Benchmarking non-attendance patterns in paediatric medical imaging: A retrospective cohort study spotlighting First Nations children

INTRODUCTION

Non-attendance at Medical Imaging (MI) appointments can result in inefficiencies in healthcare resource allocation, increased financial burdens, and lead to potential barriers to effective healthcare delivery. We evaluated factors associated with non-attendance of MI appointments for children including variables: gender; age groups; residential postcodes; Indigenous status; appointment dates; appointment reminders and socio-economic status.

METHOD

Retrospective cohort study of children with scheduled MI appointments at a Tertiary paediatric hospital in Australia, between January and December 2022. Data were extracted from the Radiology Information System and integrated with socio-economic census data through linking with postcode. Chi-squared, and logistic regression analysis were performed to identify significant predictors of non-attendance.

RESULTS

Out of 17,962 scheduled outpatient appointments, 6.2 % did not attend. Males were less likely to attend than females (7.3 % vs. 5.8 %; p < 0.001). Older children had the highest frequency of non-attendance (p < 0.001). First Nations identified children had a higher likelihood of non-attendance at 14.5 % compared to non-First Nations at 5.8 %, and the odds ratio (OR) of First Nation children not attending was 2.54 (CI 2.13-3.03; p < 0.001) higher than non-First Nations children. Children from areas of disadvantage were less likely to attend (p < 0.001). Bone mineral densitometry had the highest odds of non-attendance (19.4 % of bookings) compared to other imaging modalities (p < 0.001).

CONCLUSION

The following characteristics were associated with non-attendance: older male gender, residing in areas of socio-economic disadvantage, or identifying as First Nations Australians. By reviewing these findings with the cultural and professional experience of our Indigenous co-author, we have identified some strategies for improving attendance amongst First Nations children.

IMPLICATIONS FOR PRACTICE

Factors associated with non-attendance, or "missed opportunities for care", provide opportunities for intervention to improve attendance for vulnerable groups of children who require medical imaging.

GrassGroTM simulation of pasture, animal performance and greenhouse emissions on low and high sheep productivity grazing systems: 1-year validation and 25-year analysis

Globally, there is a focus on reducing the absolute methane (CH4) and nitrous oxide emissions, and the emissions intensity (EI, kg CO2e/kg animal product) of livestock production. Increasing the productivity of mixed pasture systems has the potential to increase food (e.g., lamb) and textile fibre (e.g., wool) production while reducing the EI of those products from grazing livestock. The objective of this study was to quantify the differences in greenhouse gas (GHG) emissions and EI between sheep on Low (i.e., low sustainable stocking rate) and High (i.e., high sustainable stocking rate) productivity grazing systems (PGSs). Therefore, a replicated breeding-ewe trial on 18 paddocks was established across 2 - years. Three flocks on Low (3 × 16 ewes/flock) and High PGSs (3 × 32 ewes/flock) rotated across three land-classes and three paddocks per PGS. In year 1, the observed on-farm pasture quantity, quality, and botanical composition, together with lamb BW (kg), and daily CH4 production (DMP, g CH4/head per day) using Open Path Fourier Transformed Infrared (OP-FTIR) spectrometers data were measured. Subsequently, two simulations using GrassGroTM were conducted: (1) a 1-year GrassGroTM simulation that used the observed on-farm data to adjust parameters: date of mating, paddock fertility, and weight of mature ewes to validate GrassGroTM predictions to achieve accuracy and precision targets; and (2) a 25-year (1986-2011) simulation to analyse the effects of Low and High PGSs on sheep production and GHG emissions across a variable climate. The 1-year validation predictions fitted well with the observed on-farm data for: pasture biomass (kg/ha), DM digestibility (%), botanical composition (kg/ha), lamb (kg) product, and DMP (g CH4/head per day). The subsequent predicted results from the 25-year GrassGroTM simulation showed minimal effect of PGS on the mean DM intake (kg DM/day) or DMP for Low and High PGSs, but this was thought to be due to the biomass in both PGSs exceeding 1 500 kg DM/ha. The EI, over the 25-year simulation, on the High PGS was 16.5% lower than the Low PGS. Additional calculations of DMP were conducted using a recent global equation, giving estimates of DMP that closely matched the observed on-farm OP-FTIR DMP measurements, but these were lower than the GrassGroTM predictions and improved the accuracy and precision. It is concluded that in some pasture situations, managing pastures and stock numbers to intensify grazing systems can allow increased livestock production, without increasing daily CH4 emissions/head while substantially decreasing the EI of the animal products generated.

Monobody adapter for functional antibody display on nanoparticles for adaptable targeted delivery applications

Vascular endothelial cells (ECs) play a central role in the pathophysiology of many diseases. The use of targeted nanoparticles (NPs) to deliver therapeutics to ECs could dramatically improve efficacy by providing elevated and sustained intracellular drug levels. However, achieving sufficient levels of NP targeting in human settings remains elusive. Here, we overcome this barrier by engineering a monobody adapter that presents antibodies on the NP surface in a manner that fully preserves their antigen-binding function. This system improves targeting efficacy in cultured ECs under flow by >1000-fold over conventional antibody immobilization using amine coupling and enables robust delivery of NPs to the ECs of human kidneys undergoing ex vivo perfusion, a clinical setting used for organ transplant. Our monobody adapter also enables a simple plug-and-play capacity that facilitates the evaluation of a diverse array of targeted NPs. This technology has the potential to simplify and possibly accelerate both the development and clinical translation of EC-targeted nanomedicines.

The UK AVATAR 1 and 2 Trials for People with Distressing Voices – Findings and Learning from AVATAR1, and AVATAR2 Developments in Theory and Therapy

Introduction

Many people suffering from psychotic disorders report persistent auditory verbal hallucinations (‘voices’) despite pharmacological and psychological therapy. Interest is growing in approaches that emphasise the personal relationship between the patient and their voice(s). AVATAR therapy is one such approach that uses a digital representation (avatar) of a selected voice to facilitate a three-way discussion between patient, therapist and voice, the therapist speaking either as him/herself or in the digitally transformed voice of the avatar. Objectives: To describe AVATAR therapy and an ongoing multi-centre clinical trial. Methods: Encouraging findings from an earlier controlled trial (AVATAR1) comparing AVATAR therapy and supportive counselling informed our current multi-site cost-effectiveness trial of brief and extended versions of the therapy compared to treatment as usual (AVATAR2). Results: AVATAR1 delivered in 7 weekly sessions resulted in a reduction in the frequency, distress and power of voices that was significantly superior to supportive counselling. Clinical experience suggested that some participants improved in response to the early focus on anxiety while others seemed more responsive to later more formulation-driven approach. These findings led us to the current ongoing three arm clinical trial comprising a brief (6 session) focus on anxiety/assertiveness, an extended (12 session) formulation-driven approach both approaches compared to treatment as usual. Conclusion: Previous AVATAR studies suggest this is a therapy with considerable promise. It can be delivered through widely available laptop computers, usually in clinic but also remotely via existing commercial platforms. The current trial will address questions about dissemination, training and cost-effectiveness in NHS settings.

Disclosure

The digital technology employed in AVATAR therapy is provided by licence for the trial from Avatar Therapy Ltd

The Emirates Mars Mission

The Emirates Mars Mission (EMM) was launched to Mars in the summer of 2020, and is the first interplanetary spacecraft mission undertaken by the United Arab Emirates (UAE). The mission has multiple programmatic and scientific objectives, including the return of scientifically useful information about Mars. Three science instruments on the mission's Hope Probe will make global remote sensing measurements of the Martian atmosphere from a large low-inclination orbit that will advance our understanding of atmospheric variability on daily and seasonal timescales, as well as vertical atmospheric transport and escape. The mission was conceived and developed rapidly starting in 2014, and had aggressive schedule and cost constraints that drove the design and implementation of a new spacecraft bus. A team of Emirati and American engineers worked across two continents to complete a fully functional and tested spacecraft and bring it to the launchpad in the middle of a global pandemic. EMM is being operated from the UAE and the United States (U.S.), and will make its data freely available.

Management of well appearing infants born to afebrile mothers with inadequate GBS prophylaxis: A retrospective comparison of the three approaches recommended by the COFN

BACKGROUND

There are three different approaches set forth by the Committee on the Fetus and Newborn (COFN) for managing asymptomatic neonates born to mothers with inadequate intrapartum antibiotic prophylaxis (IAP) for early-onset Group B Strep (GBS) infection. The first approach is that of categorical risk factor assessments, and recommends that asymptomatic infants born to afebrile mothers with inadequate IAP for GBS be monitored with clinical observation for 36-48 hours. The second approach recommends serial physical examinations and vital signs for 36-48 hours to closely monitor changes in clinical condition for all patients. The Kaiser Permanente EOS risk calculator (SRC) is an example of the third approach, a multivariate risk assessment, and it takes into consideration several perinatal risk factors. This multivariate risk assessment then provides recommendations for reassessment and management based on presume risk of the infant developing or having Early Onset Sepsis (EOS). The aim of our study was to compare these three recently published recommendations from the COFN for the management of asymptomatic neonates born to afebrile mothers with inadequate IAP for GBS.

STUDY DESIGN

This is a retrospective study of asymptomatic neonates with gestational age ≥35 weeks born to afebrile mothers with indicated inadequate IAP for GBS between April 2017 and July 2020. Management recommendations of the SRC were compared to the recommendations of categorical risk assessment and risk assessment based on clinical condition.

RESULTS

A total of 7,396 infants were born during the study period, 394 (5.3%. to mothers with inadequate IAP. Recommendations for these infants according to both the categorical risk factor guideline and the clinical condition guideline include extended, close observation. However, the SRC recommended routine newborn care for 99.7%.f these infants. None of the infants developed EOS.

CONCLUSION

The SRC recommend routine neonatal care without enhanced and prolonged observation for nearly all asymptomatic infants born to afebrile mothers with inadequate IAP. As none of the infants in this cohort had EOS, further studies in a larger cohort are needed to establish the safety of SRC in neonates born to mothers with inadequate IAP.

Management of infants born to mothers with chorioamnionitis: A retrospective comparison of the three approaches recommended by the committee on fetus and newborn

BACKGROUND

Based on the most recently published recommendations from the Committee on the Fetus and Newborn (COFN), three approaches currently exist for the use of risk factors to identify infants who are at increased risk of early-onset sepsis (EOS). Categorical risk factor assessments recommend laboratory testing and empiric antibiotic therapy for all infants born to mothers with a clinical diagnosis of chorioamnionitis. Risk assessments based on clinical condition recommend frequent examinations and close vital sign monitoring for infants born to mothers with chorioamnionitis. The Kaiser Permanente EOS risk calculator (SRC) is an example of the third approach, multivariate risk assessments. The aim of our study was to compare the three risk stratification approaches recommended by the COFN for management of chorioamnionitis-exposed infants.

METHODS

Retrospective study of 1,521 infants born ≥35 weeks to mothers with chorioamnionitis. Management recommendations of the SRC were compared to the recommendations of categorical risk assessment and risk assessment based on clinical condition (CCA).

RESULTS

Hypothetical application of SRC and CCA resulted in 79.6% and 76.8-85.1% respectively fewer infants allocated empiric antibiotic therapy. While CCA recommended enhanced observation for all chorioamnionitis-exposed infants, SRC recommended routine care without enhanced observation in 44.3% infants. For the six infants (0.39%) with EOS, SRC and CCA recommended empiric antibiotics only for three symptomatic infants.

CONCLUSION

The SRC and CCA can reduce antibiotic use but potentially delay antibiotic treatment. The SRC does not recommend enhanced observation with frequent and prolonged vital signs for >44% of chorioamnionitis-exposed infants.

Digital health screening tool for identification of elder mistreatment

PURPOSE

It is estimated that 15.7% of people aged 60 years and older were subjected to some form of Elder Mistreatment (EM) globally (Yon et al., 2017). In the USA, as many as 1 in 24 EM cases are left unidentified by professionals, with a 300% increased mortality risk for older adults who do not receive help (National Center on Elder Abuse, n.d.; Dong, 2009). Current methods of screening tend to miss less obvious signs of EM and may discourage older adults from disclosing EM, due to either a lack of understanding of what constitutes mistreatment or fear of retaliation from the perpetrator.

METHOD

Our approach shifts the focus of EM identification to the older adults themselves through an automated tablet-based tool. The Virtual cOaching in making Informed Choices on Elder Mistreatment Self-Disclosure (VOICES) tool includes various multimedia components such as videos, audio, and animations designed to educate and enhance screening. Patients screened as positive are guided through a Brief Negotiated Interview (BNI) utilizing motivational interviewing to assist in self-identification (recognize that they are experiencing elder mistreatment) or self-disclosure (inform others about their elder mistreatment experiences). During tool development, we conducted a qualitative study to evaluate the perceived value and likelihood of adopting a tablet-based approach to facilitate screening and self-disclosure of EM in the ED. We held 3 focus groups with stakeholders, including 24 adults 60 years or over, 2 social workers, 2 caregivers, and 2 ED clinicians. We used the findings from the focus groups and User-Centered Design approach (UCD) to develop the tablet-based screening tool. Once the tool was ready, we tested its usability and acceptability with 14 older adults.

RESULTS AND DISCUSSION

Focus group participants supported use of a tablet-based tool to screen for EM, indicating that digital screening benefits from feelings of privacy and anonymity. On a 7-point Likert scale ranging from "1=Very Comfortable" to "7=Very Uncomfortable", older adults scored 2.8 on average for whether they would feel comfortable using a tablet device to screen for EM. Prominent suggestions made by older adults included using a female voice for the tool narrator, larger font size, more multimedia, headphones for privacy; and having someone available during screening for assistance if needed. Participants indicated that it is difficult for older adults experiencing EM to ask for help and that any type of mistreatment screening would be helpful. They also highlighted the need to explain community resources available to older adults once EM is disclosed, especially resources offering help to the caregiver. Participants of the usability evaluation rated the tool a mean score of 86.6 (median= 88.8, iQR =18.1) on the System Usability Scale (SUS), far above the benchmark SUS score of 68, which indicates that the system is "good" or "acceptable" (Bangor et al., 2008). Shifting the focus from the provider to the older adult may encourage self-disclosure of EM by addressing major barriers to traditional screening processes. In summary, this study supported the use of self-administered automated tablet-based screening for EM. Participants generally believed that the use of digital health tools to facilitate the screening process would be beneficial in the ED setting.

THU0586 ESTABLISHING THE KEY COMPONENTS OF A EULAR PORTFOLIO FOR TRAINING IN RHEUMATOLOGY: A EULAR SCHOOL OF RHEUMATOLOGY INITIATIVE

Background:

In clinical training, a portfolio is expected to stimulate learning and encourage critical reflection. Some, but not all, European countries use a portfolio in rheumatology training, and their scope varies widely. A EULAR portfolio for Rheumatology trainees could contribute to improve overall training, raise educational standards, foster the setting of common goals and harmonize rheumatology training across countries.

Objectives:

Develop key components that should be included in a EULAR portfolio of Rheumatology.

Methods:

A working group (WG) composed of 9 rheumatologists and 1 educationalist was established. A systematic literature review (SLR) was conducted in November 2018, according to the PIM structure: Population: trainees; Instrument of interest: portfolio; Measurement of properties of interest: content portfolio. A survey was disseminated among the WG group and WG members of the EMerging EUlar NETwork (EMEUNET), inquiring about the content and structure of existing national portfolios. Portfolio materials of selected countries were reviewed. Last, the WG elected the key components of the portfolio.

Results:

13/2,034 articles were included in the SLR (12 high/1 moderate risk of bias). Information on direct observation of procedural skills (DOPS) (9/13), personal reflections (8/13), learning goals (5/13) and multisource feedback (5/13) were most often included in the portfolio. Twenty-five respondents filled out the survey (response rate ≈ 50%). Reflective writing (n=7), learning goals (n=4) and feedback (n=4) were considered the most useful components of a portfolio. About half indicated that a portfolio was a bureaucratic burden; 4 respondents mentioned lack of feedback by supervisors as a barrier. Portfolio materials of 7 European countries were reviewed. Several portfolios (Germany, Italy, Greece and Spain) were logbooks, i.e. a record of clinical activities. Other portfolios (UK, Denmark, The Netherlands) also included information on workplace-based assessments, learning goals, and personal reflections. The proposed key components of the portfolio are included in Table 1.

Table 1.

Key components of the EULAR portfolio of Rheumatology.

Key componentContentCurriculum vitaePersonal record of achievements, experiences, knowledge and skillsPersonal Development PlanLearning goals and action planClinical workInformation on managing patients (e.g. rheumatoid arthritis)Skills (e.g. joint aspiration)Assessments (summative and formative)Personal reflectionsProfessional behaviourMultisource feedbackPersonal reflectionsEducationContinuing professional development, list of formal and non-formal learning activitiesAssessments (e.g. teaching assessment, evidence based medicine assignment)Personal reflectionsResearchList of abstracts, published articlesInformation on research funding, scholarships, bursaries, academic posts

Conclusion:

This initiative resulted in the establishment of a list of key components to be included in a EULAR portfolio of Rheumatology. Assessment forms for each key portfolio component are currently being developed. Portfolio implementation, particularly in countries that do not use it yet, may contribute significantly to promote a higher standard of patient care across Europe.

Disclosure of Interests:

Marloes van Onna: None declared, Sofia Ramiro Grant/research support from: MSD, Consultant of: Abbvie, Lilly, Novartis, Sanofi Genzyme, Speakers bureau: Lilly, MSD, Novartis, Catherine Haines: None declared, M. Holland-Fischer: None declared, José Antonio P. da Silva Grant/research support from: Pfizer, Abbvie, Consultant of: Pfizer, AbbVie, Roche, Lilly, Novartis, Jean Dudler: None declared, Christopher Edwards Grant/research support from: Abbvie, Biogen, Roche, Consultant of: Abbvie, Samsung, Speakers bureau: Abbvie, BMS, Biogen, Celgene, Fresenius, Gilead, Janssen, Lilly, Mundipharma, Pfizer, MSD, Novartis, Roche, Samsung, Sanofi, UCB,

Alessia Alunno: None declared, Elena Nikiphorou: None declared, L. Falzon: None declared, Francisca Sivera: None declared

OP0179 USEFUL STUDY I: A MULTICENTRE LONGITUDINAL STUDY TO TEST WHETHER ULTRASOUND CAN IDENTIFY PATIENTS WITH MUSCULOSKELETAL SYMPTOMS OF LUPUS WITH BETTER RESPONSE TO THERAPY

Background:

In SLE, musculoskeletal manifestations impact on quality of life and trial outcomes. We previously showed that assessments based on joint swelling lack sensitivity, specificity and responsiveness compared to ultrasound (US).

Objectives:

To determine clinical features predicting US synovitis and whether patients with US synovitis respond better to therapy

Methods:

SLE patients were recruited if the referring physician deemed they had inflammatory pain warranting treatment. Swollen joints were not required. At baseline, physicians recorded features of inflammation, concurrent fibromyalgia and osteoarthritis. Stable doses of prednisolone (≤5mg/day), antimalarials or immunosuppressants were allowed. Participants received depomedrone 120mg IM then were assessed at 0, 2 and 6 weeks for 66/68 swollen and tender joint counts, BILAG-2004, SLEDAI-2K, physician global and MSK-VAS, inflammatory markers, patient pain and disease activity-VAS, HAQ-DI, LupusQoL, US of hands and wrists (blinded to patient and clinical assessor). An internal pilot determined the primary endpoint:(Early Morning stiffness-VAS (EMS-VAS) at 2 weeks (adjusted for baseline) between patients with US-synovitis (GS≥2 or PD≥1 in ≥1 joint) vs. normal US at baseline. 20% difference was considered clinically meaningful. Sensitivity analyses adjusted for prednisolone and immunosuppressants.

Results:

122/133 patients completed all visits. There was significant disagreement between clinical examination and US. 78/133 had US synovitis; 68% of these had ≥1 swollen joint. Of 66/133 patients with ≥ 1 swollen joint, 20% had normal US. US-synovitis was more likely with joint swelling, a symmetrical small joint distribution and active serology. Physician-determined EMS, other lupus features or prior response to therapy were not associated. Fibromyalgia or osteoarthritis did not reduce the probability of US synovitis.

In the full analysis set (n=133) there was no difference in EMS VAS at 2 weeks according to US synovial status at baseline (difference -8mm, 95% CI -19, 4mm, p=0.178). 32 patients had fibromyalgia. After excluding them, we found a statistically and clinically significantly better clinical response to depomedrone in patients with US-synovitis at baseline (baseline-adjusted EMS VAS at 2 weeks -12mm, 95% CI -24, 0mm, p=0.049). This difference was greater in the treatment-adjusted sensitivity analysis (-12.8 (95% CI -22, -3mm), p=0.007) and the per-protocol-adjusted sensitivity analysis (-14.8mm (95% CI -20.8, -8.8mm), p<0.001). Patient with US synovitis had higher rates of improvement in the MSK BILAG-2004 (56% vs. 26%, p=0.09) and SLEDAI-2K (37% vs. 15%, p=0.03).

Conclusion:

In lupus arthritis, distribution and serology, but not other features, help identify US-synovitis. US-synovitis was independent of features of fibromyalgia, but fibromyalgia confounded assessment of clinical response. US should be used to select SLE arthritis patients for therapy and clinical trials, especially when there are inflammatory symptoms without swollen joints.

Acknowledgments:

The Project was funded by Lupus-UK

Disclosure of Interests:

Khaled Mahmoud: None declared, Ahmed Zayat: None declared, Md Yuzaiful Md Yusof: None declared, Katherine Dutton: None declared, Lee-Suan Teh: None declared, Chee-Seng Yee: None declared, David d’cruz Grant/research support from: GlaxoSmithKline, Nora Ng: None declared, David Isenberg Consultant of: Study Investigator and Consultant to Genentech, Coziana Ciurtin Grant/research support from: Pfizer, Consultant of: Roche, Modern Biosciences, Philip G Conaghan Consultant of: AbbVie, BMS, Eli Lilly, EMD Serono, Flexion Therapeutics, Galapagos, GSK, Novartis, Pfizer, Speakers bureau: AbbVie, Eli Lilly, Novartis, Pfizer, Paul Emery Grant/research support from: AbbVie, Bristol-Myers Squibb, Merck Sharp & Dohme, Pfizer, Roche (all paid to employer), Consultant of: AbbVie (consultant, clinical trials, advisor), Bristol-Myers Squibb (consultant, clinical trials, advisor), Lilly (clinical trials, advisor), Merck Sharp & Dohme (consultant, clinical trials, advisor), Novartis (consultant, clinical trials, advisor), Pfizer (consultant, clinical trials, advisor), Roche (consultant, clinical trials, advisor), Samsung (clinical trials, advisor), Sandoz (clinical trials, advisor), UCB (consultant, clinical trials, advisor), Christopher Edwards Grant/research support from: Abbvie, Biogen, Roche, Consultant of: Abbvie, Samsung, Speakers bureau: Abbvie, BMS, Biogen, Celgene, Fresenius, Gilead, Janssen, Lilly, Mundipharma, Pfizer, MSD, Novartis, Roche, Samsung, Sanofi, UCB, Elizabeth Hensor: None declared, Edward Vital Grant/research support from: AstraZeneca, Roche/Genentech, and Sandoz, Consultant of: AstraZeneca, GSK, Roche/Genentech, and Sandoz, Speakers bureau: Becton Dickinson and GSK

FRI0599 USEFUL II: DERIVATION OF THE LUPUS ARTHRITIS AND MUSCULOSKELETAL DISEASE ACTIVITY SCORE (LAMDA) USING DATA FROM A MULTICENTRE LONGITUDINAL STUDY

Background:

Musculoskeletal (MSK) disease is the commonest manifestation of SLE. We showed that the MSK components of the BILAG index and SLEDAI have limited sensitivity, specificity and responsiveness compared to ultrasound (US) synovitis. The USEFUL study evaluated response to glucocorticoids in SLE patients with inflammatory pain.

Objectives:

To develop a disease activity tool for lupus MSK manifestations that is continuous, responsive, sensitive, and correlates with US-synovitis

Methods:

133 patients who received depomedrone 120mg IM were assessed at 0, 2 and 6 weeks for 66/68 swollen and tender joint counts, BILAG2004 index, SLEDAI-2K, physician global and MSK-VAS, inflammatory markers, patient pain and disease activity-VAS. Total US score (OMERACT-EULAR) in the hands and wrists was calculated blinded to patient and clinical assessor. Patients reported overall response using a Likert scale.

The LAMDA was developed by modelling a core set of clinical variables against total US score using penalized (Lasso) regression. Responsiveness was compared between LAMDA and other variables at week 6 using effect sizes. Minimum clinically important difference (MCID) was explored using the SEM and minimal disease activity threshold using ROC.

Results:

The variables selected for the LAMDA score were swollen joint count, patient MSK pain VAS, physician MSK disease activity VAS and ESR. A continuous score was derived. This had a theoretical range from 0 to 26.5 based on maximum ESR of 100. The highest value observed in USEFUL was 15. LAMDA was significantly higher in patients with active US (mean (SD) 5.71 (2.67), n=78) compared to patients with normal US (3.27 (1.77), n=55; difference (95% CI) -2.45 (-3.26, -1.63), t=-5.93, p<0.001). This difference remained significant in patients with no swollen joints (difference (95% CI) -0.71 (-1.40, -0.02), t=-2.06, p=0.044).

Effect size was greater for the LAMDA (0.37) than the BILAG-MSK (0.31), SLEDAI-MSK (0.27) and total US score (0.33). In patients with active US at baseline, LAMDA’s effect size was 0.42.

The MCID was 0.71 and correlated with patient-reported change in pain. A threshold for minimal disease activity of 3.23 optimized sensitivity (0.77 (0.65, 0.89)) and specificity (0.80 (0.68, 0.92)) against US score >0.

Conclusion:

The LAMDA score is a novel continuous disease activity instrument for MSK manifestations of SLE derived from variables familiar to rheumatologists. The LAMDA score is sensitive to imaging detected synovitis without swelling and more responsive than other instruments. . LAMDA may improve the ability of clinicians to accurately determine therapeutic efficacy in clinical trials and practice. Future work will validate the LAMDA score in independent cohorts and randomized trials.

Acknowledgements:

This project was funded by Lupus UK

Disclosure of Interests:

Khaled Mahmoud: None declared, Ahmed Zayat: None declared, Md Yuzaiful Md Yusof: None declared, Coziana Ciurtin Grant/research support from: Pfizer, Consultant of: Roche, Modern Biosciences, Chee-Seng Yee: None declared, David Isenberg Consultant of: Study Investigator and Consultant to Genentech, Lee-Suan Teh: None declared, Katherine Dutton: None declared, David d’cruz Grant/research support from: GlaxoSmithKline, Nora Ng: None declared, Philip G Conaghan Consultant of: AbbVie, BMS, Eli Lilly, EMD Serono, Flexion Therapeutics, Galapagos, GSK, Novartis, Pfizer, Speakers bureau: AbbVie, Eli Lilly, Novartis, Pfizer, Paul Emery Grant/research support from: AbbVie, Bristol-Myers Squibb, Merck Sharp & Dohme, Pfizer, Roche (all paid to employer), Consultant of: AbbVie (consultant, clinical trials, advisor), Bristol-Myers Squibb (consultant, clinical trials, advisor), Lilly (clinical trials, advisor), Merck Sharp & Dohme (consultant, clinical trials, advisor), Novartis (consultant, clinical trials, advisor), Pfizer (consultant, clinical trials, advisor), Roche (consultant, clinical trials, advisor), Samsung (clinical trials, advisor), Sandoz (clinical trials, advisor), UCB (consultant, clinical trials, advisor), Christopher Edwards Grant/research support from: Abbvie, Biogen, Roche, Consultant of: Abbvie, Samsung, Speakers bureau: Abbvie, BMS, Biogen, Celgene, Fresenius, Gilead, Janssen, Lilly, Mundipharma, Pfizer, MSD, Novartis, Roche, Samsung, Sanofi, UCB, Elizabeth Hensor: None declared, Edward Vital Grant/research support from: AstraZeneca, Roche/Genentech, and Sandoz, Consultant of: AstraZeneca, GSK, Roche/Genentech, and Sandoz, Speakers bureau: Becton Dickinson and GSK

THU0134 COGNITIVE IMPAIRMENT IN RHEUMATOID ARTHRITIS

Background:

Increasing evidence suggests that systemic inflammation may be associated with an increased risk of developing cognitive dysfunction and Alzheimer’s disease (AD). Some studies have found an association between rheumatoid arthritis (RA) and neurodegeneration with several finding increased incidence of mild cognitive impairment (MCI) in those with RA compared to healthy controls.

Objectives:

This study aims to use preliminary data from theRheumatoid arthritis, medication and memorystudy (RESIST) to investigate the prevalence of MCI in a population of patients with RA and explore the relationship between MCI and specific demographic and clinical characteristics.

Methods:

The Montreal Cognitive Assessment (MoCA) was used as a cognitive screening tool and was administered to subjects ≥55 years of age who had been diagnosed with RA according to the ACR/EULAR criteria. Demographic and clinical data was recorded at screening in face-to-face interviews and included age, gender, date of RA diagnosis and RA medication. RA disease activity score from 28 joints (DAS28), rheumatoid factor (RF) level, anti-cyclic citrullinated peptide (anti-CCP) level, erythrocyte sedimentation rate (ESR) were recorded. 260 participants completed both screening and baseline visits as part of the RESIST longitudinal study, MoCA scores from baseline were analysed for these participants. Statistical analysis was used to provide descriptive statistics and explore possible predictors of cognitive impairment.

Results:

A total of 636 participants (mean age 68.1 yrs, female 67.5%) were screened between May 2018 and December 2019. The mean MoCA for screened participants was 25.4; 45.3% scored <26 in the MoCA and were considered to have mild cognitive impairment. Age was negatively correlated with MoCA score and was the only significant predictor of cognitive impairment. For each year of increase in age the MoCA score reduced by a mean of 0.08 points (p<0.05). There was little evidence of a difference in mean MoCA score by gender, RA medication, duration of disease, DAS28 score, ESR, anti-CCP or RF levels. The mean MoCA scores increased by 0.4 points between screening and baseline (P<0.001).

Conclusion:

A large proportion of participants scored below the proposed cut-off for normal cognition in the MoCA suggesting a high prevalence of MCI in adults >55 years with moderately active RA. This provides further support for the role of chronic inflammation in cognitive dysfunction and AD. Screening for MCI in rheumatology clinics might be clinically useful.

DemographicsOutcomeAge mean years (+/-SD) (n=633)68.1 (8.01)Gender (n=636)Female n (%)429 (67.5)RA Medication (n=636)csDMARD n (%)TNFi n (%)368 (57.9)268 (42.1)Duration of RA mean years (+/-SD) (n=484)14.4 (13.9)DAS28 mean (+/-SD) (n=306)3.5 (2.04)ESR mean (+/-SD) (n=501)23.4 (22.0)Anti-CCP (n=387)Positive n (%)236 (61)Rheumatoid Factor (n=377)Positive n (%)277 (73.5)MoCA Score points (n=636)≥26, n (%)<26 n (%)348 (54.7)288 (45.3)Subjective memory concerns (n=430)Yes n (%)No n (%)95 (22.1)335 (77.9)

Disclosure of Interests:

Christopher Edwards Grant/research support from: Abbvie, Biogen, Roche, Consultant of: Abbvie, Samsung, Speakers bureau: Abbvie, BMS, Biogen, Celgene, Fresenius, Gilead, Janssen, Lilly, Mundipharma, Pfizer, MSD, Novartis, Roche, Samsung, Sanofi, UCB

, Bethany McDowell: None declared, Chris Holroyd: None declared, Chris Cardwell: None declared, Michelle McHenry Speakers bureau: Novartis, Pfizer, AbbVie, Celgene, Lilly, Gary Meenagh: None declared, Clive Holmes: None declared, Bernadette McGuiness: None declared

72 Prevalence of Reported and Unreported Vertebral Fractures in Ctpas in Older Adults Above 75 Years

Introduction

Identifying vertebral fractures is prudent in the diagnosis of osteoporosis as they occur early in this hidden condition. Unfortunately, due to their unspecific presentation, only 25% are clinically recognised. Computerised Tomography Pulmonary Angiogram (CTPA) are frequently requested to confirm pulmonary thromboembolisms, but could also aid in detecting clinically silent vertebral fractures. Current literature suggests that less than one-third of incidental vertebral fractures are reported. The aim of this study is to measure the prevalence of vertebral fractures in CTPA and its relevance to clinical outcomes.

Methods

This is retrospective observational study based on the analysis of existing CTPA for acutely unwell patients admitted to medical assessment unit or A & E across three acute sites within Aneurin Bevan University Health board, Wales, UK between January and December 2015. All CTPA reports were reviewed for fragility factures and CTPA images were reassessed for any unreported vertebral fractures. Age and gender were recorded for all patients. Analysis was done for all patients in respect to subsequent fragility fractures and mortality. Difference of proportion test was used to compare two groups with and without vertebral fractures.

Results

179 CTPA were reviewed, 161 patients were included for further analysis. 14.3% (n=23/161) were reported to have a vertebral fracture, however only 8.7% (n=14/161) of reports used the correct terminology of ‘fracture’. On subsequent review, an additional 24.2% (n=39/161) vertebral fractures were noted. Therefore, overall prevalence of vertebral fractures was 38.5% (n=62/161). Only 9.1% (n=9/99) of patients without a vertebral fracture developed a subsequent fragility fracture. In comparison, 22.5% (n=14/62) of patients with a previous vertebral fracture sustained a new fragility fracture over next 4 years and this was significantly higher (p = 0.017). Overall mortality over 4 years follow-up was significantly higher for patients with vertebral fractures (64.5%, n=40/62) as compared to those without fractures (43.4%, n=43/99, p = 0.009). Only 48.4% (n=30/62) received osteoporosis treatment.

Conclusions

Vertebral fractures could be underreported by radiologists, likely due to human factors as they might be concentrating on the clinical scenario to exclude a pulmonary embolism. However, considering a significant higher mortality in patients with underlying vertebral fracture, it justifies that radiologists could be asked to examine sagittal view in the bone window for possible underlying vertebral fractures, to ensure osteoporosis is treated to guidance.

Automatic Quality Assessment of Transperineal Ultrasound Images of the Male Pelvic Region, Using Deep Learning

Ultrasound guidance is not in widespread use in prostate cancer radiotherapy workflows. This can be partially attributed to the need for image interpretation by a trained operator during ultrasound image acquisition. In this work, a one-class regressor, based on DenseNet and Gaussian processes, was implemented to automatically assess the quality of transperineal ultrasound images of the male pelvic region. The implemented deep learning approach was tested on 300 transperineal ultrasound images and it achieved a scoring accuracy of 94%, a specificity of 95% and a sensitivity of 92% with respect to the majority vote of 3 experts, which was comparable with the results of these experts. This is the first step toward a fully automatic workflow, which could potentially remove the need for ultrasound image interpretation and make real-time volumetric organ tracking in the radiotherapy environment using ultrasound more appealing.

Exploring pressures, tissue reperfusion and body positioning: a pilot evaluation

OBJECTIVE

To assess the relationship in healthy adults and critically ill patients between: patient position, body mass index (BMI), patient body temperature, interface pressure (IP) and tissue reperfusion (TR). Also to determine the relationship in critically ill patients between: Sequential Organ Failure Assessment (SOFA) score, Braden Scale score for predicting pressure injury risk, Acute Physiology and Chronic Health Evaluation II (APACHE II) severity of disease classification score, IP and TR.

METHODS

This study took place in a 27-bed intensive care unit (ICU) of an Australian tertiary hospital. IP and TR outcomes were measured at the sacrum and greater trochanter. Repeated measures analyses of variance (ANOVAs) and doubly multivariate repeated measures ANOVAs were conducted using peak pressure index (PPI), peak time (PT), settled time constant (STC) and normalised hyperaemic area (NHA) measures of TR as outcomes. Participant type, body mass index (BMI), Braden and APACHE II scores and patient body temperature were considered as between-groups factors and covariates.

RESULTS

We recruited 23 low- and high-acuity ICU patients and nine healthy adult volunteers. Not all IP readings could be obtained from ICU patients. TR readings were collected from all recruited patients, but not all TR measurements were mutually uncorrelated. Controlling for age, PPI readings differed between participant types (p=0.093), with the highest values associated with high-acuity patients and the lowest with healthy adults; the association was not substantive when controlling for age and BMI. Age was a significant variable (p=0.008), with older participants having higher scores than younger ones. No statistically significant associations between any measured parameter and TR variables were observed. However, temperature was revealed to be related to TR (p=0.091).

CONCLUSIONS

Although not powered to detect significant effects, this pilot analysis has determined several associations of importance, with differences in outcomes observed between low- and high-acuity ICU patients; and between ICU patients and healthy volunteers.

Enhancing photocatalytic degradation of the cyanotoxin microcystin-LR with the addition of sulfate-radical generating oxidants

This study investigated the coupling of sulfate radical generating oxidants, (persulfate, PS and peroxymonosulfate, PMS) with TiO₂ photocatalysis for the degradation of microcystin-LR (MC-LR). Treatment efficiency was evaluated by estimating the electrical energy per order (E_EO). Oxidant addition at 4 mg/L reduced the energy requirements of the treatment by 60% and 12% for PMS and PS, respectively compared with conventional photocatalysis. Quenching studies indicated that both sulfate and hydroxyl radicals contributed towards the degradation of MC-LR for both oxidants, while Electron Paramagnetic Resonance (EPR) studies confirmed that the oxidants prolonged that lifetime of both radicals (concentration maxima shifted from 10 to 20 min), allowing for bulk diffusion and enhancing cyanotoxin removal. Structural identification of transformation products (TPs) formed during all treatments, indicated that early stage degradation of MC-LR occurred mainly on the aromatic ring and conjugated carbon double bonds of the ADDA amino acid. In addition, simultaneous hydroxyl substitution of the aromatic ring and the conjugated double carbon bonds of ADDA (m/z = 1027.5) are reported for the first time. Oxidant addition also increased the rates of formation/degradation of TPs and affected the overall toxicity of the treated samples. The detoxification and degradation order of the treatments was UVA/TiO₂/PMS > UVA/TiO₂/PS>> UVA/TiO₂.

Randomized trial of a dual-hormone artificial pancreas with dosing adjustment during exercise compared with no adjustment and sensor-augmented pump therapy

AIMS

To test whether adjusting insulin and glucagon in response to exercise within a dual-hormone artificial pancreas (AP) reduces exercise-related hypoglycaemia.

MATERIALS AND METHODS

In random order, 21 adults with type 1 diabetes (T1D) underwent three 22-hour experimental sessions: AP with exercise dosing adjustment (APX); AP with no exercise dosing adjustment (APN); and sensor-augmented pump (SAP) therapy. After an overnight stay and 2 hours after breakfast, participants exercised for 45 minutes at 60% of their maximum heart rate, with no snack given before exercise. During APX, insulin was decreased and glucagon was increased at exercise onset, while during SAP therapy, subjects could adjust dosing before exercise. The two primary outcomes were percentage of time spent in hypoglycaemia (<3.9 mmol/L) and percentage of time spent in euglycaemia (3.9-10 mmol/L) from the start of exercise to the end of the study.

RESULTS

The mean (95% confidence interval) times spent in hypoglycaemia (<3.9 mmol/L) after the start of exercise were 0.3% (-0.1, 0.7) for APX, 3.1% (0.8, 5.3) for APN, and 0.8% (0.1, 1.4) for SAP therapy. There was an absolute difference of 2.8% less time spent in hypoglycaemia for APX versus APN (p = .001) and 0.5% less time spent in hypoglycaemia for APX versus SAP therapy (p = .16). Mean time spent in euglycaemia was similar across the different sessions.

CONCLUSIONS

Adjusting insulin and glucagon delivery at exercise onset within a dual-hormone AP significantly reduces hypoglycaemia compared with no adjustment and performs similarly to SAP therapy when insulin is adjusted before exercise.

A protein-truncating R179X variant in RNF186 confers protection against ulcerative colitis

Protein-truncating variants protective against human disease provide in vivo validation of therapeutic targets. Here we used targeted sequencing to conduct a search for protein-truncating variants conferring protection against inflammatory bowel disease exploiting knowledge of common variants associated with the same disease. Through replication genotyping and imputation we found that a predicted protein-truncating variant (rs36095412, p.R179X, genotyped in 11,148 ulcerative colitis patients and 295,446 controls, MAF=up to 0.78%) in RNF186, a single-exon ring finger E3 ligase with strong colonic expression, protects against ulcerative colitis (overall P=6.89 × 10(-7), odds ratio=0.30). We further demonstrate that the truncated protein exhibits reduced expression and altered subcellular localization, suggesting the protective mechanism may reside in the loss of an interaction or function via mislocalization and/or loss of an essential transmembrane domain.

The advantages of creating a positive radiation safety culture in the higher education and research sectors

The safety culture of any organisation plays a critical role in setting the tone for both effective delivery of service and high standards of performance. By embedding safety at a cultural level, organisations are able to influence the attitudes and behaviours of stakeholders. To achieve this requires the ongoing commitment of heads of organisations and also individuals to prioritise safety no less than other competing goals (e.g. in universities, recruitment and retention are key) to ensure the protection of both people and the environment. The concept of culture is the same whatever the sector, e.g. medical, nuclear, industry, education, and research, but the higher education and research sectors within the UK are a unique challenge in developing a strong safety culture. This report provides an overview of the challenges presented by the sector, the current status of radiation protection culture, case studies to demonstrate good and bad practice in the sector and the practical methods to influence change.

Erythema action spectrum of topical 8-methoxypsoralen-sensitized skin re-evaluated: implications for routine clinical practice

BACKGROUND

Published methodology used to determine psoralen plus ultraviolet A (PUVA) erythemal action spectrum does not reflect current clinical practice for psoralen sensitization. We re-evaluated the PUVA action spectrum using aqueous 8-methoxypsoralen (8-MOP) 2·6 mg L(-1) as used routinely in current clinical practice.

OBJECTIVES

To determine the UVA erythema action spectrum of topical 8-MOP-sensitized normal skin.

METHODS

Twenty healthy volunteers with skin phototypes I-V were recruited. Forearms were psoralen-sensitized at 37 °C for 10 min. Six UVA irradiations at 10-nm intervals between 325 and 375 nm were randomly allocated to forearm sites and were applied using a 10-nm bandwidth irradiation monochromator. The visual minimal phototoxic dose (MPD) was recorded on each site at 96 h.

RESULTS

Volunteer Boston phototypes were: I, n = 2; II, n = 6; III, n = 6; IV, n = 5 and V, n = 1. The mean MPD (J cm(-2) ) for all subjects at each wavelength was as follows: 325 nm, 0·64 (SD 0·37); 335 nm, 0·80 (SD 0·58); 345 nm, 0·96 (SD 0·55); 355 nm, 1·50 (SD 0·85); 365 nm, 2·19 (SD 0·90); and 375 nm, 2·89 (SD 1·06). Therefore, the relative sensitization at each wavelength (erythemal action spectrum) was: 1, 0·83, 0·67, 0·43, 0·29 and 0·22. There were significant differences between the PUVA erythemal effectiveness at different wavelengths but none between skin types.

CONCLUSIONS

This study has established the erythemal action spectrum for bath/soak PUVA therapy as is currently performed. In all volunteers, the peak sensitivity was at 325 nm. All volunteers showed a similar trend across the wavelengths studied irrespective of skin type. The determination of the action spectrum for PUVA-induced erythema is important as it permits reliable estimates of erythemal efficacy of any UVA source where the emission spectrum of the lamp is known or can be measured.