AB1439 IS THERE AN INCREASED PREVALENCE OF DIABETES MELLITUS IN THE AXIAL SPONDYLOARTHROPATHY PATIENT GROUP: A REVIEW FROM A UK TEACHING HOSPITAL SPONDYLOARTHROPATHY SERVICE

Background

The prevalence of diabetes mellitus (DM) has often been found to be increased in patients with axial spondyloarthropathy (axSpA) compared to the general population. However, studies conducted in the United Kingdom (UK) have found varying results with regards to prevalence. One study1 found that 5% of patients with axSpA had DM, compared to 4% of patients without axSpA and another UK study2 reported that although findings showed a 1.8% increase in DM in patients with axSpA compared to controls, this result was not significant. There is also the influence of ethnicity to consider as DM is more prevalent in the Asian and Afro-Caribbean population. Therefore, it is evident that more research is required into the relationship between DM and axSpA.

Objectives

This study aims to investigate the correlation between DM and axSpA, and also explore the influence of ethnicity on DM and axSpA.

Methods

Retrospective analysis was carried out for axSpA patients attending University Hospitals of Leicester axSpA services. Inclusion criteria entailed an axSpA diagnosis and a Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) within a year of MRI spine and sacroiliac joints before starting biological therapy. Patients were excluded if they had an active infection or malignancy, BASDAI was not documented before starting biological therapy or within a year of MRI, or if clinical information was not able to be obtained. Data was obtained from electronic medical records, including age, gender, ethnicity, date of diagnosis of axSpA and DM, and cardiovascular comorbidities.

Results

Of the 149 patients, 8 (5.37%) had a diagnosis of DM. 4 (50%) of these patients were diagnosed with DM prior to diagnosis of axSpA, and 4 (50%) were diagnosed with DM post diagnosis of axSpA. Differences in ethnicity were analysed. Of the 149 axSpA patients, 102 (68.46%) were Caucasian, 45 (30.20%) were Asian, and 2 (1.34%) were Afro-Caribbean. Of the 102 Caucasian patients, 3 (2.94%) had DM, of whom 1 was diagnosed with axSpA prior to diagnosis of DM. Of the 45 Asian patients, 5 (11.11%) had DM, of whom 3 were diagnosed with axSpA prior to diagnosis of DM. Looking at cardiovascular comorbidities, of the 8 patients with axSpA and DM, 2 (25%) had hypertension, and were both diagnosed with axSpA prior to diagnosis of DM.

Conclusion

This small study has found a similar prevalence of DM in patients with axSpA (5.37%) compared to the general UK population (6%), which contrasts with published international studies which have found a higher prevalence of DM in the axSpA group. However, the study did find a higher prevalence in the Asian population (11.11%) which is in keeping with ethnic variation for DM. Larger epidemiological studies are needed to understand the reason for reported higher prevalence of DM in patients with axSpA in other countries compared to the UK.

References

[1]Dregan A, Chowienczyk P, Molokhia M. Cardiovascular and type 2 diabetes morbidity and all-cause mortality among diverse chronic inflammatory disorders. Heart (British Cardiac Society). 2017;103(23):1867-1873.

[2]Ahmed N, Prior JA, Chen Y, Hayward R, Mallen CD, Hider SL. Prevalence of cardiovascular-related comorbidity in ankylosing spondylitis, psoriatic arthritis and psoriasis in primary care: a matched retrospective cohort study. Clinical Rheumatology. 2016;35(12):3069-3073.

Disclosure of Interests

None declared

POS1275 A RETROSPECTIVE STUDY ON UVEITIS FLARES FOLLOWING COVID19 VACCINATION: SHARING EXPERIENCE FROM A TEACHING HOSPITAL COMBINED RHEUMATOLOGY AND UVEITIS CLINIC

Background

Uveitis is a sight threatening disease caused by inflammation of the uveal tract of the eye. Uveitis is a manifestation of many autoimmune conditions and is associated with seronegative axial spondyloarthritis, reactive arthritis, Behçet’s disease, inflammatory bowel disease, and psoriatic arthritis. Acute anterior uveitis is the most common presentation and is most commonly idiopathic or associated with the HLA-B27 gene (around 20% of cases). Studies have shown that anterior uveitis frequently recurs in patients after it has previously remitted. (1) Patients suffering from autoimmune conditions are frequently prescribed immunosuppressant drugs to control their illness, thus leaving them more susceptible to bacterial and viral illnesses including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) Previous studies have shown that some patients suffer exacerbation of their autoimmune condition after coronavirus vaccination, including uveitis(2). We aim to evaluate our cohort of patients suffering from autoimmune conditions treated at Leicester Uveitis Service at Leicester Royal Infirmary and explore any proposed link.

Objectives

To assess if COVID19 vaccination is associated with uveitis flares in immunosuppressed patients.

Methods

A retrospective study, to determine if patients diagnosed with autoimmune conditions suffered from uveitis following COVID-19 vaccination. A data collection sheet was used to document demographic and clinical data: age, sex, ethnicity, autoimmune condition, dates of COVID-19 vaccination(s), type of vaccine, medication at the time of vaccine, symptoms of autoimmune recurrence, date of uveitis onset and number of days between uveitis onset and latest vaccine. We used an already existing uveitis database with an active register of 2346 patients, of which 246 were on immunomodulation.

Results

After reviewing the first 50 patients on immunosuppression for uveitis, we found a total of 4 patients had a uveitis flare despite tight control previously; 3 are female and 1 male, their median age was 39.5 years. They experienced a recurrence of uveitis in the last 6 months. Of these 4 patients 3 were on synthetic DMARDS (2 mycophenolate mofetil, 1 azathioprine), 1 was on steroids and 1 was on a biological DMARD (adalimumab). 2 of the patients suffered from posterior uveitis and 2 from anterior uveitis. All the 50 patients had been vaccinated against COVID19 however there was no clear record of booster dose.

Conclusion

Our study showed that of 50 immunosuppressed patients, 4 had a uveitis flare following vaccination. Clinicians need to be aware of uvetis flares in rheumatology patients following vaccination. This is a small retrospective analysis of our cohort however a large observational study on flare of uveitis following COVID-19 primary vaccination and booster vaccination would be useful to get meaningful data.

References

[1]Grunwald L, Newcomb CW, Daniel E, Kaçmaz RO, Jabs DA, Levy-Clarke GA, Nussenblatt RB, Rosenbaum JT, Suhler EB, Thorne JE, Foster CS, Kempen JH; Systemic Immunosuppressive Therapy for Eye Diseases Cohort Study. Risk of relapse in primary acute anterior uveitis. Ophthalmology. 2011 Oct;118(10):1911-5. doi: 10.1016/j.ophtha.2011.02.044. Epub 2011 Jun 16. PMID: 21680024; PMCID: PMC3179829.

[2]Bolletta E, Iannetta D, Mastrofilippo V, De Simone L, Gozzi F, Croci S, Bonacini M, Belloni L, Zerbini A, Adani C, Fontana L, Salvarani C, Cimino L. Uveitis and Other Ocular Complications Following COVID-19 Vaccination. J Clin Med. 2021 Dec 19;10(24):5960. doi: 10.3390/jcm10245960. PMID: 34945256; PMCID: PMC8704915.

Disclosure of Interests

None declared

Complications of an uncovered metallic tracheal stent managed by veno-venous extracorporeal membrane oxygenation: a case report

Airway stents are primarily inserted for the management of airway obstruction associated with an inoperable malignancy and are rarely indicated in benign disease. We outline the complications associated with tracheal stents and describe the use of veno-venous extracorporeal membrane oxygenation (V-V ECMO) to facilitate open tracheal surgery in an apnoeic patient who had an uncovered metallic tracheal stent left in place for an inappropriately long period. Computerised tomography imaging of the neck and thorax provided information for operative planning and described of the stent in addition to the extensive granulation tissue at the distal end of the stent. Veno-venous extracorporeal membrane oxygenation was used to facilitate open tracheal surgery, removal of the tracheal stent and formation of a surgical tracheostomy. Prolonged use of an uncovered metallic airway stent in younger patients with benign disease may lead to the stent being difficult to remove. There may be an accumulation of granulation tissue with the risk of airway obstruction.

AB0873 Ethnicity and patient reported outcome BASDAI in the monitoring of axial spondyloarthropathy: Does it matter?

Background

The Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) is a patient reported outcome (PRO) used in the monitoring of axial spondyloarthropathy (axSpA). It is completed by the patient and based on their assessment of disease severity and therefore quite a subjective measure of disease (1). There has been research around the relationship between ethnicity and patient perception in Rheumatology. Many studies have demonstrated that non-Caucasian patients especially South Asians are less likely to engage with patient education, abandon their disease modifying therapy early and have more mistrust with the medical establishment (2). Quite a large population study in America examining axSpA severity in Caucasians, Afro-Caribbean’s and Latinos found Afro-Caribbean and Latino patients to score themselves higher on BASDAI compared to Caucasians (3).

With Leicester being such a diverse area, with a particularly high South Asian population we took this opportunity to investigate whether there were ethnic variations in disease severity.

Objectives

The aim was to investigate whether there is a relationship between patient-reported outcome BASDAI and ethnicity. The secondary aim was to investigate the relationship between ethnicity and radiographic findings and extra-articular manifestations.

Methods

Data was collected by retrospective analysis of axSpA patients attending University of Leicester (UHL) axSpA services. Inclusion criteria entailed a diagnosis of axSpA with a documented BASDAI within a year of MRI spine + sacroiliac joints, prior to starting any biological treatment.

Data of 149 patients was collected on demographic characteristics, extra-articular manifestations (uveitis, inflammatory back pain, enthesitis, peripheral arthritis, dactylitis, psoriasis, and inflammatory bowel disease), family history, response to NSAIDs, and HLA-B27 status.

Data was analysed using Statistical Package for the Social Sciences (SPSS) software to assess the relationship between ethnicity and collected data using Pearson’s chi squared.

Results

Of the 149 patients 68% were White Caucasian, 30% Asian and 1% Black. The average age was 43 and 66% were male and 34% female. The mean BASDAI was 6.5, there was no observable correlation between BASDAI and ethnicity (p=0.668).

There was no significant relationship between ethnicity and active sacroiliitis (p=0.926), chronic sacroiliitis (p= 0.218) or axial disease (p=0.307). 64 Caucasian patients were HLA-B27 positive compared with 27 Asian and no Black patients were positive however there was no statistical correlation between ethnicity and HLA-B27 (p=0.383). Overall, Caucasians consistently had a greater incidence of extra-articular manifestations compared with non-Caucasians however no significant p values were observed here or with response to NSAIDs, family history or familial HLA-B27 and BASDAI scores, results are summarised in Table 1.

Table 1.

Correlation with ethnicity and extra-articular manifestations, family history and HLA-B27.

Number of patientsCorrelation with ethnicityUveitis36p=0.470Peripheral arthritis24p=0.304Enthesitis22p=0.959Psoriasis7p=0.062Inflammatory bowel disease7P=0.947Dactylitis6P=0.173HLA-B27103p=0.383Inflammatory back pain139p=0.062Response to NSAIDs46p=0.718Family history of axSpA20p=0.800HLA-B27 in family10p=0.221

HLA-B27= Human leukocyte antigen B27, NSAIDs= non-steroidal anti-inflammatory drugs, axSpA= Axial Spondyloarthropathy.

Conclusion

This study did not demonstrate statistically significant finding of ethnic variations in BASDAI. There was also no relationship between ethnicity and other data sets. However, the main limitation of this study is the sample size and unequal representation of ethnicities with there being far more Caucasians than non-Caucasian patients. Though this study provides an insight into quite a limited area of research, a larger study with equal ethnic patient population samples is required to obtain more meaningful results.

References

[1]Zochling J. Measures of symptoms and disease status in ankylosing spondylitis: Ankylosing Spondylitis Disease Activity Score (ASDAS), Ankylosing Spondylitis Quality of Life Scale (ASQoL), Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Bath Ankylosing Spondylitis Functional Index (BASFI), Bath Ankylosing Spondylitis Global Score (BAS-G), Bath Ankylosing Spondylitis Metrology Index (BASMI), Dougados Functional Index (DFI), and Health Assessment Questionnaire for the Spondylarthropathies (HAQ-S). Arthritis Care Res (Hoboken). 2011;63(11):47-58.

[2]Kumar K, Klocke R. Ethnicity in rheumatic disease. Clin Med (Lond). 2010;10(4):370-372.

[3]Jamalyaria F, Ward M, Assassi S, Learch T, Lee M. Gensler L et al. Ethnicity and disease severity in ankylosing spondylitis a cross-sectional analysis of three ethnic groups. Clin Rheumatol. 2017;36(10):2359-2364.

Disclosure of Interests

None declared

AB1169 RHEUMATOLOGY PATIENT PERCEPTION OF CARDIOVASCULAR RISKS: A SURVEY AT A TEACHING HOSPITAL

Background:

It is well known that individuals with rheumatological conditions are at an increased risk for developing cardiovascular diseases (CVS) and they are the most common cause of mortality. However, there is still lack of awareness about the CVS risk among Rheumatology patients. We carried out a patient survey to assess their awareness and perception of CVS risk associated with their condition. We also assessed if the health professionals attending to these patients gave adequate education to the patients regarding the CVS risk.

Objectives:

To study awareness about CVS risks among rheumatology patients

Methods:

This was a prospective cross sectional survey where in multiple-choice questionnaires were distributed to consecutive patients attending rheumatology clinic. The questionnaire contained 18 questions including demographics, diagnosis, medications and their awareness of cardiovascular risks associated with their underlying rheumatic conditions. We also explored as patient attempted any Primary preventive measures for reducing the CVS risk.

Results:

We collected data of 57 patients with 47% of patients were above 60 years of age with Female: Male ratio of 3:1. Rheumatoid arthritis was the most common diagnosis (60%) with others including AS (22%), SLE(5%). 32% of patients had been suffering from inflammatory disorder for >10 years and 44% believed their disease was still not fully controlled. 37% had family history of heart diseases.

More than half of the patients (56%) were unaware of cardiovascular risks associated with their condition and 65% overall reported that they were not personally informed about these risks by the treating health professionals. When we analysed the newly diagnosed patients (<5years) 64% were unaware about the CVS risks which is higher compared to patients with diagnosis of >5 years. We tried to explore any ethnic differences, however the number is too small to compare. We noted that around 60% of white British with rheumatological diagnosis were not aware of CVS risk in our group. When further asked about the primary preventive measures, only 23% engage in exercise, 21% have made diet changes, 12% take aspirin, 16% have quit smoking and only 5% quit alcohol.

Conclusion:

This was a small pilot study to look at the patient awareness of CVS risks associated with rheumatological conditions. Clearly there is lack of awareness among patients about CVS risks. Furthermore, most of the patients reported they were not educated about the risks from the health professionals. Majority do not engage in any kind of primary preventive measure for heart diseases. It is crucial that the health professionals actively educate patients regarding the CVS risks and the various methods through which these can be prevented. We believe patient-targeted educational programmes and behavioural interventions can be incorporated for holistic patient management.

References:

[1]John, Holly et al. Inflammatory arthritis as a novel risk factor for cardiovascular disease European Journal of Internal Medicine, Volume 23, Issue 7, 575 – 579

Disclosure of Interests:

Nibha Jain: None declared, Anukripa Manivannan: None declared, Aswin Mahesh: None declared, Arumugam Moorthy Speakers bureau: Abbvie, Novartis,UCB,MSD

AB0694 IS THERE ANY HETEROGENEITY OF SPONDYLOARTHRITIS DISEASE MANIFESTATIONS BETWEEN TWO ETHNIC SUBGROUPS?:A MULTICENTRE INTERNATIONAL COMPARATIVE STUDY BETWEEN INDIA AND UK

Background:

Pathogenesis of Spondyloarthritis (SpA) multifactorial and remains unclear. Various hypothesis have been postulated genetics, HLAB27, IL17, Gut microbiome and Biomechanical stress. Many of these factors can be attributed to ethnic background and environment. HLAB27 accounts for 20–25 % of total heritability and 40% of genetic risk while <10% of HLA-B27 carriers in general population develop SpA1. Higher faecal calprotectin levels in SpA compared to control point towards microscopic gut inflammation2. Thus dietary habits and geographical factors can influence pathogenesis of disease. We looked in clinical manifestations of SpA patients of two very different ethnic background Caucasians and Indians from UK and India to shed more light in understanding the disease

Objectives:

To study any differences in the clinical manifestations of SpA patients of two ethnic groups

To compare outcome measure (BASDAI and ASDAS) between Caucasians and Indians

To study the difference in disease activity between Indian patients and British Asians

Methods:

Multicentre observation study where data of SpA patients attending rheumatology clinics from two major teaching hospitals collected. In India data collected from Sheth VS Hospital and NHL Medical College, Gujarat and in United Kingdom from University Hospitals Leicester, NHS trust. Leicester has a multi-ethnic demography wherein almost 30%3of population is of south Asian ethnicity, making this study unique.

Baseline demographic and clinical data was collected. Clinical and outcome measures compared to see any heterogeneity in disease manifestations. SPSS software used

Results:

Total 200 patients analysed with 148 Indians and 52 Caucasians. The Indian cohort was subdivided into British Asians (second generation Indians) and those form Gujarat, India

We found Indian subgroups were younger with shorter disease duration. Comparison in Table 1

Table 1.CaucasianIndianPAge45.9±1231±12<0.001M:F34:193:10.74TDI years9.6 ±5.93.5± 5.2<0.001BASDAI4.05±2.173.1±1.70.002ASDAS2±0.82.4±1.20.02CRP12.8±23.624±12<0.001HLAB2767%26%<0.001Uveitis25%12%0.02IBP78%90%0.03Enthesitis21%60%<0.001Peripheral Arthritis19%36%0.02Dactylitis2%10%0.07Psoriasis10%20%0.1IBD2%5%0.35Comparing British Asians to Indians, Gujarat no significant difference in clinical parameters. (Table 2)British AsianIndianPBASDAI5.16±2.763.1±1.70.006ASDAS2.53±1.32.4±1.20.74CRP15.2 ±15.424±12<0.001

Conclusion:

We found Caucasians had more HLAB27 positivity and extra-articular manifestation of uveitis however the Indian population has more enthesitis and peripheral arthritis. Enthesitis is initiated during a mechano-sensation and the cultural difference including style of footwear could probably be one of the factors explaining our findings inflammatory back pain has been reported to be higher in Indians compared to Caucasians which could be due to life style

The fact that ASDAS CRP behaves similarly in Indian patients across the two countries and is more when compared to Caucasians might point towards overall higher burden of disease in Indian population

To our knowledge this is a first study comparing clinical manifestations of SpA between Indians and Caucasians

References:

[1]Brown MAet al. Susceptibility to ankylosing spondylitis in twins: the role of genes, HLAand environment.Arthritis Rheum 1997;40: 1823–8

[2]J Simione, et al. Fecal Calprotectin, GutInflammation and SpA Archives of Medical Research. 2019;50:41-46

[3]http://www.ons.gov.uk/census

Disclosure of Interests:

Nibha Jain: None declared, Sapan Pandya: None declared, Puja Srivastava: None declared, Prashant Chotalia: None declared, Arumugam Moorthy Speakers bureau: Abbvie, Novartis,UCB,MSD

AB0953 CANNABINOIDS: FRIEND OR FOE OR A BYSTANDER?

Background:

Cannabinoids has recently gained popularity for use in chronic pain. There is a lot of inquisitiveness among our patients wherein health care professionals are asked about its efficacy, side effects and sometimes even ask for a prescription! As there is paucity of data and research about its use in rheumatology, patient reported outcome(PROM) can guide ahead in expanding our knowledge and experience.

Objectives:

To study usage of cannabinoids by rheumatology patients

To study awareness among primary physicians regarding Cannabinoid usage in rheumatology.

Methods:

Cross sectional survey with two arms. Arm 1 Information from patients attending tertiary rheumatology clinic,including perception regarding the use of Cannabinoids.

Arm 2 consisted of collecting data via web-based survey with20-question from 100 GPs of Leicestershire. Questions on demographics, perspectives on and knowledge of cannabinoid use. Statistical analysis SPSS software.

Results:

Arm1 Total 102 rheumatology patients with 60%were females and 45% secondary education. 48% were unemployed. 75% Caucasians, 18% Asians. RA most common diagnosis followed by OA and FMS. 40 % depression and anxiety in addition to Rheumatic disease. 94% reported ongoing pain with 6-8 on a VAS scale. 79% were satisfied with their current therapy. 65% had heard about complementary medicine and 15% reported using cannabinoids.

Most common form Cannabinoids oil 60% followed by smoking 20%. 56% reported using >3 months and majority 72% use daily. Median age 55 years. 88% users Caucasians. Mean disease duration 6.25 years among users indicates chronicity of disease has a direct proportion in usage. All users had ongoing pain of 7 on VAS. 87% believed it helps them managing pain effectively with a pain free state. On an average spends between 50-100 pounds per week. More than half believe cannabinoids should be available as a prescription drug in NHS and 30% interested to know more about it.

In Arm 2 consisting of Primary care physicians, response rate 50%. Average clinical experience 5 years. Only 20% heard about usage of complementary medicine by rheumatology patient. Most replied that 10% of their patients use Cannabinoids for pain management. Most did not believe use of cannabinoids benefited the patients. Only 4% recommend its usage. 25% think it should be available as prescription. 40% experienced patients asking about cannabinoids during appointment. 88% of respondents did not know much about cannabinoid usage in rheumatology and have never prescribed it in their practice.

Conclusion:

Cannabinoids widely used by the rheumatology patients with PROM favouring its efficacy for control of chronic pain. Preclinical data suggest that cannabinoids might have a therapeutic potential RA1, OA, FMS2. Clinical data regarding cannabinoid treatment for rheumatic diseases are scarce, therefore, recommendations concerning cannabinoid treatment cannot be made. All patients who reported using it suffered from moderate to severe chronic pain. Thus main indication of usage was pain rather than recreational purpose. Although a small survey it clearly highlights lack of knowledge among primary physicians. These results emphasise the need for further research regarding the benefits and risks of cannabinoids in rheumatology.

References:

[1]RichardsonD. etal Characterisation ofthe cannabinoid receptor system in synovial tissue andfluid in patients with OA and RA Arthritis Res.Ther. 10, R43 (2008).

[2]Walitt, B etal Cannabinoids for fibromyalgia. Cochrane DatabaseSyst. Rev. 7, CD011694 (2016).

Disclosure of Interests:

Nibha Jain: None declared, Neelima Reddy: None declared, Arumugam Moorthy Speakers bureau: Abbvie, Novartis,UCB,MSD

Mobile Technology for Community Health in Ghana: Is Maternal Messaging and Provider Use of Technology Cost-Effective in Improving Maternal and Child Health Outcomes at Scale?

BACKGROUND

Mobile technologies are emerging as tools to enhance health service delivery systems and empower clients to improve maternal, newborn, and child health. Limited evidence exists on the value for money of mobile health (mHealth) programs in low- and middle-income countries.

OBJECTIVE

This study aims to forecast the incremental cost-effectiveness of the Mobile Technology for Community Health (MOTECH) initiative at scale across 170 districts in Ghana.

METHODS

MOTECH's "Client Data Application" allows frontline health workers to digitize service delivery information and track the care of patients. MOTECH's other main component, the "Mobile Midwife," sends automated educational voice messages to mobile phones of pregnant and postpartum women. We measured program costs and consequences of scaling up MOTECH over a 10-year analytic time horizon. Economic costs were estimated from informant interviews and financial records. Health effects were modeled using the Lives Saved Tool with data from an independent evaluation of changes in key services coverage observed in Gomoa West District. Incremental cost-effectiveness ratios were presented overall and for each year of implementation. Uncertainty analyses assessed the robustness of results to changes in key parameters.

RESULTS

MOTECH was scaled in clusters over a 3-year period to reach 78.7% (170/216) of Ghana's districts. Sustaining the program would cost US $17,618 on average annually per district. Over 10 years, MOTECH could potentially save an estimated 59,906 lives at a total cost of US $32 million. The incremental cost per disability-adjusted life year averted ranged from US $174 in the first year to US $6.54 in the tenth year of implementation and US $20.94 (95% CI US $20.34-$21.55) over 10 years. Uncertainty analyses suggested that the incremental cost-effectiveness ratio was most sensitive to changes in health effects, followed by personnel time. Probabilistic sensitivity analyses suggested that MOTECH had a 100% probability of being cost-effective above a willingness-to-pay threshold of US $50.

CONCLUSIONS

This is the first study to estimate the value for money of the supply- and demand-side of an mHealth initiative. The adoption of MOTECH to improve MNCH service delivery and uptake represents good value for money in Ghana and should be considered for expansion. Integration with other mHealth solutions, including e-Tracker, may provide opportunities to continue or combine beneficial components of MOTECH to achieve a greater impact on health.

Mobile Technology for Community Health in Ghana: what happens when technical functionality threatens the effectiveness of digital health programs?

BACKGROUND

Despite the growing use of technology in the health sector, little evidence is available on the technological performance of mobile health programs nor on the willingness of target users to utilize these technologies as intended (behavioral performance). In this case study of the Mobile Technology for Health (MOTECH) program in Ghana, we assess the platform's effectiveness in delivering messages, along with user response across sites in five districts from 2011 to 2014.

METHODS

MOTECH is comprised of "Client Data Application" (CDA) which allows providers to digitize and track service delivery information for women and infants and "Mobile Midwife" (MM) which sends automated educational voice messages to the mobile phones of pregnant and postpartum women. Using a naturalist study design, we draw upon system generated data to evaluate message delivery, client engagement, and provider responsiveness to MOTECH over time and by level of facility.

RESULTS

A total of 7,370 women were enrolled in MM during pregnancy and 14,867 women were enrolled postpa1rtum. While providers were able to register and upload patient-level health information using CDA, the majority of these uploads occurred in Community-based facilities versus Health Centers. For MM, 25% or less of expected messages were received by pregnant women, despite the majority (>77%) owning a private mobile phone. While over 80% of messages received by pregnant women were listened to, postpartum rates of listening declined over time. Only 25% of pregnant women received and listened to at least 1 first trimester message. By 6-12 months postpartum, less than 6% of enrolled women were exposed to at least one message.

CONCLUSIONS

Caution should be exercised in assuming that digital health programs perform as intended. Evaluations should measure the technological, behavioral, health systems, and/or community factors which may lead to breaks in the impact pathway and influence findings on effectiveness. The MOTECH platform's technological limitations in 'pushing' out voice messages highlights the need for more timely use of data to mitigate delivery challenges and improve exposure to health information. Alternative message delivery channels (USSD or SMS) could improve the platform's ability to deliver messages but may not be appropriate for illiterate users.

TRIAL REGISTRATION

Not applicable.

Special care dentistry: how prepared are we?

AIM

To assess and evaluate the confidence of the undergraduate dental team in Irish dental schools regarding their training in the field of special care dentistry (SCD).

METHOD

A questionnaire was distributed amongst the undergraduate dental teams within Cork University Dental School and Hospital (CUDSH) and Dublin Dental University Hospital (DDUH). The data were analysed to assess for differences between the median responses of the various groups.

RESULTS

A total of 139 students participated in the study; 82 from DDUH (59 dental science students, seven dental hygiene students and 16 dental nursing students) and 57 from CUDSH (43 dental science students and 14 dental hygiene students). Twenty-two per cent (n = 30) of respondents agreed that their training had been sufficient in providing treatment or assistance for patients requiring SCD. Seventy-five per cent agreed that more emphasis should be placed on clinical training in SCD (n = 76). Thirty-one per cent of students anticipated a high level of confidence in treating patients requiring SCD upon graduation (n = 43), with dental science students feeling the least prepared amongst the dental team.

CONCLUSION

Confidence levels of the undergraduate dental team were low with regard to SCD. The existing hands-on clinical training in SCD was deemed insufficient by the respondents. Students believed more emphasis should be placed on SCD training in the undergraduate curriculum.

Prospective audit of postoperative instructions to patients undergoing root canal treatment in the DDUH and re-audit following introduction of a written patient information sheet

STATEMENT OF THE PROBLEM

Concerns were expressed that postoperative written instructions following endodontic treatment are not available in the Dublin Dental University Hospital.

MATERIALS AND METHODS

Data was collected in three phases: retrospective analysis of clinical notes for evidence of the delivery of postoperative instructions; a randomly distributed questionnaire to patients undergoing root canal treatment prior to the introduction of a written postoperative advice sheet; and, another survey following introduction of the advice sheet.

RESULTS

Some 56% of patients' charts documented that postoperative advice was given. Analysis of phase two revealed that patients were not consistently informed of any key postoperative messages. In phase 3 analysis, the proposed benchmarks were met in four out of six categories.

CONCLUSIONS

Postoperative advice after root canal treatment in the DDUH is both poorly recorded and inconsistently delivered. A combination of oral postoperative instructions and written postoperative advice provided the most effective delivery of patient information.

Concordance between allele-specific PCR and ultra-deep pyrosequencing for the detection of HIV-1 non-nucleoside reverse transcriptase inhibitor resistance mutations

Recent advances in genotyping technologies have allowed for detection of HIV-1 drug resistance mutations present at low levels. The presence and percentage of Y181C and K103N drug-resistant variants in the blood of 105 subtype C HIV-infected infants who failed single-dose nevirapine prophylaxis for HIV transmission were compared using two highly sensitive genotyping methods, allele-specific PCR (AS-PCR) and ultra-deep pyrosequencing. Significant correlations in detection between both methods were found for both Y181C (correlation coefficients of 0.94 [95% CI 0.91-0.96]) and K103N (0.89 [95% CI 0.84-0.92]) mutations. The majority of discordant specimens (3/5 Y181C and 8/11 K103N) had wild-type variants when population sequencing was used, but mutant variants were detectable at very low levels (≤5%) with either assay. This difference is most likely due to stochastic variations in the appearance of mutant variants. Overall, both AS-PCR and ultra-deep pyrosequencing methods have proven to be sensitive and accurate, and may confidently be used where feasible.

Slower clearance of nevirapine resistant virus in infants failing extended nevirapine prophylaxis for prevention of mother-to-child HIV transmission

Nevirapine resistance mutations arise commonly following single or extended-dose nevirapine (ED-NVP) prophylaxis to prevent mother-to-child transmission (PMTCT) of human immunodeficiency virus (HIV), but decay within 6-12 months of single-dose exposure. Use of ED-NVP prophylaxis in infants is expected to rise, but data on decay of nevirapine resistance mutations in infants in whom ED-NVP failed remain limited. We assessed, in Ethiopian infants participating in the Six-Week Extended Nevirapine (SWEN) Trial, the prevalence and persistence of nevirapine resistance mutations at 6 and 12 months following single-dose or up to 6 weeks of ED-NVP, and correlated their presence with the timing of infection and the type of resistance mutations. Standard population genotyping followed by high-throughput cloning were done on dried blood spot samples collected during the trial. More infants who received ED-NVP had nevirapine resistance detected by standard population genotyping (high frequencies) at age 6 months compared with those who received single-dose nevirapine (SD-NVP) (58% of 24 vs. 26% of 19, respectively; p = 0.06). Moreover, 56% of ED-NVP-exposed infants with nevirapine resistance at age 6 months still had nevirapine resistance mutations present at high frequencies at age 1 year. Infants infected before 6 weeks of age who received either SD- or ED-NVP were more likely to have Y181C or K103N; these mutations were also more likely to persist at high frequencies through 1 year of age. HIV-infected infants in whom ED-NVP prophylaxis fails are likely to experience delayed clearance of nevirapine-resistant virus in the first year of life, which in turn places them at risk for early selection of multidrug-resistant HIV after initial therapy with nonnucleoside reverse transcriptase inhibitor-based regimens.

Induction therapy with protease-inhibitors modifies the effect of nevirapine resistance on virologic response to nevirapine-based HAART in children

BACKGROUND

Nevirapine resistance after failed prophylaxis to prevent mother-to-child human immunodeficiency virus (HIV) transmission can compromise subsequent nevirapine-based highly active antiretroviral therapy (HAART).

METHODS

Nevirapine-exposed children who achieved virologic suppression with lopinavir/ritonavir-based induction HAART before switch to nevirapine-based HAART or who continued the lopinavir/ritonavir regimen were studied. Nevirapine-resistant HIV was quantified (≥ 1% frequency) in plasma before therapy and archived in peripheral blood mononuclear cells after induction HAART with ultradeep pyrosequencing. The primary endpoint was virologic failure (confirmed viremia ≥ 1000 copies/mL by 52 weeks) on nevirapine-based HAART, and Receiver operating characteristic analysis identified threshold levels of resistance associated with failure.

RESULTS

Nevirapine resistance mutations were detected in plasma at a median frequency of 25.6% in 41 (33%) of 124 children starting HAART at median 9 months of age. After a median nine months of induction HAART, nevirapine-resistant HIV remained archived in cells in 59 (61%) of 96 children (median 13.6% of cells). The threshold frequency of nevirapine resistance in plasma most predictive of virologic failure on nevirapine-based HAART was 25%. Children maintaining resistance before therapy at or above this threshold frequency had a 3.5 fold higher risk of failure (95% confidence interval, 1.1-10.8) than children without detectable plasma resistance. In contrast, virologic failure was not independently associated with age, resistance in plasma below 25% frequencies, or archived in cells.

CONCLUSIONS

Virologic suppression with lopinavir/ritonavir-based HAART in nevirapine-exposed children raises the threshold level of resistance at which reuse of nevirapine-based therapy is compromised. Standard genotyping may allow identification of children likely to benefit from an induction-switch approach.

Nevirapine resistance and breast-milk HIV transmission: effects of single and extended-dose nevirapine prophylaxis in subtype C HIV-infected infants

Background

Daily nevirapine (NVP) prophylaxis to HIV-exposed infants significantly reduces breast-milk HIV transmission. We assessed NVP-resistance in Indian infants enrolled in the “six-week extended-dose nevirapine” (SWEN) trial who received single-dose NVP (SD-NVP) or SWEN for prevention of breast-milk HIV transmission but who also acquired subtype C HIV infection during the first year of life.

Methods/Findings

Standard population sequencing and cloning for viral subpopulations present at ≥5% frequency were used to determine HIV genotypes from 94% of the 79 infected Indian infants studied. Timing of infection was defined based on when an infant's blood sample first tested positive for HIV DNA. SWEN-exposed infants diagnosed with HIV by six weeks of age had a significantly higher prevalence of NVP-resistance than those who received SD-NVP, by both standard population sequencing (92% of 12 vs. 38% of 29; p = 0.002) and low frequency clonal analysis (92% of 12 vs. 59% of 29; p = 0.06). Likelihood of infection with NVP-resistant HIV through breast-milk among infants infected after age six weeks was substantial, but prevalence of NVP-resistance did not differ among SWEN or SD-NVP exposed infants by standard population sequencing (15% of 13 vs. 15% of 20; p = 1.00) and clonal analysis (31% of 13 vs. 40% of 20; p = 0.72). Types of NVP-resistance mutations and patterns of persistence at one year of age were similar between the two groups. NVP-resistance mutations did differ by timing of HIV infection; the Y181C variant was predominant among infants diagnosed in the first six weeks of life, compared to Y188C/H during late breast-milk transmission.

Conclusions/Significance

Use of SWEN to prevent breast-milk HIV transmission carries a high likelihood of resistance if infection occurs in the first six weeks of life. Moreover, there was a continued risk of transmission of NVP-resistant HIV through breastfeeding during the first year of life, but did not differ between SD-NVP and SWEN groups. As with SD-NVP, the value of preventing HIV infection in a large number of infants should be considered alongside the high risk of resistance associated with extended NVP prophylaxis.

Trial Registration

ClinicalTrials.gov NCT00061321

Stat4-dependent, T-bet-independent regulation of IL-10 in NK cells

Interleukin-10 (IL-10) is intensely studied, yet little is known about the mechanisms that control IL-10 expression. We identified striking similarities between IL-10 and interferon-gamma (IFN-gamma) regulation in mouse natural killer (NK) cells. Like IFN-gamma, IL-10 expression is induced by IL-2 and IL-12 and IL-2+IL-12 stimulation is synergistic. Unlike IFN-gamma, neither IL-18 nor Ly-49D cross-linking induced IL-10 expression however. Additionally, the IL-12 homologs IL-23 and IL-27 also do not regulate NK cell-specific IL-10. We determined that a small population of NK cells accounts for IL-10 production. The induction of IL-10 by IL-2+IL-12 treatment in NK cells appears to be biphasic, with an initial burst of expression which diminishes by 12 h but spikes again at 18 h. We determined that much like IFN-gamma, Stat4 is largely required for IL-12-induced IL-10. Conversely, we observed normal induction of IL-10 in T-bet-deficient NK cells. We identified a Stat4-binding element in the fourth intron of the Il10 gene, which is completely conserved between mouse and human. This intronic Stat4 motif is within a conserved noncoding sequence, which is also a target for cytokine-induced histone acetylation. These findings highlight tissue- and receptor-specific IL-10 regulatory mechanisms, which may be part of an early feedback loop.

Aplidin® induces JNK-dependent apoptosis in human breast cancer cells via alteration of glutathione homeostasis, Rac1 GTPase activation, and MKP-1 phosphatase downregulation

Aplidin is an antitumor agent in phase II clinical trials that induces apoptosis through the sustained activation of Jun N-terminal kinase (JNK). We report that Aplidin alters glutathione homeostasis increasing the ratio of oxidized to reduced forms (GSSG/GSH). Aplidin generates reactive oxygen species and disrupts the mitochondrial membrane potential. Exogenous GSH inhibits these effects and also JNK activation and cell death. We found two mechanisms by which Aplidin activates JNK: rapid activation of Rac1 small GTPase and downregulation of MKP-1 phosphatase. Rac1 activation was diminished by GSH and enhanced by L-buthionine (SR)-sulfoximine, which inhibits GSH synthesis. Downregulation of Rac1 by transfection of small interfering RNA (siRNA) duplexes or the use of a specific Rac1 inhibitor decreased Aplidin-induced JNK activation and cytotoxicity. Our results show that Aplidin induces apoptosis by increasing the GSSG/GSH ratio, a necessary step for induction of oxidative stress and sustained JNK activation through Rac1 activation and MKP-1 downregulation.

Productive HIV infection of resting CD4+ T cells: role of lymphoid tissue microenvironment and effect of immunomodulating agents

The ability of resting CD4+ T cells to support HIV replication is relevant to understanding how the reservoir of HIV-1-infected resting CD4+ T cells is generated, maintained and, hopefully, how it might be reduced or eliminated. We have utilized a tonsillar histoculture system to demonstrate that HIV, particularly X4 strains, can productively infect phenotypically resting CD4+ T cells in vitro and that this event is largely dependent on the lymphoid tissue microenvironment. Highly purified CD4+ tonsillar T cells that lack expression of both cell surface and nuclear antigens characteristic of classic T cell activation produce X4 HIV-1 mRNA, p24, and infectious virus while maintaining a resting phenotype when cultured in a tonsillar tissue microenvironment; in contrast, comparable purified resting CD4+ tonsillar T cells that have been exposed to X4 HIV do not support HIV replication when cultured in the absence of a lymphoid tissue microenvironment. HIV production from phenotypically resting CD4+ T cells is dramatically inhibited by anti-proinflammatory cytokine agents or immunosuppressive cytokines, but is only modestly suppressed by an inhibitor of the cell cycle. The ability of resting CD4+ T cells to support HIV replication in the microenvironment of the lymphoid tissue has implications in the pathogenesis of HIV disease and may provide an additional avenue for therapeutic intervention.

Tumor-specific CD8+ T lymphocytes derived from the peripheral blood of prostate cancer patients by in vitro stimulation with autologous tumor cell lines

To identify tumor-associated antigens as putative targets for developing immunotherapies against prostate cancer, we investigated the ability of T cells derived from the peripheral blood lymphocytes of prostate cancer patients to recognize autologous tumor cells. The technical challenge of growing in vitro carcinoma cell lines from small prostate cancer samples was previously addressed by immortalization of early epithelial cell cultures with the HPV16 transforming proteins E6 and E7 and by genetic characterization of the carcinoma and normal prostate cell lines. In our study, peripheral blood lymphocytes were stimulated in vitro using autologous IFNgamma-treated prostate carcinoma cells transduced with the B7.1 molecule as a source of T-cell costimulation. Tumor-specific CD8+ T lymphocytes were obtained from 3 of 6 prostate cancer patients tested and included T cells restricted by classical and nonclassical HLA molecules. In 1 case, we demonstrated that the prostate cancer-reactive T cells were TCRalpha/beta+ and recognized autologous tumor cells but not autologous normal cells in the context of HLA-B or -C molecules. These results validate the approach of in vitro stimulation of peripheral blood lymphocytes from prostate cancer patients with autologous tumor cell lines to isolate prostate cancer-specific T cells and demonstrate the existence of a functionally diverse immune response against prostate cancer.

N-linked carbohydrates in tyrosinase are required for its recognition by human MHC class II-restricted CD4(+) T cells

Glycosylation of mammalian proteins is known to influence their intracellular trafficking, half life, and susceptibility to enzymatic degradation. Rare instances of natural T cell epitopes dependent upon glycosylation for recognition have been described. We report here on human CD4(+) T lymphocyte cultures and clones from two melanoma patients that recognize the melanoma-associated Ag tyrosinase in the context of HLA-DR4 and -DR8. These T cells recognize tyrosinase, normally a heavily glycosylated molecule, when expressed constitutively in melanoma cells or in COS-7 transfectants pulsed as lysates onto autologous APC. However, these T cells fail to recognize tyrosinase expressed in bacteria, nor do they react with overlapping peptides covering full-length tyrosinase, suggesting a critical role for glycosylation in the processing and / or composition of the stimulatory epitopes. The requirement for glycosylation was demonstrated by the failure of tyrosinase-specific CD4(+) T cells to recognize tyrosinase synthesized in the presence of glycosylation inhibitors, or deglycosylated enzymatically. Site-directed mutagenesis of each of seven potential N-glycosylation sites showed that four sites were required to generate forms of tyrosinase that could be recognized by individual T cell clones. These data indicate that certain carbohydrate moieties are required for processing the tyrosinase peptides recognized by CD4(+) T cells. Post-translational modifications of human tumor-associated proteins such as tyrosinase could be a critical factor for the development of antitumor immune responses.