Fractures in Patients With Acute Calcium Pyrophosphate Crystal Arthritis Versus Matched Comparators in a Large Cohort Study

OBJECTIVE

Calcium pyrophosphate deposition (CPPD) disease was associated with osteopenia in two cross-sectional studies. We compared fracture risks in patients with acute calcium pyrophosphate (CPP) crystal arthritis versus matched comparators.

METHODS

We performed a longitudinal cohort study using electronic health record data from a single large academic health system, with data from 1991 to 2023. Patients with one or more episodes of acute CPP crystal arthritis were matched to comparators on the index date (first documentation of "pseudogout" or synovial fluid CPP crystals or matched encounter) and first encounter in the health system. The primary outcome was first fracture at the humerus, wrist, hip, or pelvis. We excluded patients with fracture before the index date. Covariates included demographics, body mass index, smoking, comorbidities, health care use, glucocorticoids, and osteoporosis treatments. We estimated incidence rates and adjusted hazard ratios for fracture. Sensitivity analyses excluded patients prescribed glucocorticoids, patients prescribed osteoporosis treatments, or patients with rheumatoid arthritis and additionally adjusted for chronic kidney disease.

RESULTS

We identified 1,148 patients with acute CPP crystal arthritis matched to 3,730 comparators, with a mean age of 73 years. Glucocorticoids and osteoporosis treatments were more frequent in the acute CPP crystal arthritis cohort. Fracture incidence rates were twice as high in the acute CPP crystal arthritis cohort (11.7 per 1,000 person-years) versus comparators (5.5 per 1,000 person-years). After multivariable adjustment, fracture relative risk was twice as high in the acute CPP crystal arthritis cohort (hazard ratio 1.8 [95% confidence interval 1.3-2.3]); results were similar in sensitivity analyses.

CONCLUSION

In this first published study of fractures and CPPD, fracture risk was nearly doubled in patients with acute CPP crystal arthritis.

An explorative single-arm clinical study to assess craving in patients with alcohol use disorder using Virtual Reality exposure (CRAVE)-study protocol

BACKGROUND

Alcohol use disorder (AUD) belongs to the most burdensome clinical disorders worldwide. Current treatment approaches yield unsatisfactory long-term effects with relapse rates up to 85%. Craving for alcohol is a major predictor for relapse and can be intentionally induced via cue exposure in real life as well as in Virtual Reality (VR). The induction and habituation of craving via conditioned cues as well as extinction learning is used in Cue Exposure Therapy (CET), a long-known but rarely used strategy in Cognitive Behavioral Therapy (CBT) of AUD. VR scenarios with alcohol related cues offer several advantages over real life scenarios and are within the focus of current efforts to develop new treatment options. As a first step, we aim to analyze if the VR scenarios elicit a transient change in craving levels and if this is measurable via subjective and psychophysiological parameters.

METHODS

A single-arm clinical study will be conducted including n = 60 patients with AUD. Data on severity of AUD and craving, comorbidities, demographics, side effects and the feeling of presence in VR will be assessed. Patients will use a head-mounted display (HMD) to immerse themselves into three different scenarios (neutral vs. two target situations: a living room and a bar) while heart rate, heart rate variability, pupillometry and electrodermal activity will be measured continuously. Subjective craving levels will be assessed before, during and after the VR session.

DISCUSSION

Results of this study will yield insight into the induction of alcohol craving in VR cue exposure paradigms and its measurement via subjective and psychophysiological parameters. This might be an important step in the development of innovative therapeutic approaches in the treatment of patients with AUD.

TRIAL REGISTRATION

This study was approved by the Charité-Universitätsmedizin Berlin Institutional Review Board (EA1/190/22, 23.05.2023). It was registered on ClinicalTrials.gov (NCT05861843).

The 2023 ACR/EULAR Classification Criteria for Calcium Pyrophosphate Deposition Disease

OBJECTIVE

Calcium pyrophosphate deposition (CPPD) disease is prevalent and has diverse presentations, but there are no validated classification criteria for this symptomatic arthritis. The American College of Rheumatology (ACR) and EULAR have developed the first-ever validated classification criteria for symptomatic CPPD disease.

METHODS

Supported by the ACR and EULAR, a multinational group of investigators followed established methodology to develop these disease classification criteria. The group generated lists of candidate items and refined their definitions, collected de-identified patient profiles, evaluated strengths of associations between candidate items and CPPD disease, developed a classification criteria framework, and used multi-criterion decision analysis to define criteria weights and a classification threshold score. The criteria were validated in an independent cohort.

RESULTS

Among patients with joint pain, swelling, or tenderness (entry criterion) whose symptoms are not fully explained by an alternative disease (exclusion criterion), the presence of crowned dens syndrome or calcium pyrophosphate crystals in synovial fluid are sufficient to classify a patient as having CPPD disease. In the absence of these findings, a score >56 points using weighted criteria, comprising clinical features, associated metabolic disorders, and results of laboratory and imaging investigations, can be used to classify as CPPD disease. These criteria had a sensitivity of 92.2% and specificity of 87.9% in the derivation cohort (190 CPPD cases, 148 mimickers), whereas sensitivity was 99.2% and specificity was 92.5% in the validation cohort (251 CPPD cases, 162 mimickers).

CONCLUSION

The 2023 ACR/EULAR CPPD disease classification criteria have excellent performance characteristics and will facilitate research in this field.

Consolidative Radiotherapy for Residual PET-Avid Disease on Day +30 Post CAR T-Cell Therapy in Non-Hodgkin Lymphoma

PURPOSE/OBJECTIVE(S)

Up to30% of non-Hodgkin lymphoma (NHL) patients achieve a partial response (PR) to anti-CD19 Chimeric Antigen Receptor T-cell Therapy (CART) on day +30. Most PR patients relapse and only 30% achieve spontaneous complete response (CR) without additional therapies. This study is the first to report on the role of consolidative radiotherapy (cRT) for PR PET-avid disease on day +30 post-CART in NHL.

MATERIALS/METHODS

Aretrospective review across 3 institutions from 2018 to 2022 identified 60 patients with B-cell NHL who received CART and achieved PR (Deauville 4-5) with <5 PET-avid disease sites on day +30. Progression-free survival (PFS) was defined from CART infusion to any disease progression. Overall survival (OS) was defined from CART infusion to death. Local relapse-free survival (LRFS), calculated based on the total number of PR sites, was defined from CART infusion to local relapse (LR) in the PR site identified on day +30. cRT was defined as comprehensive (compRT) - treated all PR PET-avid sites - or focal (focRT).

RESULTS

Followingday +30 PET scan, 45 PR patients were observed and 15 received cRT. Only one patient received consolidative systemic therapy and belonged to the cRT group. Prior to CART, bridging RT was given to 13 patients (9 in observation group and 4 in cRT group). There were no significant differences in the pre-CART and day +30 baseline characteristics, including the median size and SUVmax of the PR sites, between the two groups. However, the median number of PR sites on day +30 was higher in the cRT group (2 [range 1-3] vs 1 [range 1-3], p = 0.003). The median equivalent 2 Gy dose was 39.1 (Interquartile range 36.8-41) Gy, and the most common cRT regimen was 37.5 Gy in 15 fractions. The median follow-up was 21 months. Among the observed patients, 15 (33%) achieved spontaneous CR, and 27 (60%) experienced disease progression with all relapses involving the initial PR sites. Among patients who received cRT, 10 (67%) achieved CR, and 3 (20%) had disease progression with no relapses in the radiated PR sites. None of the 10 cRT patients achieving CR relapsed or required subsequent therapies. The 2-year PFS was 80% and 37% (p = 0.012) and the 2-year OS was 78% and 43% (p = 0.12) in the cRT and observation groups, respectively. Patients consolidated with compRT (n = 12) had superior 2-year PFS (92% vs 37%, p = 0.003) and 2-year OS (86% vs 43%, p = 0.048) compared to observed or focRT patients (n = 48). There were no grade 3+ RT-related toxicities. A total of 90 PR sites were identified; 64 were observed and 26 received cRT. Fourteen (22%) observed PR sites achieved spontaneous sustained CR and 42 (66%) experienced LR. Twenty-four (92%) PR sites consolidated with cRT achieved sustained CR and none experienced LR. The 2-year LRFS was 100% in the cRT sites and 31% in the observed sites (p<0.001).

CONCLUSION

NHL patients who achieve PR by PET to CART are at high risk of local progression. cRT for residual PET-avid disease on day +30 post-CART appears to alter the pattern of relapse and improve LRFS and PFS.

The Role of Radiation Therapy in the Management of Gray Zone Lymphoma

PURPOSE/OBJECTIVE(S)

Gray zone lymphoma (GZL) is a relatively rare disease predominantly affecting young adults with purportedly poor outcomes with current treatment approaches. The role of radiation therapy (RT) in the management of GZL is not well established. This is the largest study to report on the outcomes of GZL patients treated with and without RT.

MATERIALS/METHODS

A retrospective review of 30 patients with GZL treated across 3 institutions from 2009 to 2021 was performed. Event-free survival (EFS) was defined from initiation of frontline chemotherapy (CHT) to disease progression/relapse, initiation of salvage therapy, or death. Local control (LC) was defined from RT start date to in-field recurrence.

RESULTS

The median age was 32 (range: 18-86) years, and 16 (53%) patients had early stage (I-II) disease. Bulky mediastinal disease was present in 63% of patients, and the median tumor diameter was 10 (range: 1.5-18) cm. Patients received ABVD (20%), RCHOP (33%), or REPOCH (47%) as frontline CHT. Among 25 patients with interim PET/CT scan, there were 6 rapid early responders and 14 slow early responders (SER), with 2-year EFS of 33% and 24%, respectively (p = 0.13). After the completion of CHT, 15 (50%) patients achieved complete response (CR) and 10 (33%) achieved partial response (PR), with 2-year EFS of 46% and 10%, respectively (p = 0.004). RT was given to 9 patients in CR (n = 3) or in PR (n = 6). The median RT dose was 36 (30.6-48.6) Gy, at 1.8-2 Gy/fraction. Those receiving RT had bulkier disease at diagnosis (p = 0.049) and lower rates of CR following CHT (p = 0.03). After RT, 3/6 (50%) PR patients converted to CR. At a median follow-up of 4 years, the 2-year EFS was 26% for all patients, 33% for RT and 23% for noRT (p = 0.44). Among patients who did not receive upfront RT and experienced progression (n = 17), 16 (94%) relapsed in pre-existing sites. The 5-year OS was 80% for all patients, 88% for RT and 78% for no RT (p = 0.63). Patients who achieved PR to CHT and received RT had better 2-year EFS (17% vs 0%, p = 0.007) compared to patients who did not receive RT. Similarly, patients with SER who received RT had superior 2-year EFS (33% vs 13%, p = 0.038). Patients with bulky mediastinal disease had a 2-year EFS of 43% with RT and 11% without RT (p = 0.08). After 1st line treatment, 22 (73%) patients relapsed and 18 were successfully salvaged with a sustained CR. The most common salvage regimen involved high dose CHT followed by hematopoietic cell transplantation (HCT) (n = 15). RT was given for 7 patients in the relapsed/refractory setting (consolidative peri-HCT n = 4; definitive salvage n = 3) and 5 (71%) achieved a sustained CR. Among the 16 patients who received RT in the upfront (n = 9) or salvage (n = 7) setting, 3 patients experienced in-field recurrence translating to 2-year LC of 79%.

CONCLUSION

GZL patients have high risk of relapse and maximal upfront combined modality therapy should be considered. RT provides good local control and improves EFS particularly for SER, PR, and bulky mediastinal disease.

The 2023 ACR/EULAR classification criteria for calcium pyrophosphate deposition disease

OBJECTIVE

Calcium pyrophosphate deposition (CPPD) disease is prevalent and has diverse presentations, but there are no validated classification criteria for this symptomatic arthritis. The American College of Rheumatology (ACR) and EULAR have developed the first-ever validated classification criteria for symptomatic CPPD disease.

METHODS

Supported by the ACR and EULAR, a multinational group of investigators followed established methodology to develop these disease classification criteria. The group generated lists of candidate items and refined their definitions, collected de-identified patient profiles, evaluated strengths of associations between candidate items and CPPD disease, developed a classification criteria framework, and used multi-criterion decision analysis to define criteria weights and a classification threshold score. The criteria were validated in an independent cohort.

RESULTS

Among patients with joint pain, swelling, or tenderness (entry criterion) whose symptoms are not fully explained by an alternative disease (exclusion criterion), the presence of crowned dens syndrome or calcium pyrophosphate crystals in synovial fluid are sufficient to classify a patient as having CPPD disease. In the absence of these findings, a score>56 points using weighted criteria, comprising clinical features, associated metabolic disorders, and results of laboratory and imaging investigations, can be used to classify as CPPD disease. These criteria had a sensitivity of 92.2% and specificity of 87.9% in the derivation cohort (190 CPPD cases, 148 mimickers), whereas sensitivity was 99.2% and specificity was 92.5% in the validation cohort (251 CPPD cases, 162 mimickers).

CONCLUSION

The 2023 ACR/EULAR CPPD disease classification criteria have excellent performance characteristics and will facilitate research in this field.

Cardiovascular Disease Risk in Calcium Pyrophosphate Deposition Disease: A Nationwide Study of Veterans

OBJECTIVE

Calcium pyrophosphate deposition (CPPD) disease represents a common crystalline arthritis with a range of manifestations. Our goal was to investigate risks for cardiovascular events in patients with CPPD.

METHODS

We performed a retrospective matched cohort analysis in the Veterans Health Administration Corporate Data Warehouse, 2010-2014. CPPD was defined by ≥1 International Classification of Diseases, Ninth Revision codes for chondrocalcinosis or calcium metabolism disorder. CPPD patients were age- and sex-matched to approximately 4 patients without codes for CPPD; we excluded patients with a cardiovascular event during the 365 days prior to the index date. Demographic information, traditional cardiovascular risk factors, medications, and health care utilization were assessed at baseline. The primary outcome was a major adverse cardiovascular event (MACE: myocardial infarction, acute coronary syndrome, coronary revascularization, stroke, or death). Secondary outcomes included individual components of MACE. Cox proportional hazards models estimated fully adjusted hazard ratios (HRs) and 95% confidence intervals (95% CIs).

RESULTS

We identified 23,124 CPPD patients matched to 86,629 non-CPPD patients with >250,000 person-years of follow-up. The study population was 96% male, mean age was 78 years, and 75% were White. The frequency of traditional cardiovascular risk factors was similar between the 2 cohorts. CPPD was not significantly associated with risk for MACE (HR 0.98 [95% CI 0.94-1.02]) in fully adjusted models, though risks of myocardial infarction, acute coronary syndrome, and stroke were significantly higher in the CPPD cohort compared to the non-CPPD cohort.

CONCLUSION

CPPD did not confer an increased risk for MACE, a composite end point including all-cause mortality. Our results propose CPPD as a novel risk factor for MACE components, including myocardial infarction, acute coronary syndrome, and stroke.

Identifying Potential Classification Criteria for Calcium Pyrophosphate Deposition Disease: Item Generation and Item Reduction

OBJECTIVE

Classification criteria for calcium pyrophosphate deposition (CPPD) disease will facilitate clinical research on this common crystalline arthritis. Our objective was to report on the first 2 phases of a 4-phase process for developing CPPD classification criteria.

METHODS

CPPD classification criteria development is overseen by a 12-member steering committee. Item generation (phase I) included a scoping literature review of 5 literature databases and contributions from a 35-member combined expert committee and 2 patient research partners. Item reduction and refinement (phase II) involved a combined expert committee meeting, discussions among clinical, imaging, and laboratory advisory groups, and an item-rating exercise to assess the influence of individual items toward classification. The steering committee reviewed the modal rating score for each item (range -3 [strongly pushes away from CPPD] to +3 [strongly pushes toward CPPD]) to determine items to retain for future phases of criteria development.

RESULTS

Item generation yielded 420 items (312 from the literature, 108 from experts/patients). The advisory groups eliminated items that they agreed were unlikely to distinguish between CPPD and other forms of arthritis, yielding 127 items for the item-rating exercise. Fifty-six items, most of which had a modal rating of +/- 2 or 3, were retained for future phases. As numerous imaging items were rated +3, the steering committee recommended focusing on imaging of the knee and wrist and 1 additional affected joint for calcification suggestive of CPP crystal deposition.

CONCLUSION

A data- and expert-driven process is underway to develop CPPD classification criteria. Candidate items comprise clinical, imaging, and laboratory features.

Patient and healthcare team recommended medication adherence strategies for hydroxychloroquine: results of a qualitative study informing intervention development

OBJECTIVE

Patients identified as black and from disadvantaged backgrounds have a twofold higher hydroxychloroquine (HCQ) non-adherence, which contributes to worse lupus outcomes and disparities. Yet, most adherence interventions lack tailored strategies for racially and socioeconomically diverse patients who face unique challenges with HCQ. We aimed to examine a broadly representative group of patients with SLE and physician perspectives on HCQ adherence and adherence strategies to redesign an adherence intervention.

METHODS

We conducted four virtual focus groups (90 min each) with 11 racially and socioeconomically diverse patients with SLE recruited from two health systems. Additionally, we hosted two focus group meetings with nine healthcare advisors. In focus groups, patients: (1) shared their perspectives on using HCQ; (2) shared concerns leading to non-adherence; (3) discussed strategies to overcome concerns; (4) prioritised strategies from the most to least valuable to inform an adherence intervention. In two separate focus groups, healthcare advisors gave feedback to optimise an adherence intervention. Using content analysis, we analysed transcripts to redesign our adherence intervention.

RESULTS

Worry about side effects was the most common barrier phrase mentioned by patients. Key themes among patients' concerns about HCQ included: information gaps, logistical barriers, misbeliefs and medication burden. Finally, patients suggested adherence strategies and ranked those most valuable including co-pay assistance, personal reminders, etc. Patient and healthcare advisors informed designing a laminate version of an adherence intervention to link each barrier category with four to six patient-recommended adherence strategies.

CONCLUSION

We developed a patient stakeholder-informed and healthcare stakeholder-informed tailored intervention that will target non-adherence at the individual patient level.

P-251 Cumulus cell analysis as a non-invasive oocyte selection strategy to reduce the number of oocytes/embryos cultured and increase pregnancy rates

Study question

Can non-invasive gene expression analysis of cumulus cells (CC) improve efficiency in ART by prioritizing oocytes for further culture and fresh single embryo transfer?

Summary answer

CC analysis can be used for the selective processing of oocytes. This may reduce culture work and improve the outcome in ICSI elective SETs (eSET).

What is known already

In an interventional, blinded, prospective cohort study (Van Vaerenbergh et al. 2021), 113 patients underwent a fresh Day3 eSET with embryos ranked and transferred based on morphology and CC gene expression (Aurora Test), while 520 control patients underwent a Day3 eSET without the Aurora Test. This resulted in a significant higher clinical pregnancy of 61% in the patients with eSET based on CC ranking applied on good morphology embryos, compared to 29% in the controls with eSET based on embryo morphology only. Live birth rate was also significantly increased, while time-to-pregnancy was significantly reduced with 3 transfer cycles.

Study design, size, duration

In a retrospective analysis, in a subset of patients with at least 6 growing follicles and at least five 2PN oocytes (n = 80), it was investigated whether the Aurora Test, used to select transferrable Day3-embryos, could also be applied to select oocytes on Day0/1. The effect of processing only the three highest ranked oocytes (based on the Aurora Test) on embryo development and clinical pregnancy was studied compared to processing all oocytes.

Participants/materials, setting, methods

Patients included in this single centre study had their first or second GnRH-antagonist ICSI cycle, were younger than 40y, had normal BMI, were stimulated with HP-hMG and scheduled for Day3 eSET. Two-sided statistical analysis (p &lt; 0,05) was performed between a strategy of processing only the top 3 Aurora ranked oocytes, according to CC gene expression, and a strategy of processing all available oocytes.

Main results and the role of chance

On average, 8 MII oocytes were obtained per patient and the average fertilization rate was 83%. In total, 407 good quality embryos (GQE) on Day3 were generated from these 80 patients when utilising all 639 oocytes. Processing the three top-ranked oocytes only (240/639 oocytes) would have reduced the number of embryos to 169 GQE and would have resulted in 2.1 GQE on average on Day3 per patient; 75/80 (94%) patients would have had a fresh Day3 transfer resulting in a 63% clinical pregnancy rate. Processing all 639 available 2PN oocytes (standard of care) resulted in a fresh Day3 transfer in all 80 patients and a similar 64% clinical pregnancy rate (ns). However, 399 more oocytes would need to be processed. The strategy of restricting the number of oocytes to be processed would not have compromised cumulative cycle outcome. Considering all subsequent freeze/thawing cycles the cumulative clinical pregnancy rate calculated per all 80 patients would increase to 90%.

Limitations, reasons for caution

The limitation of this approach is that the Aurora Test requires individual oocyte denudation and individual oocyte vitrification. Secondly, this new strategy should be validated in a prospective study.

Wider implications of the findings

By applying this oocyte selection strategy patients would benefit from a high pregnancy rate in the fresh transfer cycle, while the lab would see reduction in embryo culture work, because freeze/thawing cycles and culture of embryos with lower competence would be prevented.

Trial registration number

NA

Inorganic pyrophosphate is reduced in patients with systemic sclerosis

OBJECTIVE

The pathogenesis of calcinosis cutis, a disabling complication of SSc, is poorly understood and effective treatments are lacking. Inorganic pyrophosphate (PPi) is a key regulator of ectopic mineralization, and its deficiency has been implicated in ectopic mineralization disorders. We therefore sought to test the hypothesis that SSc may be associated with reduced circulating PPi, which might play a pathogenic role in calcinosis cutis.

METHODS

Subjects with SSc and age-matched controls without SSc were recruited from the outpatient rheumatology clinics at Rutgers and Northwestern Universities (US cohort), and from the Universities of Szeged and Debrecen (Hungarian cohort). Calcinosis cutis was confirmed by direct palpation, by imaging or both. Plasma PPi levels were determined in platelet-free plasma using ATP sulfurylase to convert PPi into ATP in the presence of excess adenosine 5' phosphosulfate.

RESULTS

Eighty-one patients with SSc (40 diffuse cutaneous, and 41 limited cutaneous SSc) in the US cohort and 45 patients with SSc (19 diffuse cutaneous and 26 limited cutaneous SSc) in the Hungarian cohort were enrolled. Calcinosis was frequently detected (40% of US and 46% of the Hungarian cohort). Plasma PPi levels were significantly reduced in both SSc cohorts with and without calcinosis (US: P = 0.003; Hungarian: P < 0.001).

CONCLUSIONS

Circulating PPi are significantly reduced in SSc patients with or without calcinosis. Reduced PPi may be important in the pathophysiology of calcinosis and contribute to tissue damage with chronic SSc. Administering PPi may be a therapeutic strategy and larger clinical studies are planned to confirm our findings.

Advancing TB research using digitized programmatic data

The use of real-world data from national TB care programs has great potential to answer key research questions in TB control and is now opportune due to increasing digital data collection and storage. We summarize an expert stakeholder workshop conducted on this topic in October 2019, with perspectives from academics, national TB program officers, and data managers. We discuss challenges and opportunities in the use of TB programmatic data for research and describe digital data availability in two large, high TB burden countries, Brazil and South Africa. From this, we posit that with a standardized data collection set, improved data management, and greater collaboration, more TB programmatic data can be used for research with measurable public health impact.

POS1124 IDENTIFYING POTENTIAL CLASSIFICATION CRITERIA FOR CALCIUM PYROPHOSPHATE DEPOSITION DISEASE (CPPD): RESULTS FROM THE INITIAL PHASES

Background:

Classification criteria for calcium pyrophosphate deposition disease (CPPD) will facilitate clinical research on this common crystalline arthritis. ACR/EULAR are jointly sponsoring development of CPPD classification criteria using a multi-phase process.

Objectives:

To report preliminary results from the first two phases of a four-phase process for developing CPPD classification criteria.

Methods:

CPPD classification criteria development is overseen by a 12-member Steering Committee. Item generation (Phase I) included a scoping literature review of five literature databases and contributions from a 35-member Combined Expert Committee and two Patient Research Partners. Item reduction and refinement (Phase II) involved a Combined Expert Committee meeting, discussions among Clinical, Imaging, and Laboratory Advisory Groups, and an item rating exercise to assess the influence of individual items toward classification. The Steering Committee reviewed the modal rating score for each item (range -3 [strongly pushes away from CPPD] to +3 [strongly pushes toward CPPD]) to determine items to retain for future phases of criteria development.

Results:

Item generation yielded 420 items (312 from the literature, 108 from experts/patients). The Advisory Groups eliminated items they agreed were unlikely to distinguish between CPPD and other forms of arthritis, yielding 127 items for the item rating exercise. Fifty-six items, most of which had a modal rating of +/- 2 or 3, were retained for future phases (see Table 1). As numerous imaging items were rated +3, the Steering Committee recommended focusing on imaging of the knee, wrist, and one additional affected joint for calcification suggestive of CPP crystal deposition.

Conclusion:

The ACR/EULAR CPPD classification criteria working group has adopted both data- and expert-driven approaches, leading to 56 candidate items broadly categorized as clinical, imaging, and laboratory features. Remaining steps for criteria development include domain establishment, item weighting through a multi-criteria decision analysis exercise, threshold score determination, and criteria validation.

Table 1.

Categories of items retained for future phases of classification criteria development

Age in decade at symptom onsetAcute inflammatory arthritis (e.g. knee, wrist, 1st MTP joint*)Recurrence and pattern of joint involvement (e.g. 1 self-limited episode, >1 self-limited episode)Physical findings (e.g. palpable subcutaneous tophus*, psoriasis*)Co-morbidities and family history (e.g. Gitelman disease, hemochromatosis, familial CPPD)Osteoarthritis location and features (e.g. 2nd or 3rd MCP joint, wrist)Synovial fluid findings (e.g. CPP crystals present, CPP crystals absent on 1 occasion* or 2 occasions*, monosodium urate crystals present*)Laboratory findings (e.g. hypomagnesemia, hyperparathyroidism, rheumatoid factor*, anti-CCP*)Plain radiograph: calcification in regions of fibro- or hyaline cartilage+Plain radiograph: calcification of the synovial membrane/capsule/tendon+Conventional CT: calcification in regions of fibro- or hyaline cartilage+Conventional CT: calcification of the synovial membrane/capsule/tendon+Ultrasound: CPP crystal deposition in fibro- or hyaline cartilage+Ultrasound: CPP crystal deposition in synovial membrane/capsule/tendons+Dual-energy CT: CPP crystal deposition in fibro- or hyaline cartilage+Dual-energy CT: CPP crystal deposition in synovial membrane/capsule/tendon+

*Potential negative predictor +Assessed in the knee, wrist, and/or 1 additional affected joint

Disclosure of Interests:

Sara Tedeschi Consultant of: NGM Biopharmaceuticals, Tristan Pascart: None declared, Augustin Latourte Consultant of: Novartis, Cattleya Godsave: None declared, Burak Kundaki: None declared, Raymond Naden: None declared, William Taylor: None declared, Nicola Dalbeth Speakers bureau: Abbvie and Janssen, Consultant of: AstraZeneca, Dyve, Selecta, Horizon, Arthrosi, and Cello Health, Tuhina Neogi: None declared, Fernando Perez-Ruiz: None declared, Ann Rosenthal: None declared, Fabio Becce Consultant of: Horizon Therapeutics, Grant/research support from: Siemens Healthineers, Eliseo Pascual: None declared, Mariano Andrés: None declared, Thomas Bardin: None declared, Michael Doherty: None declared, Hang Korng Ea: None declared, Georgios Filippou: None declared, John FitzGerald: None declared, Marwin Gutierrez: None declared, Annamaria Iagnocco: None declared, Tim Jansen Speakers bureau: Abbvie, Amgen, BMS, Grunenthal, Olatec, Sanofi Genzyme, Consultant of: Abbvie, Amgen, BMS, Grunenthal, Olatec, Sanofi Genzyme, Minna Kohler Speakers bureau: Lilly, Consultant of: Novartis, Frederic Lioté: None declared, Mark Matza: None declared, Geraldine McCarthy Consultant of: PK Med, Roberta Ramonda: None declared, Anthony Reginato: None declared, Pascal Richette: None declared, Jasvinder Singh Speakers bureau: Simply Speaking, Consultant of: Crealta/Horizon, Medisys, Fidia, UBM LLC, Trio health, Medscape, WebMD, Adept Field Solutions, Clinical Care options, Clearview healthcare partners, Putnam associates, Focus forward, Navigant consulting, Spherix, Practice Point communications, Francisca Sivera: None declared, Alexander So: None declared, Lisa Stamp: None declared, Janeth Yinh: None declared, Chio Yokose: None declared, Robert Terkeltaub Consultant of: Sobi, Horizon Therapeutics, Astra-Zeneca, Selecta, Grant/research support from: Astra-Zeneca, Hyon Choi: None declared, Abhishek Abhishek Consultant of: NGM Biopharmaceuticals.

Patient Perspectives on Smoking Cessation and Interventions in Rheumatology Clinics

OBJECTIVE

Although smoking is a risk factor for cardiovascular and rheumatic disease severity, only 10% of rheumatology visits document cessation counseling. After implementing a rheumatology clinic protocol that increased tobacco quitline referrals 20-fold, we undertook this study to examine patients' barriers and facilitators to smoking cessation based on prior rheumatology experiences, to solicit reactions to the new cessation protocol, and to identify patient-centered outcomes or signs of cessation progress following improved care.

METHODS

We recruited 19 patients who smoke (12 with rheumatoid arthritis [RA] and 7 with systemic lupus erythematosus [SLE]) to participate in 1 of 3 semistructured focus groups. Transcripts of the focus group discussions were analyzed using thematic analysis to classify barriers, facilitators, and signs of cessation progress.

RESULTS

Participant-reported barriers and facilitators to cessation involved psychological, health-related, and social and economic factors, as well as health care messaging and resources. Commonly discussed barriers included viewing smoking as a crutch amid rheumatic disease, rarely receiving cessation counseling in rheumatology clinics, and very limited awareness that smoking can worsen rheumatic diseases or reduce efficacy of some rheumatic disease medications. Participants endorsed our cessation protocol with rheumatology-specific education and accessible resources, such as a quitline. Beyond quitting, participants prioritized knowing why and how to quit as signs of progress outcomes.

CONCLUSION

Focus groups identified themes and categories of facilitators/barriers to smoking cessation at the levels of patient and health system. Two key outcomes of improving cessation care for patients with RA and SLE were knowing why and how to quit. Emphasizing rheumatologic health benefits and cessation resources is essential when designing and evaluating rheumatology smoking cessation interventions.

2020 American College of Rheumatology Guideline for the Management of Gout

OBJECTIVE

To provide guidance for the management of gout, including indications for and optimal use of urate-lowering therapy (ULT), treatment of gout flares, and lifestyle and other medication recommendations.

METHODS

Fifty-seven population, intervention, comparator, and outcomes questions were developed, followed by a systematic literature review, including network meta-analyses with ratings of the available evidence according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology, and patient input. A group consensus process was used to compose the final recommendations and grade their strength as strong or conditional.

RESULTS

Forty-two recommendations (including 16 strong recommendations) were generated. Strong recommendations included initiation of ULT for all patients with tophaceous gout, radiographic damage due to gout, or frequent gout flares; allopurinol as the preferred first-line ULT, including for those with moderate-to-severe chronic kidney disease (CKD; stage >3); using a low starting dose of allopurinol (≤100 mg/day, and lower in CKD) or febuxostat (<40 mg/day); and a treat-to-target management strategy with ULT dose titration guided by serial serum urate (SU) measurements, with an SU target of <6 mg/dl. When initiating ULT, concomitant antiinflammatory prophylaxis therapy for a duration of at least 3-6 months was strongly recommended. For management of gout flares, colchicine, nonsteroidal antiinflammatory drugs, or glucocorticoids (oral, intraarticular, or intramuscular) were strongly recommended.

CONCLUSION

Using GRADE methodology and informed by a consensus process based on evidence from the current literature and patient preferences, this guideline provides direction for clinicians and patients making decisions on the management of gout.

2020 American College of Rheumatology Guideline for the Management of Gout

OBJECTIVE

To provide guidance for the management of gout, including indications for and optimal use of urate-lowering therapy (ULT), treatment of gout flares, and lifestyle and other medication recommendations.

METHODS

Fifty-seven population, intervention, comparator, and outcomes questions were developed, followed by a systematic literature review, including network meta-analyses with ratings of the available evidence according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology, and patient input. A group consensus process was used to compose the final recommendations and grade their strength as strong or conditional.

RESULTS

Forty-two recommendations (including 16 strong recommendations) were generated. Strong recommendations included initiation of ULT for all patients with tophaceous gout, radiographic damage due to gout, or frequent gout flares; allopurinol as the preferred first-line ULT, including for those with moderate-to-severe chronic kidney disease (CKD; stage >3); using a low starting dose of allopurinol (≤100 mg/day, and lower in CKD) or febuxostat (<40 mg/day); and a treat-to-target management strategy with ULT dose titration guided by serial serum urate (SU) measurements, with an SU target of <6 mg/dl. When initiating ULT, concomitant antiinflammatory prophylaxis therapy for a duration of at least 3-6 months was strongly recommended. For management of gout flares, colchicine, nonsteroidal antiinflammatory drugs, or glucocorticoids (oral, intraarticular, or intramuscular) were strongly recommended.

CONCLUSION

Using GRADE methodology and informed by a consensus process based on evidence from the current literature and patient preferences, this guideline provides direction for clinicians and patients making decisions on the management of gout.

Assessment of aeration control strategies for biofilm-based partial nitritation/anammox systems

The objective of this work was to compare the nitrogen removal in mainstream, biofilm-based partial nitritation anammox (PN/A) systems employing (1) constant setpoint dissolved oxygen (DO) control, (2) intermittent aeration, and (3) ammonia-based aeration control (ABAC). A detailed water resource recovery facility (WRRF) model was used to study the dynamic performance of these aeration control strategies with respect to treatment performance and energy consumption. The results show that constant setpoint DO control cannot meet typical regulatory limits for total ammonia nitrogen (NH_x-N). Intermittent aeration shows improvement but requires optimisation of the aeration cycle. ABAC shows the best treatment performance with the advantages of continuous operation and over 20% lower average energy consumption as compared to intermittent aeration.

Investigating lupus retention in care to inform interventions for disparities reduction: an observational cohort study

BACKGROUND

Systemic lupus erythematous (SLE) disproportionately impacts patients of color and socioeconomically disadvantaged patients. Similar disparities in HIV were reduced through a World Health Organization-endorsed Care Continuum strategy targeting "retention in care," defined as having at least two annual visits or viral load lab tests. Using similar definitions, this study aimed to examine predictors of lupus retention in care, to develop an SLE Care Continuum and inform interventions to reduce disparities. We hypothesized that Black patients and those residing in disadvantaged neighborhoods would have lower retention in care.

METHODS

Abstractors manually validated 545 potential adult cases with SLE codes in 2013-2014 using 1997 American College of Rheumatology (ACR) or 2012 Systemic Lupus Erythematosus International Collaborating Clinics (SLICC) criteria. We identified 397 SLE patients who met ACR or SLICC criteria for definite lupus, had at least one baseline rheumatology visit, and were alive through 2015. Retention in care was defined as having two ambulatory rheumatology visits or SLE labs (e.g., complement tests) during the outcome year 2015, analogous to HIV retention definitions. Explanatory variables included age, sex, race, ethnicity, smoking status, neighborhood area deprivation index (ADI), number of SLE criteria, and nephritis. We used multivariable logistic regression to test our hypothesis and model predictors of SLE retention in care.

RESULTS

Among 397 SLE patients, 91% were female, 56% White, 39% Black, and 5% Hispanic. Notably, 51% of Black versus 5% of White SLE patients resided in the most disadvantaged ADI neighborhood quartile. Overall, 60% met visit-defined retention and 27% met complement lab-defined retention in 2015. Retention was 59% lower for patients in the most disadvantaged neighborhood quartile (adjusted OR 0.41, CI 0.18, 0.93). No statistical difference was seen based on age, sex, race, or ethnicity. More SLE criteria and non-smoking predicted greater retention.

CONCLUSIONS

Disadvantaged neighborhood residence was the strongest factor predicting poor SLE retention in care. Future interventions could geo-target disadvantaged neighborhoods and design retention programs with vulnerable populations to improve retention in care and reduce SLE outcome disparities.

Gout, Hyperuricemia, and Crystal-Associated Disease Network Consensus Statement Regarding Labels and Definitions for Disease Elements in Gout

OBJECTIVE

The language currently used to describe gout lacks standardization. The aim of this project was to develop a consensus statement on the labels and definitions used to describe the basic disease elements of gout.

METHODS

Experts in gout (n = 130) were invited to participate in a Delphi exercise and face-to-face consensus meeting to reach consensus on the labeling and definitions for the basic disease elements of gout. Disease elements and labels in current use were derived from a content analysis of the contemporary medical literature, and the results of this analysis were used for item selection in the Delphi exercise and face-to-face consensus meeting.

RESULTS

There were 51 respondents to the Delphi exercise and 30 attendees at the face-to-face meeting. Consensus agreement (≥80%) was achieved for the labels of 8 disease elements through the Delphi exercise; the remaining 3 labels reached consensus agreement through the face-to-face consensus meeting. The agreed labels were monosodium urate crystals, urate, hyperuric(a)emia, tophus, subcutaneous tophus, gout flare, intercritical gout, chronic gouty arthritis, imaging evidence of monosodium urate crystal deposition, gouty bone erosion, and podagra. Participants at the face-to-face meeting achieved consensus agreement for the definitions of all 11 elements and a recommendation that the label "chronic gout" should not be used.

CONCLUSION

Consensus agreement was achieved for the labels and definitions of 11 elements representing the fundamental components of gout etiology, pathophysiology, and clinical presentation. The Gout, Hyperuricemia, and Crystal-Associated Disease Network recommends the use of these labels when describing the basic disease elements of gout.

Gout, Hyperuricaemia and Crystal-Associated Disease Network (G-CAN) consensus statement regarding labels and definitions of disease states of gout

OBJECTIVE

There is a lack of standardisation in the terminology used to describe gout. The aim of this project was to develop a consensus statement describing the recommended nomenclature for disease states of gout.

METHODS

A content analysis of gout-related articles from rheumatology and general internal medicine journals published over a 5-year period identified potential disease states and the labels commonly assigned to them. Based on these findings, experts in gout were invited to participate in a Delphi exercise and face-to-face consensus meeting to reach agreement on disease state labels and definitions.

RESULTS

The content analysis identified 13 unique disease states and a total of 63 unique labels. The Delphi exercise (n=76 respondents) and face-to-face meeting (n=35 attendees) established consensus agreement for eight disease state labels and definitions. The agreed labels were as follows: 'asymptomatic hyperuricaemia', 'asymptomatic monosodium urate crystal deposition', 'asymptomatic hyperuricaemia with monosodium urate crystal deposition', 'gout', 'tophaceous gout', 'erosive gout', 'first gout flare' and 'recurrent gout flares'. There was consensus agreement that the label 'gout' should be restricted to current or prior clinically evident disease caused by monosodium urate crystal deposition (gout flare, chronic gouty arthritis or subcutaneous tophus).

CONCLUSION

Consensus agreement has been established for the labels and definitions of eight gout disease states, including 'gout' itself. The Gout, Hyperuricaemia and Crystal-Associated Disease Network recommends the use of these labels when describing disease states of gout in research and clinical practice.

Skin cancer prevention: a review of current topical options complementary to sunscreens

The incidence of non-melanoma skin cancer (NMSC) is dramatically increasing worldwide, despite the increased use of improved sunscreens. In 2014, the Surgeon General estimated that 2.2-5.0 million people were treated annually for NMSC. As the number of newly diagnosed skin cancers continues to rise, there is a need for additional preventative measures beyond sunscreens. Several newer topical products that focus on boosting DNA repair, modulating DNA transcription, decreasing inflammation and selectively targeting precancerous cells may play an important role in future skin cancer prevention.

Comparing the Resistance, Resilience, and Stability of Replicate Moving Bed Biofilm and Suspended Growth Combined Nitritation-Anammox Reactors

Combined partial nitritation-anammox (PN/A) systems are increasingly being employed for sustainable removal of nitrogen from wastewater, but process instabilities present ongoing challenges for practitioners. The goal of this study was to elucidate differences in process stability between PN/A process variations employing two distinct aggregate types: biofilm [in moving bed biofilm reactors (MBBRs)] and suspended growth biomass. Triplicate reactors for each process variation were studied under baseline conditions and in response to a series of transient perturbations. MBBRs displayed elevated NH₄⁺ removal rates relative to those of suspended growth counterparts over six months of unperturbed baseline operation but also exhibited significantly greater variability in performance. Transient perturbations led to strikingly divergent yet reproducible behavior in biofilm versus suspended growth systems. A temperature perturbation prompted a sharp reduction in NH₄⁺ removal rates with no accumulation of NO₂^- and rapid recovery in MBBRs, compared to a similar reduction in NH₄⁺ removal rates but a high level of accumulation of NO₂^- in suspended growth reactors. Pulse additions of a nitrification inhibitor (allylthiourea) prompted only moderate declines in performance in suspended growth reactors compared to sharp decreases in NH₄⁺ removal rates in MBBRs. Quantitative fluorescence in situ hybridization demonstrated a significant enrichment of anammox in MBBRs compared to suspended growth reactors, and conversely a proportionally higher AOB abundance in suspended growth reactors. Overall, MBBRs displayed significantly increased susceptibility to transient perturbations employed in this study compared to that of suspended growth counterparts (stability parameter), including significantly longer recovery times (resilience). No significant difference in the maximal impact of perturbations (resistance) was apparent. Taken together, our results suggest that aggregate architecture (biofilm vs suspended growth) in PN/A processes exerts an unexpectedly strong influence on process stability.

Abstract P3-03-05: Establishment and evaluation of ER+ breast cancer models using an optimized methodology for exogenous hormone delivery

Preclinical in vivo models of estrogen receptor positive (ER+) breast cancer rely on exogenous supplementation of hormones for growth. This requirement leads to animal toxicity and mortality over time, limiting development and drug testing in these types of models. Efficacy of test agents, particularly endocrine therapies, may also be altered in these models due to excessive hormone exposure, highlighting the need to improve methods for the establishment and testing of ER+ breast models.

We have developed an alternative method of hormone supplementation in ER+ breast cancer models and optimized this method for testing of endocrine therapies. Using two cell-based breast models, we demonstrated improved breast tumor take and time to tumor volume endpoint while reducing animal toxicity and mortality associated with standard hormone supplementation. Subsequent studies identified the lowest effective dose (LED) of supplement for hormone dependent model growth with a preclinically relevant time to tumor volume endpoint. Activity of endocrine therapies including tamoxifen, letrozole, fulvestrant and exemestane were compared at the standard and LED hormone concentrations. In these studies tamoxifen treatment resulted in tumor regressions which was not appreciably improved using the LED dose of supplement. However letrozole activity was improved in the LED study suggesting hormone supplementation can impact activity of some agents. Using this process we also generated a panel of ER+ patient-derived xenograft (PDX) models, including two novel hormone therapy responsive models from chemo-naïve or hormone therapy pretreated patients, designated ST986 and ST2177, respectively.

This improved method of hormone supplementation diminishes the adverse effects of standard hormone supplementation and provides utility for development of anticancer therapies in ER+ breast models.

Citation Format: Wick MJ, Vaught T, Meade J, Gamez L, Farley M, Tolcher AW, Rasco D, Patnaik A, Drengler RL, Rosenthal A, Papadopoulos KP. Establishment and evaluation of ER+ breast cancer models using an optimized methodology for exogenous hormone delivery. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P3-03-05.

Carfilzomib and the cardiorenal system in myeloma: an endothelial effect?

Carfilzomib (Cfz) has been associated with an ~5% incidence of unexplained and unpredictable cardiovascular toxicity in clinical trials. We therefore implemented a detailed, prospective, clinical cardiac and renal evaluation of 62 Cfz-treated myeloma patients, including serial blood pressure (BP), creatinine, troponin, NT-proBNP and pre- and post-treatment echocardiograms, including ejection fraction (EF), average global longitudinal strain and compliance. Pre-treatment elevations in NT-proBNP and BP, as well as abnormal cardiac strain were common. A rise in NT-proBNP occurred frequently post-treatment often without corresponding cardiopulmonary symptoms. A rise in creatinine was common, lessened with hydration and often reversible. All patients had a normal EF pre-treatment. Five patients experienced a significant cardiac event (four decline in EF and one myocardial infarction), of which 2 (3.2%) were considered probably attributable to Cfz. None were rechallenged with Cfz. The ideal strategy for identifying patients at risk for cardiac events, and parameters by which to monitor for early toxicity have not been established; however, it appears baseline echocardiographic testing is not consistently predictive of toxicity. The toxicities observed suggest an endothelial mechanism and further clinical trials are needed to determine whether or not this represents a class effect or is Cfz specific.

Shoulder symptoms and function in geriatric patients

BACKGROUND AND PURPOSE

Musculoskeletal problems, including shoulder pain, are common in the general population and are often cited as reasons for physician visits. Although many risk factors for shoulder pain are postulated, the effects of shoulder pain on functional level and perceived quality of life are poorly characterized in older adults. In this study, we set out to determine the prevalence and impact of shoulder symptoms and dysfunction in an older adult veteran population.

METHODS

A chart review, cross-sectional survey, and examination were performed. A sample of 93 individuals, aged 60 years or older, was recruited from a primary clinic outpatient waiting room at the Clement J. Zablocki VA Medical Center in Milwaukee, Wisconsin. Patients were asked about shoulder symptoms and self-assessed health and completed the Stanford Modified Health Assessment Questionnaire. A series of 3 shoulder maneuvers was used to assess shoulder mobility and pain. The presence of diabetes and statin use was documented. A more thorough chart review was performed on individuals who reported shoulder pain and disability.

RESULTS

Severe shoulder pain was common in the study group, reported by 31% of all participants. Functional limitation measured by the Modified Health Assessment Questionnaire and answering "yes" to greater difficulty performing daily tasks was associated with reduced internal rotation, which was present in almost 36% of all participants. Symptoms were often bilateral. No statistically significant risk factors emerged in this small sample, but suggestive trends were apparent. Interestingly, few patients reported discussing these problems with their providers, and shoulder-related problems were documented in only 10% of corresponding problem lists of symptomatic patients.

CONCLUSIONS

With an aging population, the high prevalence of shoulder pain may have considerable impact on public health. It will become increasingly important to define risk factors, delineate etiologies, and devise new management strategies for patients with symptomatic shoulder disease.

Sentinel lymph node status in vulval cancer: systematic reviews of test accuracy and decision-analytic model-based economic evaluation

BACKGROUND

Vulval cancer causes 3-5% of all gynaecological malignancies and requires surgical removal and inguinofemoral lymphadenectomy (IFL). Complications affect > 50% of patients, including groin wound infection, lymphoedema and cellulitis. A sentinel lymph node (SLN) is the first groin node with the highest probability of malignancy. SLN biopsy would be useful if it could accurately identify patients in whom cancer has spread to the groin, without removing all groin nodes. SLNs can be identified by isosulfan blue dye and/or technetium-99 ((99m)Tc) radioactive tracer during lymphoscintigraphy. The blue dye/(99m)Tc procedure only detects SLN, not metastases - this requires histological examination, which can include ultrastaging and staining with conventional haematoxylin and eosin (H&E) or immunohistochemistry.

OBJECTIVES

To determine the test accuracy and cost-effectiveness of the SLN biopsy with (99m)Tc and/or blue dye compared with IFL or clinical follow-up for test negatives in vulval cancer, through systematic reviews and economic evaluation.

DATA SOURCES

Standard medical databases, including MEDLINE, EMBASE, Science Citation Index and The Cochrane Library, medical search gateways, reference lists of review articles and included studies were searched to January 2011.

METHODS

For accuracy and effectiveness, standard methods were used and reported according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Searches were to January 2011, with no language restrictions. Meta-analyses were carried out with Meta-Disc version 1.4 (Javier Zamora, Madrid, Spain) for accuracy; none was appropriate for effectiveness. The economic evaluation from a NHS perspective used a decision-tree model in DATA TreeAge Pro Healthcare 2001 (TreeAge Software, Inc., Williamstown, MA, USA). Six options (blue dye with H&E, blue dye with ultrastaging, (99m)Tc with H&E, (99m)Tc with ultrastaging, blue dye/(99m)Tc with H&E, blue dye/(99m)Tc with ultrastaging) were compared with IFL. Deterministic and probabilistic sensitivity analyses were conducted.

RESULTS

For accuracy, of the 26 included studies, most evaluated (99m)Tc/blue dye combined. Four studies had clinical follow-up only for test negatives and five had clinical follow-up for all and IFL for test negatives. Numbers with no SLN found were difficult to distinguish from those with negative SLN biopsies. The largest group of 11 studies using (99m)Tc/blue dye, ultrastaging and immunohistochemistry had a pooled sensitivity of 95.6% [95% confidence interval (CI) 91.5% to 98.1%] and a specificity of 100% (95% CI 99.0% to 100%). Mean SLN detection rates were 94.6% for (99m)Tc, 68.7% for blue dye and 97.7% for both. One study measured global health status quality of life (QoL) and found no difference between SLN biopsy and IFL. One patient preference evaluation showed that 66% preferred IFL rather than a 5% false-negative rate from SLN biopsy. For effectiveness, of 14,038 references, one randomised controlled trial, three case-control studies and 13 case series were found. Approximately 50% died from vulval cancer and 50% from other causes during follow-ups. Recurrences were in the ratio of approximately 4 : 2 : 1 vulval, groin and distant, with more recurrences in node-positive patients. No studies reported QoL. For cost per death averted, IFL was less costly and more effective than strategies using SLN biopsy. For morbidity-free survival and long-term morbidity-free survival, (99m)Tc with ultrastaging was most cost-effective. Strategies with blue dye only and H&E only were never cost-effective. The incremental cost-effectiveness ratio for (99m)Tc with ultrastaging compared with IFL was £4300 per case of morbidity-free survival and £7100 per long-term morbidity-free survival.

LIMITATIONS

The main limitations of this study include the lack of good-quality evidence on accuracy, effectiveness and QoL. A large project such as this takes time to publish, so the most recent studies are not included.

CONCLUSIONS

A sensitive and specific combined metastatic SLN detection test and information on generic QoL in vulval cancer is urgently required.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Effect of citral and carvacrol on the susceptibility of Listeria monocytogenes and Listeria innocua to antibiotics

The aim of this study was to evaluate the antibiotic susceptibility of Listeria innocua (L. innocua) and Listeria monocytogenes (L. monocytogenes) cells in the presence of citral and carvacrol at sublethal concentrations in an agar medium. The presence of terpenes in the L. monocytogenes and L. innocua culture medium provided a reduction in the minimal inhibitory concentration (MIC) of all the antibiotics tested. These effects were dependent on the concentration of terpenes present in the culture medium. The combination of citral and carvacrol potentiated antibiotic activity by reducing the MIC values of bacitracin and colistin from 32.0 and 128.0 μg ml⁻¹ to 1.0 and 2.0 μg ml⁻¹, respectively. Thus, both Listeria species became more susceptible to these drugs. In this way, the colistin and bacitracin resistance of L. monocytogenes and L. innocua was reversed in the presence of terpenes. Results obtained in this study show that the phytochemicals citral and carvacrol potentiate antibiotic activity, reducing the MIC values of cultured L. monocytogenes and L. innocua.

SIGNIFICANCE AND IMPACT OF THE STUDY

Phytochemicals citral and carvacrol potentiate antibiotic activity of erythromycin, bacitracin and colistin by reducing the MIC values of cultured Listeria monocytogenes and Listeria innocua. This effect in reducing the MIC values of the antibiotics tested in both micro-organisms was increased when natural antimicrobials were combined. This finding indicated that the combination among terpenes and antibiotic may contribute in reducing the required dosage of antibiotics due to the possible effect of terpenes on permeation barrier of the micro-organism cell membrane.

Modulation of neurotrophin signaling by monoclonal antibodies

The neurotrophin family is comprised of the structurally related secreted proteins nerve growth factor (NGF), brain-derived neurotrophic factor (BDNF), neurotrophin-3 (NT-3), and neurotrophine-4 (NT-4). They bind and activate the tyrosine kinase receptors Trk A, B, and C in a ligand-specific manner and additionally bind a shared p75NTR receptor. The neurotrophins were originally defined by their ability to support the survival and maturation of embryonic neurons. However, they also control important physiological functions of the adult nervous system including learning and memory, sensation, and energy homeostasis. For example, NGF/trkA signaling is critical for normal and pathological sensation of pain. Likewise, the BDNF/trkB pathway controls feeding and metabolism, and its dysfunction leads to severe obesity. Antibodies can modulate neurotrophin signaling. Thus, NGF blocking agents can attenuate pain in several animal models, and a recombinant humanized NGF blocking antibody (Tanezumab) has shown promising results in human clinical trials for osteoarthritic pain. On the other hand trkB agonist antibodies can modulate food intake and body weight in rodents and nonhuman primates. The power of monoclonal antibodies to modulate neurotrophin signaling promises to turn the rich biological insights into novel human medicines.

Prediction of acid lactic-bacteria growth in turkey ham processed by high hydrostatic pressure

High hydrostatic pressure (HHP) has been investigated and industrially applied to extend shelf life of meat-based products. Traditional ham packaged under microaerophilic conditions may sometimes present high lactic acid bacteria population during refrigerated storage, which limits shelf life due to development of unpleasant odor and greenish and sticky appearance. This study aimed at evaluating the shelf life of turkey ham pressurized at 400 MPa for 15 min and stored at 4, 8 and 12 °C, in comparison to the non pressurized product. The lactic acid bacteria population up to 10(7) CFU/g of product was set as the criteria to determine the limiting shelf life According to such parameter the pressurized sample achieved a commercial viability within 75 days when stored at 4 °C while the control lasted only 45 days. Predictive microbiology using Gompertz and Baranyi and Roberts models fitted well both for the pressurized and control samples. The results indicated that the high hydrostatic pressure treatment greatly increased the turkey ham commercial viability in comparison to the usual length, by slowing down the growth of microorganisms in the product.

Experimental evaluation of the nitrite sensitivity coefficient in granular anammox biomass

Nitrite is widely reported to inhibit anammox activity and growth. One modeling approach for nitrite impairment of anammox growth is the use of a nitrite sensitivity coefficient which increases the endogenous decay coefficient of anammox bacteria proportionally to nitrite concentration. The objective of this study was to measure nitrite concentration profiles within active anammox granules incubated at fixed bulk nitrite concentrations and to compare these with nitrite concentration profiles predicted by a biofilm model that incorporates the nitrite sensitivity coefficient. We developed an apparatus for the repeated measurement of nitrite concentration profiles along the radius of granular anammox biomass over a period of 6 days at fixed bulk nitrite concentrations. Granular anammox biomass was obtained from a two-stage bench-scale partial nitritation/anammox reactor system. There was no apparent effect of nitrite concentration on nitrite utilization kinetics after 6 days at exposures up to 90 mg NO(2)(-)-N/L. These findings suggest that anammox bacteria tolerate extended exposures to elevated nitrite concentrations, and in its present form, the nitrite sensitivity coefficient is not applicable for anammox growth modeling.

Limb activation ameliorates body-related deficits in spatial neglect

Many neglect patients show deficits in the mental representation of their contralesional body side or body parts, termed personal neglect. These deficits include impairments in identifying body parts on schematic drawings of human bodies. Limb activation and alertness cues have been shown to modulate neglect transiently, and are effective treatments for several symptoms of the neglect syndrome. Here, we tested on eight patients with right-hemispheric stroke and left-sided spatial neglect whether these two techniques modulate deficits in the mental representation of hands, assessed with a hand-test in which the subjects had to decide whether a depicted schematic hand belongs to the left or right side of the human body. The results showed that neglect patients made marginally significant (p = 0.065) more errors in left-hand-decisions than right-hand-decisions, indicating a neglect-specific disorder. Moreover, we found that left-sided limb activation but not non-lateralized alertness cueing (a loud noise immediately before patients made their perceptual decision) significantly reduced misidentifications for depicted left hands as compared to baseline. No effect of any intervention was observed on error rates for depicted right hands. We conclude that the amelioration of the performance in the hand task is modulated by the activation of the body schema or other body representations through left-sided limb activation.