RETROSPECTIVE REAL-WORLD EUROPEAN STUDY ON 142 PATIENTS

Background:

Evidence on the efficacy of Mepolizumab (MEPO) in Eosinophilic Granulomatosis with Polyangiitis (EGPA) is scarce [1].

Objectives:

To assess the efficacy and safety of MEPO in real-life clinical practice.

Methods:

We retrospectively included patients diagnosed with EGPA and treated with MEPO (100 or 300 mg/month). MEPO efficacy was evaluated in the first 12 months in terms of systemic disease and asthma control. The occurrence of any adverse event (AE) was recorded.

Results:

142 patients were included (38% males; median age 46.4 (IQR 36.7-54.4); 110 and 32 on MEPO 100 and 300 mg/month, respectively). General, ear-nose-throat, pulmonary, and neurological symptoms significantly decreased during treatment (table 1). MEPO accounted for a significant reduction in the BVAS (figure 1) and for a steroid sparing effect (figure 2). The proportion of patients with asthma attacks decreased by 90% at 12 months compared to t0, and asthma-related emergency accesses dropped from 17.4% to 2.3%. Overall, 21.1% of patients had a non-serious AE.

Table 1.

Control of clinical symptoms

MEPO beginning (t0)3 monthsp-value(t3 vs t0)6 monthsp-value(t6 vs t0)12 monthsp-value(t12 vs t0)N obsN=142N=135N=123N=89General symptoms40 (28.2%)17 (12.6%)<0.00119 (15.5%)<0.00113 (14.6%)0.002Cutaneous manifestations13 (9.2%)6 (4.4%)0.0085 (4.1%)0.0254 (4.5%)0.180ENT manifestations106 (74.7%)52 (38.5%)<0.00144 (35.8%)<0.00129 (32.6%)<0.001Pulmonary manifestations130 (91.6%)59 (43.7%)<0.00139 (31.7%)<0.00128 (31.5%)<0.001Cardiac manifestations6 (4.2%)2 (1.5%)0.0832 (1.6%)0.08300.157Intestinal manifestations10 (7.0%)1 (0.7%)0.0054 (3.3%)0.0593 (3.4%)0.059Renal manifestations5 (3.5%)3 (2.2%)0.41400.0461 (1.1%)0.317Neurological manifestations36 (25.4%)22 (16.3%)0.01218 (14.6%)0.00310 (11.2%)0.035Figure 1.

Changes in BVAS

Figure 2.

Steroid treatment

Conclusion:

MEPO effectively controlled systemic and respiratory EGPA symptoms in a large European cohort, with no major safety concerns.

References:

[1]Wechsler et al. MEPO or Placebo for Eosinophilic Granulomatosis with Polyangiitis. NEJM. 2017

Disclosure of Interests:

Alessandra Bettiol: None declared, Maria Letizia Urban: None declared, Federico Alberici: None declared, Carlo Agostini: None declared, Chiara Baldini: None declared, Enrica Bozzolo: None declared, Paolo Cameli: None declared, Nunzio Crimi: None declared, Stefano Del Giacco: None declared, Allyson Egan: None declared, Georgina Espigol-Frigole Consultant of: Roche and Janssen, Mara Felicetti: None declared, Marco Folci: None declared, Paolo Fraticelli: None declared, Marcello Govoni: None declared, Anna Kernder Grant/research support from: Grant/research support from: GlaxoSmithKline and UCB Pharma for performing the LuLa-study., Carlo Lombardi: None declared, Giuseppe Lopalco: None declared, Claudio Lunardi: None declared, Aladdin J Mohammad Speakers bureau: lecture fees from Roche and Elli Lilly Sweden, PI (GiACTA study), Frank Moosig: None declared, Simone Negrini: None declared, Thomas Neumann: None declared, Pavel Novikov Grant/research support from: This work was supported by the 5-100 Project, Sechenov University, Moscow, Giuseppe Paolazzi: None declared, paola parronchi: None declared, Luca Quartuccio Consultant of: Abbvie, Bristol, Speakers bureau: Abbvie, Pfizer, Vito Racanelli: None declared, Carlo Salvarani: None declared, Maxime Samson: None declared, Jan Schroeder: None declared, Savino Sciascia: None declared, Renato A. Sinico: None declared, Benjamin Terrier: None declared, Paola Toniati: None declared, Domenico Prisco: None declared, Augusto Vaglio: None declared, Giacomo Emmi: None declared

AB0470 EOSINOPHILIC GRANULOMATOSIS WITH POLYANGIITIS (EGPA) - ONE-YEAR FOLLOW-UP STUDY USING MEPOLIZUMAB ANTI-IL5 THERAPY AS A STEROID SPARING THERAPEUTIC APPROACH

Background:

EGPA is a small vessel vasculitis characterised by the presence of tissue eosinophilia, necrotising vasculitis and granulomatous inflammation1. Typically, a prodromal asthmatic phase, leads to an eosinophilic stage, which can evolve to include the presence of vasculitis with renal manifestations. In the recent randomised, placebo-controlled MIRRA trial for relapsing and refractory EGPA, adjuvant therapy with anti-IL5 mAB Mepolizumab [MEPO] at 300mg s/c monthly, accrued longer times in remission, reduced steroid exposure and reduced relapse rates2.

Objectives:

The aim of our study was to analyse the response and outcome for EGPA patients who received 100mg s/c of MEPO monthly for a minimum of 52 weeks, with particular focus on the steroid minimisation benefits.

Methods:

This retrospective, descriptive study analysed 13 patients with EGPA, who received 100mg s/m monthly MEPO therapy under the eosinophilic asthma care-pathway. Time points of assessment included MEPO commencement [M0] and 12 [M12] months.

Results:

Table 1.

EGPA patients receiving Mepolizumab therapy for one year [100mg s/c]

DemographicsAll [n=13]Gender ratio M/F4M:9FANCA positive/ negativeANCA: 3MPO, 1 PR3 positive/ 9 ANCA negativeAge of diagnosis of asthma35 yrs [IQR 28.5-40]Age of diagnosis of EGPA47 yrs [IQR 43.5-53.5]Median age51 yrs [IQR 47.5- 60.5]EGPA disease characteristicsN=13 [%]Asthma 13 [100]Serum eosinophilia or biopsy evidence [N= 12] 12 [100]Pulmonary infiltrates, non-fixed 8[61.5]Neuropathy, mono/poly 4[30.7]Sino-nasal abnormality 12[92.3]Glomerulonephritis 3[23]Cardiovascular 4[30.7]Prior ImmunosuppressantsN=13 [%]Steroids13[100%]Cyclophosphamide 6[46%]Rituximab6[46%]Azathioprine10[77%]Mycophenolate mofetil8[62%]Methotrexate4[31%]Campath 1[7%]Response to therapyM0 [%] Post M12 [%]Prednisolone dose N= 13Mean ±SD 18.925 mg ±11.44 10.575mg ± 5.85Eosinophil count X109/L N=13Mean ±SD 0.415mg ±0.25 0.035±0.039Asthma Control Questionnaire [ACQ] N=5Mean ±SD 2.92 ±1.27 1.31± 0.79BVAS N= 13Mean ±SD 7.307±6.29 2.2307±1.69Creatinine N=9Mean ±SD 68.44±15.03 69.11±17.84Continuation of anti-IL5 therapy N=13 12/13 [92.3%]

Conclusion:

The relapsing nature of EGPA places a potential dependency of therapy on steroids for asthmatic and vasculitic flares. This underscores the importance of targeted pathway specific biologic therapy to minimise steroid exposure, prevent tissue damage and ensure early response to therapy. This study demonstrates that anti-IL5 serves as a favourable model with steroid minimisation, improvement in asthma control questionnaire, reduction in BVAS and eosinophil counts at the 100mg s/c dosage. ANCA positive serology normalised in all four patients, independent of subtype. Well tolerated, it demonstrated considerable clinical benefit, with 12 patients [92.3%] continuing anti-IL5 therapy beyond 12 months.

Long term plan > 12 monthsN=13 [%] Current Months Adjuvant therapy 12M1 Continue15 Aza2 Switched Benralizumab 26 MMF [+], IVIG [-]3 Continue 184 Switched Benralizumab 145 Discontinued Rituximab 12 MTX6 Continue 147 Continue 24 MMF Reduced8 Continue 18 MTX [+]9 Continue 15 MMF [-]10 Continue 1411 Continue 1312 Continue 13 Aza13 Continue 12

References:

[1]J.C.Jenette,et alRevised International Chapel Hil Consensus Conference Nomenclature of Vasculitides.65, 1–11 (2013).

[2]Wechsler, M. E.et al.Mepolizumab or Placebo for Eosinophilic Granulomatosis with Polyangiitis.N. Engl. J. Med.376, 1921–1932 (2017).

Disclosure of Interests:

Allyson Egan: None declared, pasupathy Sivasothy: None declared, Robin Gore: None declared, Marcos Martinez Del-Pero: None declared, Caroline Owen: None declared, Lisa Willcocks: None declared, Rona Smith: None declared, Stella Burns: None declared, David Jayne Grant/research support from: ChemoCentryx, GSK, Roche/Genentech, Sanofi-Genzyme, Consultant of: Astra-Zeneca, ChemoCentryx, GSK, InflaRx, Takeda, Insmed, Chugai, Boehringer-Ingelheim

Mass and the Dangers of Syncope

Introduction Syncope is defined as a transient, self-limited loss of consciousness with an inability to maintain postural tone that is followed by spontaneous recovery. We revisit situational syncope focusing on one situation, Mass. Methods We interrogated our electronic syncope database for key terms associated with situational syncope. From the most commonly encountered situation, Mass, we interrogated the results of tilt testing performed to identify evidence of orthostatic hypotension. Results There were 110 cases of situational syncope identified with 56.3% (n=62) taking place at mass. All had tilt table testing performed and 15.4% (n=17) had evidence of orthostatic hypotension. Conclusion The multiple sudden changes in position during mass from sitting to kneeling to standing can precipitate an episode of orthostatic hypotension. Consideration should be given as to whether it is safe for older mass goers to be subjected to such significant orthostatic stress.

The use of digital media by women using the maternity services in a developed country

The provision of high quality healthcare information about pregnancy is important to women and to healthcare professionals and it is 1 driven, in part, by a desire to improve clinical outcomes,. The objective of this study was to examine the use of digital media by women' to access pregnancy information. A questionnaire was distributed to women attending a large maternity hospital. Of the 522 respondents, the mean age was 31.8 years, 45% (235/522) were nulliparous, 62% (324/522) lived in the capital city and 29% (150/522) attended the hospital as private patients. Overall 95% (498/522) used the internet for pregnancy information, 76% (399/522) had a smartphone and 59% (235/399) of smartphone owners had used a pregnancy smartapp. The nature of internet usage for pregnancy information included discussion forums (70%), social networks (67%), video media (48%), e-books (15%), blogs (13%), microblogs (9%) and podcasts (4%). Even women who were socially disadvantaged reported high levels of digital media usage. In contemporary maternity care women use digital media extensively for pregnancy information. All maternity services should have a digital media strategy.

Isolated pancreatic metastases from a bronchogenic small cell carcinoma

We describe the case of a 60 year old female smoker who presented with a three month history of weight loss (14 Kg), generalized abdominal discomfort and malaise. Chest radiography demonstrated a mass projected inferior to the hilum of the right lung. Computed Tomography of thorax confirmed a lobulated lesion in the right infrahilar region and subsequent staging abdominal CT demonstrated a low density lesion in the neck of the pancreas. Percutaneous Ultrasound guided pancreatic biopsy was performed, histology of which demonstrated pancreatic tissue containing a highly necrotic small cell undifferentiated carcinoma consistent with metastatic small cell carcinoma of the bronchus.

Construct validity for the LAPSIM laparoscopic surgical simulator

BACKGROUND

The skills required for laparoscopic surgery are amenable to simulator-based training. Several computerized devices are now available. We hypothesized that the LAPSIM simulator can be shown to distinguish novice from experienced laparoscopic surgeons, thus establishing construct validity.

METHODS

We tested residents of all levels and attending laparoscopic surgeons. The subjects were tested on eight software modules. Pass/fail (P/F), time (T), maximum level achieved (MLA), tissue damage (TD), motion, and error scores were compared using the t-test and analysis of variance.

RESULTS

A total of 54 subjects were tested. The most significant difference was found when we compared the most (seven attending surgeons) and least experienced (10 interns) subjects. Grasping showed significance at P/F and MLA (p < 0.03). Clip applying was significant for P/F, MLA, motion, and errors (p < 0.02). Laparoscopic suturing was significant for P/F, MLA, T, TD, as was knot error (p < 0.05). This finding held for novice, intermediate, and expert subjects (p < 0.05) and for suturing time between attending surgeons and residents (postgraduate year [PGY] 1-4) (p < 0.05).

CONCLUSIONS

LAPSIM has construct validity to distinguish between expert and novice laparoscopists. Suture simulation can be used to discriminate between individuals at different levels of residency and expert surgeons.

Abattoir-associated Q fever: a Q fever outbreak during a Q fever vaccination program

OBJECTIVES

To investigate an abattoir outbreak of Q fever in southem New South Wales with reference to the protective effect and safety of the formalin-inactivated Q fever vaccine (Q Vax) administered before and during the outbreak.

METHODS

In September 1998, after notification of four Q fever cases in the abattoir, a cohort investigation of 103 workers was undertaken. Data on age, sex, immune status, vaccination status and main work area were obtained from the medical officer administering the vaccination program and abattoir records. Symptoms and occupational risk factors for illness were obtained from interview of 63 (61%) employees.

RESULTS

Of 103 abattoir employees, 16 (16%) had immunity from previous Q fever exposure and 19 (18 %) had been vaccinated at least six weeks before the first case of Q fever exposure in the abattoir. Of the remaining 68 workers who were susceptible to primary infection, 29 (43%) had laboratory confirmed acute primary Q fever and eight were suspected cases. No workers vaccinated before the likely period of exposure developed Q fever. Of 32 workers vaccinated post-exposure, four developed laboratory-confirmed Q fever within eight days of vaccination. Vaccination administered 10 or more days after the likely period of exposure showed no significant protective effect (RR=0.57; 95% CI 0.13-2.57; p=0.60).

CONCLUSIONS

Q-Vax was highly effective when administered in advance of the likely period of Q fever exposure. Post exposure vaccination was not shown to be protective.

IMPLICATIONS

This study reinforces meat industry vaccination guidelines for abattoir employees. The optimal time to vaccinate workers is before they are put at occupational risk.

Immunogenicity and efficacy in aotus monkeys of four recombinant Plasmodium falciparum vaccines in multiple adjuvant formulations based on the 19-kilodalton C terminus of merozoite surface protein 1

The immunogenicity and protective efficacy of four versions of recombinant C-terminal 19-kDa epidermal growth factor-like region of the major surface protein 1 (rMSP1(19)) of Plasmodium falciparum was studied in Aotus monkeys. Vaccination with each of the four rMSP1(19) constructs elicited high levels of antibodies to MSP1(19) but only one construct, the 19-kDa fragment expressed as a secreted fusion protein from Saccharomyces cerevisiae (yP30P2MSP1(19)), induced a high degree of protective immunity in Aotus nancymai against lethal P. falciparum challenge. Protective formulation required Freund's adjuvant; vaccination with yP30P2MSP1(19) in six other adjuvants that are suitable for human use induced lower levels of antibody response and no protection. These results emphasize the need to continue the search for an adjuvant that is comparable to Freund's adjuvant in potency and is safe for use in humans.

Phase I trial of two recombinant vaccines containing the 19kd carboxy terminal fragment of Plasmodium falciparum merozoite surface protein 1 (msp-1(19)) and T helper epitopes of tetanus toxoid

The safety and immunogenicity of 2 yeast-derived, blood-stage malaria vaccines were evaluated in a phase l trial. Healthy adults were given 2 or 3 doses of alum-adsorbed vaccine containing the 19 kDa carboxy-terminal fragment of the merozoite surface protein-1 (MSP-1(19)) derived from the 3D7 or the FVO strain of Plasmodium falciparum fused to tetanus toxoid T-helper epitopes P30 and P2. The first 2 doses of MSP-1(19) were well tolerated. Hypersensitivity reactions occurred in 3 subjects after the third dose of MSP-1(19), including bilateral injection site reactions in 2 (one with generalized skin rash), and probable histamine-associated hypotension in 1. Serum antibody responses to MSP-1(19) occurred in 5/16, 9/16 and 0/8 subjects given 20 microg of MSP-1(19), 200 microg of MSP-1(19), and control vaccines (hepatitis B or Td), respectively. Both MSP-1(19) vaccines were immunogenic in humans, but changes in formulation will be necessary to improve safety and immunogenicity profiles.

Enhanced diffiraction limited output powerof tapered gain semiconductor lasers

The spatiotemporal dynamics of linearly and trumpet flared high brightness semiconductor lasers are compared and contrasted using a comprehensive model built up from the microscopic physics. While both devices display complex multi longitudinal mode dynamics, the trumpet flared device is less susceptible to transverse filamentation instabilities and, hence, displays superior time-averaged far-field imaging properties.

Characterization of human T- and B-cell epitopes in the C terminus of Plasmodium falciparum merozoite surface protein 1: evidence for poor T-cell recognition of polypeptides with numerous disulfide bonds

We have investigated the relationship between cellular and humoral immune responses to defined epitopes of the C terminus of merozoite surface protein 1 (MSP-1) of the human malaria parasite, Plasmodium falciparum, in immune blood donors. Sera from almost all donors contained antibodies to the 33-kDa processing product of the MAD20 allele of MSP-1 (MSP-1(33)), but these antibodies did not cross-react with the equivalent sequence of the Wellcome allele. In contrast, T-cell responses to MSP-1(33) are directed towards epitopes that are conserved between the two allelic families. Only 50% of adult blood donors possessed antibodies which recognized the 19-kDa processing product of MSP-1 (MSP-1(19)). These antibodies predominantly recognized conserved epitopes involving both of the constituent epidermal growth factor-like domains of MSP-1(19). T-cell responses were found in only 26% (for recombinant proteins) or 44% (for synthetic peptides) of donors and were directed mainly at dimorphic sequences of the protein. There was no obvious association, at an individual level, between the presence of antibodies and the detection of T-cell proliferative or gamma interferon responses, suggesting that the T cells identified in this manner are not providing significant levels of help to B cells. T-cell responses to reduced recombinant proteins and linear peptides were more prevalent than responses to disulfide-bonded proteins, suggesting that the complex disulfide-bonded structure of native MSP-1(19) may inhibit antigen processing or presentation.

Selective recognition of malaria antigens by human serum antibodies is not genetically determined but demonstrates some features of clonal imprinting

Malaria infection induces the production of serum antibodies to a variety of malaria antigens but the prevalence of antibodies to any particular antigen is typically much less than 100%. It has been assumed that non-responsiveness to defined antigens in malaria immune subjects is due to HLS-mediated restriction of the immune response. In this study we have investigated the role of HLA and non-HLA genes in the antibody response to two merozoite surface antigens (MSP1 and MSP2) and a sexual stage antigen (Ps260/230) of Plasmodium falciparum, and conclude that host genotype is not a major determinant of responsiveness. Although antibody levels vary in accordance with seasonal variations in malaria transmission in semi-immune children, antibody levels remain stable in clinically immune adults. Antigen recognition is selective with individual donors showing consistent high titre responses to some antigens/epitopes whilst consistently failing to recognize adjacent regions/epitopes of the same protein. An alternative explanation, consistent with the data presented here, is that selective antibody responses to malaria antigens in immune individuals result from a process akin to clonal imprinting (original antigenic sin).

Thermotoga elfii sp. nov., a novel thermophilic bacterium from an African oil-producing well

A thermophilic, glucose-fermenting, strictly anaerobic, rod-shaped bacterium, strain SEBR 6459T (T = type strain), was isolated from an African oil-producing well. This organism was identified as a member of the genus Thermotoga on the basis of the presence of the typical outer sheath-like structure (toga) and 16S rRNA signature sequences and its ability to grow on carbohydrates (glucose, arabinose, fructose, lactose, maltose, and xylose). Major differences in its 16S rRNA gene sequence, its lower optimum temperature for growth (66 degrees C), its sodium chloride range for growth (0 to 2.8%), its lack of lactate as an end product from glucose fermentation, and its peritrichous flagella indicate that strain SEBR 6459T is not similar to the three previously described Thermotoga species. Furthermore, this organism does not belong to any of the other genera related to the order Thermotogales that have been described. On the basis of these findings, we propose that this strain should be described as a new species, Thermotoga elfii. The type strain of T. elfii is SEBR 6459 (= DSM 9442).

The effect of irradiation on the third stage larvae of Brugia pahangi

The effect of irradiation on the third stage larvae of the filarial nematode Brugia pahangi was investigated. Labelling with 35S methionine of control or irradiated L3, post-infective L3 or L4 revealed no consistent alterations in the pattern of proteins synthesized. The only significant difference observed was in 125I labelling, where the specific activity of labelling of soluble cuticular proteins was lower in irradiated than in control parasites. This difference may be related to the reduced size of irradiated parasites rather than to a specific effect of irradiation on the expression of cuticular proteins. Irradiated parasites recovered on day 14 post-infection were significantly shorter than control parasites. Irradiation also appeared to have a lethal effect on male parasites, as no recognizable males were recovered from animals given irradiated L3, nor were microfilariae ever observed in these animals. The mechanisms by which irradiation may enhance the immunogenicity of L3 of filarial nematodes are discussed.

The expression of small heat shock proteins in the microfilaria of Brugia pahangi and their possible role in development

Development of the microfilariae of Brugia pahangi in the mammalian host is blocked until uptake by a mosquito vector when the developmental cycle is re-initiated. Comparison of the profile of polypeptides labelled in microfilariae cultured at mammalian temperature (37 degrees C) or mosquito temperature (28 degrees C) revealed a complex of low-molecular-weight proteins (18 kDa and 22-24 kDa) synthesized only in microfilariae at 37 degrees C. The synthesis of these proteins was also induced by transfer of microfilariae to 41 degrees C (i.e., heat shock conditions), suggesting that these are heat shock proteins. The expression of the small heat shock proteins in the Brugia life cycle is developmentally regulated, as they are not observed in the mature adult female. Their synthesis is strictly temperature dependent and is repressed upon transfer of the microfilariae to 28 degrees C.

Duplex Doppler ultrasound for the detection of vascular occlusion following liver transplantation in children

Sixty-three children and adolescent patients who received 78 consecutive orthotopic liver transplants and had serial duplex ultrasound monitoring were retrospectively reviewed for episodes of occlusion of the hepatic artery or portal vein. There were 13 documented episodes of complete occlusion of the main hepatic artery or a major branch, of which nine were diagnosed by the absence of flow during duplex ultrasound examination. Four occlusions were not detected, two affected hepatic artery branches, one an accessory hepatic artery, and one the main hepatic artery. The overall sensitivity of the method was 69% and specificity 100%. Six portal vein occlusions were documented in five patients and all six were successfully diagnosed on ultrasound examination, giving a sensitivity and specificity of 100%. Three of the patients had simultaneous occlusions of both vessels. In the early post-operative period duplex Doppler ultrasound examination has proved an effective non-invasive method for the detection of vascular occlusion, but is not yet sensitive enough to replace angiography fully for the detection of hepatic artery occlusion, particularly when this occurs distal to the main hepatic artery.

Enterotoxigenic aeromonads on retail lamb meat and offal

Enrichment in alkaline peptone water was compared with the direct plating method for the isolation of Aeromonas spp. from lamb meat and offal samples. The enrichment method significantly increased the isolation rate of aeromonads. Motile Aeromonas species (A. hydrophila, A. sobria and A. caviae) were present in all kinds of samples investigated. Seventy-three Aeromonas strains isolated in this survey were characterized to species level and examined for their ability to produce virulence factors. Strains identified as A. sobria were the strongest producers of haemolysin and enterotoxin, whereas A. caviae strains were consistently non-haemolytic and non-enterotoxigenic. Thus it is likely that lamb meat and offal are potentially significant sources of virulent Aeromonas species and may play an important role in the aetiology of Aeromonas-associated gastro-enteritis.