Childhood-Onset Lupus Nephritis in the Childhood Arthritis and Rheumatology Research Alliance Registry: Short-Term Kidney Status and Variation in Care

OBJECTIVE

The goal was to characterize short-term kidney status and describe variation in early care utilization in a multicenter cohort of patients with childhood-onset systemic lupus erythematosus (cSLE) and nephritis.

METHODS

We analyzed previously collected prospective data from North American patients with cSLE with kidney biopsy-proven nephritis enrolled in the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry from March 2017 through December 2019. We determined the proportion of patients with abnormal kidney status at the most recent registry visit and applied generalized linear mixed models to identify associated factors. We also calculated frequency of medication use, both during induction and ever recorded.

RESULTS

We identified 222 patients with kidney biopsy-proven nephritis, with 64% class III/IV nephritis on initial biopsy. At the most recent registry visit at median (interquartile range) of 17 (8-29) months from initial kidney biopsy, 58 of 106 patients (55%) with available data had abnormal kidney status. This finding was associated with male sex (odds ratio [OR] 3.88, 95% confidence interval [95% CI] 1.21-12.46) and age at cSLE diagnosis (OR 1.23, 95% CI 1.01-1.49). Patients with class IV nephritis were more likely than class III to receive cyclophosphamide and rituximab during induction. There was substantial variation in mycophenolate, cyclophosphamide, and rituximab ever use patterns across rheumatology centers.

CONCLUSION

In this cohort with predominately class III/IV nephritis, male sex and older age at cSLE diagnosis were associated with abnormal short-term kidney status. We also observed substantial variation in contemporary medication use for pediatric lupus nephritis between pediatric rheumatology centers. Additional studies are needed to better understand the impact of this variation on long-term kidney outcomes.

Molecular architecture of the ciliary tip revealed by cryo-electron tomography

Cilia are essential organelles that protrude from the cell body. Cilia are made of a microtubule-based structure called the axoneme. In most types of cilia, the ciliary tip is distinct from the rest of the cilium. Here, we used cryo-electron tomography and subtomogram averaging to obtain the structure of the ciliary tip of the ciliate Tetrahymena thermophila. We show the microtubules in the tip are highly cross-linked with each other and stabilised by luminal proteins, plugs and cap proteins at the plus ends. In the tip region, the central pair lacks the typical projections and twists significantly. By analysing cells lacking a ciliary tip-enriched protein CEP104/FAP256 by cryo-electron tomography and proteomics, we discovered candidates for the central pair cap complex and explain potential functions of CEP104/FAP256. These data provide new insights into the function of the ciliary tip and inform about the mechanisms of ciliary assembly and length regulation.

Intraarticular steroids as DMARD-sparing agents for juvenile idiopathic arthritis flares: Analysis of the Childhood Arthritis and Rheumatology Research Alliance Registry

BACKGROUND

Children with juvenile idiopathic arthritis (JIA) who achieve a drug free remission often experience a flare of their disease requiring either intraarticular steroids (IAS) or systemic treatment with disease modifying anti-rheumatic drugs (DMARDs). IAS offer an opportunity to recapture disease control and avoid exposure to side effects from systemic immunosuppression. We examined a cohort of patients treated with IAS after drug free remission and report the probability of restarting systemic treatment within 12 months.

METHODS

We analyzed a cohort of patients from the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry who received IAS for a flare after a period of drug free remission. Historical factors and clinical characteristics and of the patients including data obtained at the time of treatment were analyzed.

RESULTS

We identified 46 patients who met the inclusion criteria. Of those with follow up data available 49% had restarted systemic treatment 6 months after IAS injection and 70% had restarted systemic treatment at 12 months. The proportion of patients with prior use of a biologic DMARD was the only factor that differed between patients who restarted systemic treatment those who did not, both at 6 months (79% vs 35%, p < 0.01) and 12 months (81% vs 33%, p < 0.05).

CONCLUSION

While IAS are an option for all patients who flare after drug free remission, it may not prevent the need to restart systemic treatment. Prior use of a biologic DMARD may predict lack of success for IAS. Those who previously received methotrexate only, on the other hand, are excellent candidates for IAS.

Social determinants of health influence disease activity and functional disability in Polyarticular Juvenile Idiopathic Arthritis

BACKGROUND

Social determinants of health (SDH) greatly influence outcomes during the first year of treatment in rheumatoid arthritis, a disease similar to polyarticular juvenile idiopathic arthritis (pJIA). We investigated the correlation of community poverty level and other SDH with the persistence of moderate to severe disease activity and functional disability over the first year of treatment in pJIA patients enrolled in the Childhood Arthritis and Rheumatology Research Alliance Registry.

METHODS

In this cohort study, unadjusted and adjusted generalized linear mixed effects models analyzed the effect of community poverty and other SDH on disease activity, using the clinical Juvenile Arthritis Disease Activity Score-10, and disability, using the Child Health Assessment Questionnaire, measured at baseline, 6, and 12 months.

RESULTS

One thousand six hundred eighty-four patients were identified. High community poverty (≥20% living below the federal poverty level) was associated with increased odds of functional disability (OR 1.82, 95% CI 1.28-2.60) but was not statistically significant after adjustment (aOR 1.23, 95% CI 0.81-1.86) and was not associated with increased disease activity. Non-white race/ethnicity was associated with higher disease activity (aOR 2.48, 95% CI: 1.41-4.36). Lower self-reported household income was associated with higher disease activity and persistent functional disability. Public insurance (aOR 1.56, 95% CI 1.06-2.29) and low family education (aOR 1.89, 95% CI 1.14-3.12) was associated with persistent functional disability.

CONCLUSION

High community poverty level was associated with persistent functional disability in unadjusted analysis but not with persistent moderate to high disease activity. Race/ethnicity and other SDH were associated with persistent disease activity and functional disability.

Anaesthesia management of a child with aromatic L-amino acid decarboxylase deficiency

Aromatic L-amino acid decarboxylase deficiency is an autosomal recessive disorder that results in a lack of neurotransmitters including serotonin, dopamine, noradrenaline and adrenaline. It is characterised by developmental delay, severe hypotonia and autonomic disturbance. In patients with this condition, catecholamine deficiency and autonomic dysfunction, resulting in haemodynamic instability under anaesthesia is a primary concern. There is increased sensitivity to exogenous catecholamines and indirect acting agents, such as ephedrine, are ineffective. Hypoglycaemia, difficult airway status and drug interactions such as with monoamine oxidase inhibitors are also of concern, and these patients are at risk of dystonic crises peri-operatively. A 6-year-old boy with aromatic L-amino acid decarboxylase deficiency presented for gastrointestinal endoscopy. Following multidisciplinary discussion, we elected to provide general anaesthesia with a propofol target-controlled infusion, which proceeded without incident. In this report, we describe the precautions taken in this case, and discuss the provision of general anaesthesia for children with rare neurometabolic disorders.

139 OLDER PERSONS REHABILITATION: A SIX MONTH PATIENT PROFILE

Background

For quality improvement to be assessed in a healthcare setting, understanding the specific patient profile is vital. Only then can system performance and service development be reviewed accurately. The purpose of this review was to analyse the patient profile of a 20 bed older persons rehabilitation unit.

Methods

Data was collected weekly for patients admitted and discharged to a sub-acute rehabilitation unit over a six month period (January to June 2021) by a multi-disciplinary team (MDT). Information collected included; age, clinical frailty scale (CFS, revised 2008, Rockwood et al., 2005), MDT involvement, care needs on discharge, onward community referrals and length of stay.

Results

62 patients were included (25 males and 37 females) with an average age of 81 (range 61–99). The CFS was measured for 58 patients and ranged from 1 to 7. On examination, 9% of patients had a CFS of 1–2, 38% a CFS of 3–4, 46% a CFS of 5–6 and 7% a CFS of 7.

Of the 62 patients included, all received physiotherapy and occupational therapy, 28 speech and language therapy, 25 dietetics and 48 medical social work.

The average length of stay was 42 days (range 10–162).

On discharge 42% of patients went home with existing supports, 50% went home with increased supports and 8% went to a residential care facility. Referrals to community services were sent for 65% of patients.

Conclusion

53% of patients admitted to an older person rehabilitation unit had a CFS of 5 or more, indicating they were at least mildly frail. The average length of stay was six weeks and all patients required a minimum of two MDT members during their stay. This highlights the presence of frailty and the importance of effective MDT working in the sub-acute rehabilitation setting.

151 THERAPY OUTCOME MEASURES IN AN OLDER PERSONS REHABILITATION UNIT

Background

The mission of an older person’s sub-acute rehabilitation unit is to improve the individual’s function and quality of life. This is achieved through patient and multidisciplinary team (MDT) collaboration. The MDT collect Therapy Outcome Measure (TOM) (Enderby and John 2015) data to measure the effectiveness of rehabilitation and facilitate analysis of patient and service outcomes. This abstract will present 6 months of data collection with the aim of evaluating the impact of MDT intervention from January 2021.

Methods

The MDT meet weekly to jointly record patient TOM scores on admission and discharge. The TOM scales used are; multifactorial conditions, stroke and neurological disorder. The patient is scored from 0–5 in four domains; impairment, activity, participation and well-being. There are 11 parts to the scale with 0.5 scores permitted (Enderby and John 2015).

Results

Data was analysed on 62 patients. Across an episode of rehabilitation an increase of 0.5 or more on the TOM is a clinically significant (positive) change. 84% of patients had an overall improvement in the total TOM score. There was an average overall increase of 2.6 points on the scale which equates to a 25% overall change. 63% improved in the domain of impairment, 77% in activity, 73% in participation and 66% in wellbeing. 100% of patients post-stroke, 81% with multifactorial conditions and 75% with neurological conditions experienced an overall improvement.

Conclusion

The data objectively shows positive patient outcomes in older persons rehabilitation. Individuals experienced the most positive change in their activity and participation function and high levels of change are also evident in impairment levels and well-being. Overall, TOM is a very useful MDT outcome measure tool. It has been successfully implemented and maintained in the service and facilitates the ongoing analysis of individual and service outcomes to understand the impact of intervention.

Medication use and deprescribing in older patients in the last 14 days of life

Introduction

Older patients may continue to receive potential inappropriate medications (PIMs) at the end of life. Application of consensus-based tools to identify PIMs may result in the identification of candidate medications for deprescribing, with the aim of overcoming the harm of inappropriate medication and improving clinical outcomes. This study aims to describe medication use and deprescribing patterns, and to assess prescribing appropriateness for older people in the last 14 days of life in the hospice setting.

Methods

Longitudinal, retrospective cohort study of deceased patients (≥65 years) who died between 1 January 2018 and 31 December 2018 in three hospices in a region of the United Kingdom. We identified prescribed and deprescribed medications and assessed medication appropriateness using consensus-based criteria, namely STOPPFrail[1] and criteria developed by Morin et al.[2] Unexpected/sudden deaths were excluded. Statistical analysis was conducted using SPSS statistics 26.0.

Preliminary results

Data collection is currently ongoing. To date, data from 69 deceased patients have been collected (mean age 76.1 years). Of these decedents, 62.3% were female and the majority (just under 90%) had cancer reported as the cause of death. During the last 14 days of life, each patient was prescribed a mean of 17 ± 5 different medications. The mean number of medications decreased significantly between day 14 and the day of death from 13.2 ± 4.4 to 9.4 ± 3.7 (P &lt; 0.01). Six hundred and thirty-nine medications were discontinued, with just under 70% stopped in the last seven days before death. 34.9% of those discontinued were prescribed for chronic conditions and 22% were proton pump inhibitors. In most decedents, swallowing difficulty was the reason for medication discontinuation. According to the STOPPFrail criteria [1], 42 (60.1%) of decedents received at least one PIM between day 14 and the day of death. There were 59 PIMs in total for these patients; of these 20.3% were hyoscine butyl-bromide and 16.9% were gliclazide. Using the criteria developed by Morin et al [2], 103 medications were assessed as being of questionable (81.6%) or inadequate (18.4%) clinical benefit. Of these, 64.1% were initiated during hospice admission. There was a statistically significant association between medications of questionable clinical benefit and medication number during the last 14 days of life (P &lt; 0.01). Three of the PIMs were vitamins, considered inappropriate by both sets of criteria. Prescribing of PIMs reduced as patients neared death.

Conclusion

A substantial proportion of older patients with life-limiting diseases receive PIMs during their last days of life. No systematic discontinuation of inappropriate medications was observed thus guidelines and resources are needed to facilitate rationalisation and deprescribing of drug treatments for older patients in the last days of life. The small sample size makes the relationship between most variables insignificant; however, data extraction is still ongoing in hospices.

References

1. Lavan H, Gallagher P, Parsons C, Mahony O. STOPPFrail (Screening Tool of Older Persons’ Prescriptions in Frail adults with a limited life expectancy): Consensus validation. Age and ageing. 2017; 46 (4): 600–607.

2. Morin L, Laroche M L, Vetrano D L, Fastbom J, Johnell K. Adequate, questionable, and inadequate drug prescribing for older adults at the end of life: A European expert consensus. European Journal of Clinical Pharmacology. 2018; 74(10): 1333–1342.

The association between secondary care multimorbidity in mid-life and premature mortality

Background

Multimorbidity (MM) is the co-existence of two or more health conditions. Whilst its prevalence is higher in older adults, in absolute numbers there are more multimorbid young people. Recently, the trends for increasing life expectancy observed in high income countries have stalled or reversed. The relationship between MM and premature mortality requires exploration. We assessed the prevalence of secondary care MM in mid-life and its association with premature mortality in the Scottish Aberdeen Children of the 1950s (ACONF) cohort.

Methods

Prospective cohort study. ACONF members were linked to electronic hospital records and mortality records. Secondary care MM was assessed using hospital records in 2001 when participants were aged 45-51 years. The association between MM and mortality over 15 years (to age 60-66 years) was assessed using Cox proportional hazards regression. There was adjustment for key covariates: age, gender, social class at birth, childhood intelligence, educational attainment, alcohol, smoking, body mass index and adult social class.

Results

Of 9,625 participants (51% male), 3% had MM. Higher childhood intelligence and adult social class were associated with reduced MM. In relation to the reference group (no MM), those with MM had a mortality hazard ratio of 4.5 (95% CI 3.4-6.0) over 15 years. The association remained when adjusted for the covariates (2.5 [95% CI 1.5-4.0]).

Conclusions

Secondary care MM prevalence was 3% in mid-life and associated with premature mortality. Younger adults with MM are an important group at risk of premature mortality which should be the focus of public health action. This includes reducing the impact of social inequality and reconfiguring secondary care services to offer comprehensive management of younger multimorbid adults.

Key messages

Multimorbidity in mid-life is associated with premature mortality and may be an important influence on reducing life expectancy trends. Much focus is upon multimorbidity in older adults, however younger adults with multimorbidity are at risk of premature mortality, requiring public health action.

Co-design of data collection with participants of the Aberdeen Children of the 1950s cohort study

Background

The Aberdeen Children of the 1950s (ACONF) cohort comprises 12,150 people born in Scotland in the 50s. It contains rich early life data, questionnaire data from mid-life and linked electronic health records. Involving participants in designing future data collection is key to ensure research is acceptable and reflects public priorities.

Aim

Gather ACONF members views to inform how to: research healthy ageing, optimise recruitment and maximise participation.

Methods

3 co-design workshops with 30 ACONF members. A discussion was led by a facilitator using guidance questions developed by the study team. Workshops were recorded and transcribed.

Results

Participants viewed healthy ageing as keeping socially and physically active, taking responsibility for oneself and having a positive attitude to ageing. Research priorities were dementia, improvements in the social care system and engaging hard-to-reach groups. Members were keen for future research involvement. Recruitment may be maximised by: more information online, involving participants in recruiting other study members and clarity about potential benefits to themselves or others. It was acceptable to ask their offspring to participate. There were high levels of trust in researchers, but ongoing data protection is vital. Participation may be improved by regular contact (informing members of results, engagement events, phone “apps”). Participants viewed various data collection methods (questionnaires, applications, wearable devices, in-person tests, DNA collection and electronic record linkage) as acceptable.

Conclusions

Participant involvement is a fundamental part of securing a social license for research. Participants were in favour of ongoing research, including recruitment of their children. The workshops highlighted key considerations for future research and data collection.

Key messages

Co-design is vital for highlighting research topics which are important and relevant to the general population. Co-design can highlight strategies for maximising research participation and securing a social license for research.

The association between psychological distress in mid-life and hospital-based multimorbidity

Background

Mental ill-health is common with significant impact on individuals and services. Using healthcare records to identify poor mental health missed individuals who do not seek healthcare treatment. A screening questionnaire (General Health Questionnaire (GHQ)) can detect psychological distress. However, before considering implementing such a screening tool, we need to understand if it detects those at high risk of experiencing poorer outcomes. Hospital-based multimorbidity is a rising healthcare challenge. The aim was to assess the prevalence of psychological distress in mid-life and its influence on hospital-based multimorbidity by older age in the Aberdeen Children of the 1950s (ACONF) cohort.

Methods

Prospective cohort study using ACONF. GHQ-4 was measured in mid-life from questionnaire. Multimorbidity (2 or more co-existing conditions) was measured using linked hospital records in older age (15 years after the questionnaire). The relationship between psychological distress (GHQ-4 score of 1 or more) and multimorbidity was assessed using logistic regression with adjustment for key life-course variables.

Results

Of 5,839 individuals (48% male, mean age 48), psychological distress prevalence was 20% and was associated with being female, lower childhood cognition, lower educational attainment, lower adult social class, unemployment, higher adult body mass index, smoking and alcohol misuse. In comparison to the asymptomatic reference group, the odds ratio for multimorbidity in older age in those with psychological distress was 2.2 (95% CI 1.8-2.7) in the unadjusted model. In the adjusted model this was 1.4 (95% CI 1.1-1.8).

Conclusions

1 in 5 individuals in the general population in mid-life had psychological distress. This was associated with hospital-based multimorbidity by older age. Intervening early could reduce costs to both individuals and healthcare services. The next step is research of the cost-effectiveness of population screening for psychological distress.

Key messages

Psychological distress in mid-life is associated with hospital-based multimorbidity by older age. Screening for psychological distress early in life should be explored as an intervention to reduce costs to individuals and healthcare services.

Characterisation and evaluation of the regenerative capacity of Stro-4+ enriched bone marrow mesenchymal stromal cells using bovine extracellular matrix hydrogel and a novel biocompatible melt electro-written medical-grade polycaprolactone scaffold

Many skeletal tissue regenerative strategies centre around the multifunctional properties of bone marrow derived stromal cells (BMSC) or mesenchymal stem/stromal cells (MSC)/bone marrow derived skeletal stem cells (SSC). Specific identification of these particular stem cells has been inconclusive. However, enriching these heterogeneous bone marrow cell populations with characterised skeletal progenitor markers has been a contributing factor in successful skeletal bone regeneration and repair strategies. In the current studies we have isolated, characterised and enriched ovine bone marrow mesenchymal stromal cells (oBMSCs) using a specific antibody, Stro-4, examined their multipotential differentiation capacity and, in translational studies combined Stro-4+ oBMSCs with a bovine extracellular matrix (bECM) hydrogel and a biocompatible melt electro-written medical-grade polycaprolactone scaffold, and tested their bone regenerative capacity in a small in vivo, highly vascularised, chick chorioallantoic membrane (CAM) model and a preclinical, critical-sized ovine segmental tibial defect model. Proliferation rates and CFU-F formation were similar between unselected and Stro-4+ oBMSCs. Col1A1, Col2A1, mSOX-9, PPARG gene expression were upregulated in respective osteogenic, chondrogenic and adipogenic culture conditions compared to basal conditions with no significant difference between Stro-4+ and unselected oBMSCs. In contrast, proteoglycan expression, alkaline phosphatase activity and adipogenesis were significantly upregulated in the Stro-4+ cells. Furthermore, with extended cultures, the oBMSCs had a predisposition to maintain a strong chondrogenic phenotype. In the CAM model Stro-4+ oBMSCs/bECM hydrogel was able to induce bone formation at a femur fracture site compared to bECM hydrogel and control blank defect alone. Translational studies in a critical-sized ovine tibial defect showed autograft samples contained significantly more bone, (4250.63 mm3, SD = 1485.57) than blank (1045.29 mm3, SD = 219.68) ECM-hydrogel (1152.58 mm3, SD = 191.95) and Stro-4+/ECM-hydrogel (1127.95 mm3, SD = 166.44) groups. Stro-4+ oBMSCs demonstrated a potential to aid bone repair in vitro and in a small in vivo bone defect model using select scaffolds. However, critically, translation to a large related preclinical model demonstrated the complexities of bringing small scale reported stem-cell material therapies to a clinically relevant model and thus facilitate progression to the clinic.

FRI0513 TREATMENT PERSISTENCE IN PATIENTS CYCLING ON SUBCUTANEOUS TUMOR NECROSIS FACTOR-ALPHA INHIBITORS IN INFLAMMATORY ARTHRITIS – A RETROSPECTIVE STUDY

Background:

Patient persistence with biologic treatment of rheumatoid arthritis (RA), psoriatic arthritis (PsA) and ankylosing spondylitis (AS) (collectively inflammatory arthritis, IA) may be considered a proxy for efficacy, safety and treatment satisfaction. Patients who discontinue their first line of subcutaneous tumor necrosis factor alpha inhibitors (SC-TNFis) and switch to at least one subsequent line of SC-TNFi can be defined as cyclers.

Objectives:

To assess persistence by line of therapy in Swedish IA patients cycling on SC-TNFis.

Methods:

Using data from the Swedish Health Data Registers, adult IA patients initiating treatment with any available SC-TNFi (adalimumab, etanercept, certolizumab, or golimumab) between May 1st2010 and October 31st2016 were eligible for inclusion. Treatment persistence was derived using information from filled prescriptions (e.g. dispensing date, pack information, and defined daily dose) with a 60-day grace period. Analyses were restricted the first two lines of treatments (i.e. 1stand 2nd) in patients defined as SC-TNFi cyclers. Persistence estimates across treatment lines were assessed graphically using Kaplan-Meier curves. Unadjusted and adjusted marginal Cox proportional hazards models were fitted to estimate the relative risk of discontinuation across treatment lines, using robust sandwich covariance matrix estimates to account for intrapatient dependence (i.e. multiple treatment lines per patient). Covariates in the adjusted analysis included age, gender, diagnosis, year of treatment initiation, comorbidities, co-medication, and the number of specialized outpatient care visits and inpatient stays.

Results:

Of 11,668 patients initiating SC-TNFi treatment, 3,181 patients were identified as cyclers. Among these, a majority were female (68%) with a mean age of 50 years; 46%, 28%, and 26% were diagnosed with RA, AS and PsA, respectively. Figure 1 indicated that, among cyclers, persistence with second line treatment was higher compared to first line treatment persistence. This finding was confirmed by the analyses accounting for intrapatient dependence. Both the unadjusted and the adjusted analyses showed that the relative risk of discontinuing SC-TNFi treatment were significantly lower in 2ndline compared to 1stline (Hazard Ratio [HR]; 0.60 [0.57, 0.63] and 0.59 [0.56, 0.62], respectively). This finding was also consistent across IA indications (Table 1).

Table 1.

Relative risk of discontinuing subcutaneous Tumor Necrosis Factor-α inhibitor treatment for IA in 2nd line treatment compared to 1st line treatment, by analysis population

Analysis populationNUnadjusted analysis, HR [95%CI]Adjusted analysis, HR [95%CI]Cyclers overall3,1810.60 [0.57, 0.63]0.59 [0.56, 0.62]RA1,4790.62 [0.57, 0.67]0.61 [0.56, 0.66]PsA8910.60 [0.54, 0.67]0.59 [0.53, 0.65]AS8110.58 [0.52, 0.64]0.55 [0.50, 0.61]

HR: Hazard Ratio, 95%CI: 95% confidence interval

Figure 1.

Persistence, among cyclers, with subcutaneous Tumor Necrosis Factor-α inhibitors treatment for IA by line of treatment

Conclusion:

In this preliminary analysis of IA patients cycling on SC-TNFis, persistence was greater in 2ndline compared to 1stline treatment. The finding was consistent across all IA indications. Hence, IA patients who fail to respond, lose response, or for other reasons discontinue their 1stline treatment may still benefit from switching to an alternative SC-TNFi as a 2ndline therapy.

Disclosure of Interests:

Johan Dalén Consultant of: Merck & Co., Inc. in conjunction with the development of this abstract. JD is an employee of ICON plc. ICON plc have received funding from several pharmaceutical companies involved in the marketing products for treatment of inflammatory arthritis., Amy Puenpatom Shareholder of: shareholder at Merck & Co, Inc, Employee of: Employed at Merck & Co, Inc., Karin Luttropp Consultant of: Merck & Co., Inc. in conjunction with the development of this abstract. KL is an employee of ICON plc. ICON plc have received funding from several pharmaceutical companies involved in the marketing products for treatment of inflammatory arthritis., Christopher Black Shareholder of: I own shares of MSD, Employee of: I am an employee of MSD

Measurement of α-Amylase Activity in White Wheat Flour, Milled Malt, and Microbial Enzyme Preparations, Using the Ceralpha Assay: Collaborative Study

This study was conducted to evaluate the method performance of a rapid procedure for the measurement of α-amylase activity in flours and microbial enzyme preparations. Samples were milled (if necessary) to pass a 0.5 mm sieve and then extracted with a buffer/salt solution, and the extracts were clarified and diluted. Aliquots of diluted extract (containing α-amylase) were incubated with substrate mixture under defined conditions of pH, temperature, and time. The substrate used was nonreducing end-blocked p-nitrophenyl maltoheptaoside (BPNPG7) in the presence of excess quantities of thermostable α-glucosidase. The blocking group in BPNPG7 prevents hydrolysis of this substrate by exo-acting enzymes such as amyloglucosidase, α-glucosidase, and β-amylase. When the substrate is cleaved by endo-acting α-amylase, the nitrophenyl oligosaccharide is immediately and completely hydrolyzed to p-nitrophenol and free glucose by the excess quantities of α-glucosidase present in the substrate mixture. The reaction is terminated, and the phenolate color developed by the addition of an alkaline solution is measured at 400 nm. Amylase activity is expressed in terms of Ceralpha units; 1 unit is defined as the amount of enzyme required to release 1 μmol p-nitrophenyl (in the presence of excess quantities of α-glucosidase) in 1 min at 40°C. In the present study, 15 laboratories analyzed 16 samples as blind duplicates. The analyzed samples were white wheat flour, white wheat flour to which fungal α-amylase had been added, milled malt, and fungal and bacterial enzyme preparations. Repeatability relative standard deviations ranged from 1.4 to 14.4%, and reproducibility relative standard deviations ranged from 5.0 to 16.7%.

Long term effects of gestational hypertension and pre-eclampsia on kidney function: Record linkage study

•

We examine risk of chronic kidney disease (CKD) after pregnancy hypertension.

•

We found increased risk of chronic kidney disease after gestational hypertension.

•

Risk of chronic kidney disease was further increased after preeclampsia.

•

Women with pregnancy hypertension develop CKD earlier than normotensive women.

Objective

To assess the long term effects of hypertensive disorders of pregnancy on renal function.

Design

Cohort study where exposure was gestational hypertension or preeclampsia in the first pregnancy. Normotensive women formed the comparison group.

Setting

Aberdeen, Scotland.

Participants

All women with date of birth on or before 30th June 1969 and at least their first singleton delivery recorded in the Aberdeen Maternity and Neonatal Databank.

Methods

Participants were linked to the Renal Biochemistry Register, Scottish Morbidity Records, Scottish Renal Registry and National Register for deaths.

Main outcome measures

Occurrence of chronic kidney disease (CKD) as identified from renal function tests in later life, hospital admissions or death from kidney disease or recorded as receiving renal replacement therapy.

Results

CKD was diagnosed in 7.5% and 5.2% of women who previously had GH and PE respectively compared to 3.9% in normotensive women. The unadjusted odds ratio (95% confidence interval) of having CKD in PE was 2.04 (1.53, 2.71) and that for GH was 1.37 (1.15, 1.65), while the adjusted odds ratio (95% confidence interval) of CKD was 1.93 (1.44, 2.57) and 1.36 (1.13, 1.63) in women with PE and GH respectively. Kaplan–Meier curves of survival time to development of chronic kidney disease revealed that women with preeclampsia were susceptible to kidney function impairment earliest, followed by those with gestational hypertension.

Conclusions

There was an increased subsequent risk of CKD associated with hypertensive disorders of pregnancy. Women with GH and PE were also found to have CKD earlier than normotensive women.

Prospective purification of perivascular presumptive mesenchymal stem cells from human adipose tissue: process optimization and cell population metrics across a large cohort of diverse demographics

BACKGROUND

Adipose tissue is an attractive source of mesenchymal stem cells (MSC) as it is largely dispensable and readily accessible through minimally invasive procedures such as liposuction. Until recently MSC could only be isolated in a process involving ex-vivo culture and their in-vivo identity, location and frequency remained elusive. We have documented that pericytes (CD45-, CD146+, and CD34-) and adventitial cells (CD45-, CD146-, CD34+) (collectively termed perivascular stem cells or PSC) represent native ancestors of the MSC, and can be prospectively purified using fluorescence activated cell sorting (FACS). In this study we describe an optimized protocol that aims to deliver pure, viable and consistent yields of PSC from adipose tissue. We analysed the frequency of PSC within adipose tissue, and the effect of patient and procedure based variables on this yield.

METHODS

Within this twin centre study we analysed the adipose tissue of n = 131 donors using flow cytometry to determine the frequency of PSC and correlate this with demographic and processing data such as age, sex, BMI and cold storage time of the tissue.

RESULTS

The mean number of stromal vascular fraction (SVF) cells from 100 ml of lipoaspirate was 34.4 million. Within the SVF, mean cell viability was 83 %, with 31.6 % of cells being haematopoietic (CD45+). Adventitial cells and pericytes represented 33.0 % and 8 % of SVF cells respectively. Therefore, a 200 ml lipoaspirate would theoretically yield 23.2 million viable prospectively purified PSC - sufficient for many reconstructive and regenerative applications. Minimal changes were observed in respect to age, sex and BMI suggesting universal potential application.

CONCLUSIONS

Adipose tissue contains two anatomically and phenotypically discreet populations of MSC precursors - adventitial cells and pericytes - together referred to as perivascular stem cells (PSC). More than 9 million PSC per 100 ml of lipoaspirate can be rapidly purified to homogeneity using flow cytometry in clinically relevant numbers potentially circumventing the need for purification and expansion by culture prior to clinical use. The number and viability of PSC are minimally affected by patient age, sex, BMI or the storage time of the tissue, but the quality and consistency of yield can be significantly influenced by procedure based variables.

Oxidative DNA damage is associated with antidepressant use, not depression or anxiety disorders

Introduction

Oxidative stress has been implicated in the pathophysiology of depression and anxiety disorders and may be influenced by antidepressant use.

Objectives

This study investigated the association of oxidative stress, measured by plasma levels of F2-isoprostanes and 8-hydroxy-2′-deoxyguanosine (8-OHdG), reflecting oxidative lipid and DNA damage respectively, with major depressive disorder (MDD), generalized anxiety disorder, social phobia, panic disorder, agoraphobia and antidepressant use in a large cohort.

Methods

Data was derived from the Netherlands Study of Depression and Anxiety including patients with current (n = 1641) or remitted (n = 610) MDD and/or anxiety disorder(s) (of which n = 709 antidepressant users) and 633 controls. Diagnoses were established with the Composite Interview Diagnostic Instrument. Plasma 8-OHdG and F2-isoprostanes were measured using UHPLC-MS/MS. ANCOVA was performed adjusting for sampling, sociodemographic, health and lifestyle variables.

Results

F2-isoprostanes did not differ between controls and patients, or by antidepressant use. Patients (current or remitted) using antidepressants had lower 8-OHdG (adjusted mean 38.3 pmol/L) compared to patients (current or remitted) without antidepressants (44.7 pmol/L) and controls (44.9 pmol/L, P < 0.001; Cohen's d 0.26). Findings for 8-OHdG were similar over all disorders and all antidepressant types (SSRIs, TCAs, SNRIs; P < 0.001).

Conclusion

Contrary to previous findings this large-scale study did not find increased oxidative stress measured by F2-isoprostanes or 8-OHdG in MDD or anxiety disorders. 8-OHdG levels were lower in antidepressant users, which suggests antidepressants may have antioxidant properties.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Vibrio cholerae ghosts elicit the production of soluble immunostimulatory factors and prevent development of Chlamydia infection (INM3P.408)

Infections by the obligate intracellular pathogen Chlamydia trachomatis cause infertility in women of childbearing age. Currently infections caused by the pathogen are treated with antimicrobial therapy. Bacterial ghosts offer a cost-effective, long-term, protective therapy as vaccine delivery vectors. In the present study we tested the hypothesis that factors contained in culture supernatant exhibit anti-chlamydial activity. THP-1 monocytes were differentiated into macrophages (Mdm) by incubating with phorbol myristate acetate (PMA). Activated Mdm were pulsed with Vibrio cholerae ghosts (VCG) for 24 h, followed by the addition of murine splenocytes for an additional 48 h. After 72 h the supernatant was collected and assayed for cytokine concentration. Samples presented observable levels of immunostimulatory factors necessary for containing or clearing infections with chlamydia. Following these assay results, Chlamydia pneumonia (MoPn) elementary bodies (EBs) were suspended in VCG-pulsed THP-1 Mdm supernatant (conditioned media) and used to culture HeLa cells. As a positive control, MoPn was suspended in Earle’s MEM - a medium used for HeLa cell culture. Immunostimulatory factors contained in the conditioned media prevented the development of Chlamydia infection forming units (5.87%) vs. our positive control (94.1%). These results indicate that immunostimulatory factors induced by VCG confer protective immunity against the development cycle of Chlamydia.

Metabolic monitoring in the intensive care unit: a comparison of the Medgraphics Ultima, Deltatrac II, and Douglas bag collection methods

BACKGROUND

The accuracy of oxygen consumption measurement by indirect calorimeters is poorly validated in mechanically ventilated intensive care patients where multiple confounders exist. This study sought to compare the Medgraphics Ultima (MGU) and Deltatrac II (DTII) devices, and the Douglas bag (DB) technique in mechanically ventilated patients at rest.

METHODS

Prospective comparison of oxygen consumption measurement using three indirect calorimetry techniques in stable, resting mechanically ventilated patients at rest. Oxygen consumption (VO2), carbon dioxide production (VCO2), resting energy expenditure (REE), and respiratory quotient (RQ) were recorded breath-by-breath by the MGU over a 30-75 min period. During this time, simultaneous measurements were taken using the DTII, the DB, or both.

RESULTS

While there was no systematic error (bias) between measurements made by the three techniques (VO2: MGU vs DTII 3.6%, MGU vs DB 3.3%), the limits of agreement were wide (VO2: MGU vs DTII 33%, MGU vs DB 54%).

CONCLUSIONS

Resting oxygen consumption values in stable mechanically ventilated patients measured by the three techniques showed acceptable bias but poor precision. There is an important clinical and research need to develop new indirect calorimeters specifically tailored to measure oxygen consumption during mechanical ventilation.

Structural phase transitions in the kagome lattice based materials Cs2−xRbxSnCu3F12 (x = 0, 0.5, 1.0, 1.5)

The system Cs_2−xRb_xSnCu₃F₁₂ exhibits several different distorted variants of the kagome lattice, which are probed in detail by powder diffraction methods.

Non-pharmacological interventions to reduce the risk of diabetes in people with impaired glucose regulation: a systematic review and economic evaluation

BACKGROUND

The prevalence of type 2 diabetes mellitus (T2DM) is increasing in the UK and worldwide. Before the onset of T2DM, there are two conditions characterised by blood glucose levels that are above normal but below the threshold for diabetes. If screening for T2DM in introduced, many people with impaired glucose tolerance (IGT) will be found and it is necessary to consider how they should be treated. The number would depend on what screening test was used and what cut-offs were chosen.

OBJECTIVE

To review the clinical effectiveness and cost-effectiveness of non-pharmacological interventions, including diet and physical activity, for the prevention of T2DM in people with intermediate hyperglycaemia.

DATA SOURCES

Electronic databases, MEDLINE (1996-2011), EMBASE (1980-2011) and all sections of The Cochrane Library, were searched for systematic reviews, randomised controlled trials (RCTs) and other relevant literature on the effectiveness of diet and/or physical activity in preventing, or delaying, progression to T2DM.The databases were also searched for studies on the cost-effectiveness of interventions.

REVIEW METHODS

The review of clinical effectiveness was based mainly on RCTs, which were critically appraised. Subjects were people with intermediate hyperglycaemia, mainly with IGT. Interventions could be diet alone, physical activity alone, or the combination. For cost-effectiveness analysis, we updated the Sheffield economic model of T2DM. Modelling based on RCTs may not reflect what happens in routine care so we created a 'real-life' modelling scenario wherein people would try lifestyle change but switch to metformin after 1 year if they failed.

RESULTS

Nine RCTs compared lifestyle interventions (predominantly dietary and physical activity advice, with regular reinforcement and frequent follow-up) with standard care. The primary outcome was progression to diabetes. In most trials, progression was reduced, by over half in some trials. The best effects were seen in participants who adhered best to the lifestyle changes; a scenario of a trial of lifestyle change but a switch to metformin after 1 year in those who did not adhere sufficiently appeared to be the most cost-effective option.

LIMITATIONS

Participants in the RCTs were volunteers and their results may have been better than in general populations. Even among the volunteers, many did not adhere. Some studies were not long enough to show whether the interventions reduced cardiovascular mortality as well as diabetes. The main problem is that we know what people should do to reduce progression, but not how to persuade most to do it.

CONCLUSION

In people with IGT, dietary change to ensure weight loss, coupled with physical activity, is clinically effective and cost-effective in reducing progression to diabetes.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Equity and efficiency: striving for a solution for the introduction of new medicines

The aim of this study was to describe the evolution of mechanisms to manage the introduction of new medicines and their impact on the health-care system in Scotland. The study was a review of published and unpublished national audits and surveys on the introduction of new medicines in Scotland. Before the Scottish Medicines Consortium (SMC) was established, Area Drug and Therapeutics Committees (ADTCs) played a key role in advising National Health Service (NHS) Boards in Scotland on the use of new medicines. There was evidence of variation in the medicines evaluated and, in some cases, the evidence used leading to different decisions for the same medicine. After the SMC was established, ADTC decisions had become more consistent and comprehensive. The role of ADTCs evolved from evaluation of medicines to assessment of local implications and implementation of SMC advice. There was increased recognition of the importance of monitoring medicine use. This review demonstrated a clear evolution in the evaluation and implementation of new medicines by ADTCs across NHS Scotland. After the SMC was established, more medicines were considered by ADTCs and there was greater consistency in those considered for local implementation. ADTCs have moved from evaluation of new medicines to other aspects of medicine management, including assessment of local implications and implementation of SMC advice.

Traumatic wound microbiome workshop

On May 9-10, 2011, the Walter Reed Army Institute of Research, as the Army Center of Excellence for Infectious Disease, assembled over a dozen leaders in areas related to research into the communities of microorganisms which colonize and infect traumatic wounds. The objectives of the workshop were to obtain guidance for government researchers, to spur research community involvement in the field of traumatic wound research informed by a microbiome perspective, and to spark collaborative efforts serving the Wounded Warriors and similarly wounded civilians. During the discussions, it was made clear that the complexity of these infections will only be met by developing a new art of clinical practice that engages the numerous microbes and their ecology. It requires the support of dedicated laboratories and technologists who advance research methods such as community sequencing, as well as the kinds of data analysis expertise and facilities. These strategies already appear to be bearing fruit in the clinical management of chronic wounds. There are now funding announcements and programs supporting this area of research open to extramural collaborators.

PP038. Are women with gestational hypertension or preeclampsia at an increased long term risk of kidney function impairment?

INTRODUCTION

Preeclampsia is known to cause impairment of kidney function in pregnancy, which manifests as proteinuria. Previous studies have found an association between preeclampsia and kidney disease but were restricted in their numbers or had a short follow up time.

OBJECTIVES

To assess the long term effects of hypertensive disorders of pregnancy on kidney function in later life.

METHODS

From the Aberdeen maternity and neonatal databank (AMND), we identified the first singleton pregnancy of all women with date of birth on or before 30th June 1969. These women were linked by means of their identifying information to the local renal biochemistry database (GRBD). GRBD captures all kidney function tests from primary and secondary care in the health region. A cohort study design was used to assess the odds ratios with 95% confidence intervals for chronic kidney disease stage 1-5 (predefined based on internationally accepted KDOQI definition) occurring at least 1year following delivery. Those with gestational hypertension and preeclampsia were compared to normotensive women using multivariate logistic regression to adjust for potential confounders.

RESULTS

A total of 14675 women who had been linked to the RBD and had complete information regarding age, socio-economic class, smoking category, and body mass index (BMI) were included in a multivariate model. The unadjusted odds ratio (95% confidence interval) of having chronic kidney disease (according to previously stated definition) in preeclamptic women was 2.04 (1.53,2.71) and that in women with gestational hypertension was 1.37 (1.15,1.65), while the adjusted odds ratio (95% confidence interval) of having chronic kidney disease was 1.93 (1.44,2.57) and 1.36 (1.13,1.63) in preeclamptic women and women with gestational hypertension respectively compared to women who were normotensive in their first pregnancy.

CONCLUSION

Women who had gestational hypertension or preeclampsia in their first pregnancy had a higher risk of impairment of renal function compared to women who were normotensive.

Low levels of food involvement and negative affect reduce the quality of diet in women of lower educational attainment

BACKGROUND

Women of lower educational attainment tend to have poorer quality diets and lower food involvement (an indicator of the priority given to food) than women of higher educational attainment. The present study reports a study of the role of food involvement in the relationship between educational attainment and quality of diet in young women.

METHODS

The first phase uses six focus group discussions (n = 28) to explore the function of food involvement in shaping the food choices of women of lower and higher educational attainment with young children. The second phase is a survey that examines the relationship between educational attainment and quality of diet in women, and explores the role of mediating factors identified by the focus group discussions.

RESULTS

The focus groups suggested that lower food involvement in women of lower educational attainment might be associated with negative affect (i.e. an observable expression of negative emotion), and that this might mean that they did not place a high priority on eating a good quality diet. In support of this hypothesis, the survey of 1010 UK women found that 14% of the effect of educational attainment on food involvement was mediated through the woman's affect (P ≤ 0.001), and that 9% of the effect of educational attainment on quality of diet was mediated through food involvement (P ≤ 0.001).

CONCLUSIONS

Women who leave school with fewer qualifications may have poorer quality diets than women with more qualifications because they tend to have a lower level of food involvement, partly attributed to a more negative affect. Interventions to improve women's mood may benefit their quality of diet.

Patent ductus arteriosus repair in general practice

A 3-month-old female German Shepherd puppy was presented for routine vaccination. Clinical evaluation revealed a grade 5/6 continuous murmur with the point of maximal intensity over the left 4th intercostal space. Echocardiography revealed a patent ductus arteriosus (PDA). The PDA was closed by a team of general practitioners using the Jackson-Henderson technique, via a standard 4th intercostal thoracotomy. A multi-modal approach to analgesia and premedication was employed. A successful outcome was achieved with no murmur or evidence of cardiac disease present 6 months after surgical occlusion. The literature is reviewed with an emphasis placed on choosing techniques that are appropriate to the level of expertise of the surgical and anaesthetic teams, as well as the surgical facilities available.