Patient and clinician priorities for information on treatment outcomes for advanced ovarian cancer: a Delphi exercise

OBJECTIVE

Patients with advanced ovarian cancer face a range of treatment options, and there is unwarranted variation in treatment decision-making between UK providers. Decision support tools that produce data on treatment outcomes as a function of individual patient characteristics, would help both patients and clinicians to make informed, preference- and values-based choices. However, data on treatment outcomes to include in such tools are lacking.

METHODS

Following a literature review, a questionnaire was designed for use in a Delphi process to establish which treatment outcomes are important to both patients and clinicians in decision-making for treatment for advanced ovarian cancer. Patient and clinician panels were established.

RESULTS

Following 2 Delphi rounds, consensus was achieved for 7/11 items in the patient panel and 8/11 items in the clinician panel. Consensus across both panels was achieved for inclusion of both overall survival and progression free survival as important items in the decision-making process, although there remained differences of opinion as to whether these should be presented as relative or absolute values.

CONCLUSION

Information needs for treatment decision-making in ovarian cancer differ between and within patient and clinician groups. Whilst overall survival and progression free survival are universally accepted as important data items, decision support tools will need to be nuanced to allow presentation of a range of outcomes and associated probabilities, and in a range of formats, that can be tailored to the preferences of clinician and patients.

Presence and identity of Babesia microti in Ireland

Babesia microti is a tick-transmitted protozoan parasite of wildlife that can also cause serious disease in humans. It is now well established that B. microti represents an assemblage of different strains or species, only some of which are important zoonotic pathogens. Therefore, in order to assess the potential public health risk associated with B. microti in any given location, it is important to determine the strains that are present. This is the first study on the presence and identity of B. microti in Ireland. Overall, 314 wood mice (Apodemus sylvaticus), 243 bank voles (Myodes glareolus) and 634 questing Ixodes ricinus nymphs collected in various locations across Ireland were screened for the presence of B. microti by metabarcoding and nested PCR, respectively. Overall 8 rodent spleen samples (1.4%) were positive for B. microti, while all tick samples tested negative. Rodent isolates were identified as the 'Munich' strain which rarely causes human disease and is chiefly transmitted by the mouse tick, Ixodes trianguliceps. Together with reports from the UK these results suggest that B. microti does not represent a significant public health risk in Britain or Ireland.

Experimental Validation of a Kinetic Ballooning Mode in High-Performance High-Bootstrap Current Fraction Fusion Plasmas

We report the observation of a set of coherent high frequency electromagnetic fluctuations that leads to a turbulence induced self-regulating phenomenon in the DIII-D high bootstrap current fraction plasma. The fluctuations have frequency of 130-220  kHz, the poloidal wavelength and phase velocity are 16-30  m^{-1} and ∼30  km/s, respectively, in the outboard midplane with the estimated toroidal mode number n∼5-9. The fluctuations are located in the internal transport barrier (ITB) region at large radius and are experimentally validated to be kinetic ballooning modes (KBM). Quasilinear estimation predicts the KBM to be able to drive experimental particle flux and non-negligible thermal flux, suggesting its significant role in regulating the ITB saturation.

A-45 Clinical Considerations of Neuropsychologists for Treating Concussions

Purpose: The purpose of this study was to explore sex specific clinical considerations by neuropsychologists’ and general clinical considerations for the treatment of concussion. Methods: Fourteen clinical neuropsychologists who see concussion patients regularly (>1 case per week) were interviewed using a semi-structured guide that included a generic patient vignette. Participants were asked about clinical considerations that they faced while assessing, managing, and treating concussion. Two investigators independently coded the transcriptions and met to compare coding processes, definitions, and categories. A final codebook was developed in an iterative fashion and reapplied to all transcripts. Independent coding and member checks contributed to the trustworthiness of the data. Results: Participants’ clinical experience in treating concussion ranged from 1 to 40 years, and the sample was 64% female (9/14). Four major themes were identified, including patients’ sex considerations, sleep and napping, patient education and reassurance, and mental health considerations. Several participants (4/14; 29%) noted the lack of action-oriented clinical recommendations for previously documented sex differences (i.e., menstruation). There was a lack of uniformity in sleep and napping recommendations across the participants (e.g., permitting napping vs recommended nap-length). Participants noted that a large portion of their clinical time was spent educating and reassuring patients that concussion is treatable. Comorbid mental health considerations such as anxiety were a prevailing clinical concern across participants. Conclusions: The study revealed the need for better action-oriented clinical recommendations in consensus statements that address the four main themes of sex considerations, sleep and napping considerations, patient education and reassurance, and mental health considerations.

POS0684 IS UPADACITINIB CAPABLE OF IMPROVING PATIENT-REPORTED OUTCOMES OF RHEUMATOID ARTHRITIS IN A REAL-WORLD SETTING? RESULTS FROM THE POST-MARKETING OBSERVATIONAL UPwArds STUDY

Background

The efficacy of Upadacitinib (UPA), a selective Janus kinase inhibitor, has been evaluated in the SELECT clinical program 1-6. In addition, recent results from the non-interventional UPwArds study further confirmed UPAs clinical effectiveness regarding standard disease activity scores for rheumatoid arthritis (RA) in a real-world setting 7. However, patient-reported outcomes (PROs) as another cornerstone of clinical decision making yet remain to be addressed in the context of a post-marketing setting. This interim analysis, conducted after 250 patients had completed the 6-month follow-up visit, aims to fill this gap.

Objectives

To evaluate the change of selected PROs over 6 months in patients treated with UPA in a real-world data environment.

Methods

UPwArds is a prospective, open-label, multicenter, non-interventional, post-marketing study including adult patients with moderate-to-severe RA (swollen joint count [SJC28] ≥ 3 and inadequate response or intolerance to at least one previous disease-modifying antirheumatic drug). According to the German label, patients were treated with UPA 15 mg once daily, as monotherapy or in combination with methotrexate. For this analysis, the following PROs were included: 0-10 numerical rating scales (NRS) for pain and fatigue, the Health Assessment Questionnaire Disability Index (HAQ-DI), the duration and severity of morning stiffness, the Patient Health Questionnaire 9 (PHQ-9), and the Rheumatoid Arthritis Impact of Disease Questionnaire (RAID). Changes from baseline were evaluated for follow-up periods of 1 month, 3 months, and 6 months. Results are presented for the total sample using descriptive measures reflecting sample size (N), average values (standard deviation) for each assessment and average change scores (standard deviation) for follow-up visits. All data were analyzed as observed, with no imputation of missing data.

Results

483 patients (369 female, 114 male) were included in the study, with available baseline PRO information for 481 patients. 6-months follow-up data were yet available from 279 patients The baseline average age and disease duration were 58.0 (12.3) years and 9.0 (8.0) years, respectively, whereas the mean initial DAS28-CRP was 4.6 (1.0). At baseline, 60.8% of enrolled patients had previously been treated with biologic or targeted synthetic disease-modifying antirheumatic drugs. Overall, PRO scores improved from baseline throughout month 6 with a considerable amelioration at month 3, which was maintained at month 6. Responses were rapid, with improvement already evident at month 1 (Table 1). The NRS pain as a crucial PRO in RA confirmed the previously described pattern of results seen for most of the other PROs (Figure 1).

Table 1.

Baseline scores and average changes from baseline scores

NBaseline scores (SD)NChange from baseline - month 1 (SD)NChange from baseline - month 3 (SD)NChange from baseline - month 6(SD)Pain (NRS)4816.2 (2.2)393-2.2 (2.3)392-2.5 (2.5)258-2.4 (2.4)Fatigue (NRS)4815.5 (2.6)393-1.4 (2.3)393-1.6 (2.4)259-1.5 (2.3)HAQ-DI4711.3 (0.6)380-0.2 (0.3)376-0.2 (0.4)253-0.2 (0.4)Morning stiffness (duration, minutes)43968.9 (63.9)313-25.0 (55.3)296-29.6 (54.9)179-31.6 (51.7)Morning stiffness (severity)4785.2 (2.7)386-1.8 (2.3)393-2.2 (2.6)258-2.2 (2.9)PHQ-94778.7 (5.2)383-1.9 (3.9)381-2.3 (4.0)255-2.2 (3.8)RAID4815.6 (2.0)393-1.7 (1.8)392-2.0 (2.0)258-1.9 (1.9)

Conclusion

This interim analysis confirmed a meaningful improvement regarding included PROs that cover various RA-related symptoms, depressiveness and the impact of symptoms of RA on daily life.

References

[1]Smolen JS, et al. Lancet 2019;393:2303–11

[2]Burmester GR, et al. Lancet 2018;391:2503–12

[3]Genovese MC, et al. Lancet 2018;391:2513–24

[4]van Vollenhoven R, et al. Arthritis Rheumatol 2020;72:1607–20

[5]Fleischmann R, et al. Arthritis Rheumatol 2019;71:1788–800

[6]Rubbert-Roth A, et al. N Engl J Med 2020;383:1511–21

[7]Witte T et al. P0833 at ACR, Nov 5–9, 2021

Acknowledgements

AbbVie funded this study; contributed to its design; participated in data collection, analysis, and interpretation of the data; and in the writing, review, and approval of the abstract. AbbVie and the authors thank all study investigators for their contributions and the patients who participated in this study. No honoraria or payments were made for authorship. The medical writing support was provided by Matthias Englbrecht, Freelance Healthcare Data Scientist (Eckental, Germany) and was funded by AbbVie. Statistical analyses were provided by Dr. Daniela Adolf of StatConsult GmbH (Magdeburg, Germany) which was funded by AbbVie.

Disclosure of Interests

Torsten Witte Grant/research support from: AbbVie, Amgen, Bristol-Myers Squibb, Celgene, Chugai, Gilead, Janssen, Lilly, MSD, Mylan, Novartis, Pfizer, Roche, and UCB, Uta Kiltz Consultant of: AbbVie, Biocad, Eli Lilly and Company, Grünenthal, Hexal, Janssen, MSD, Novartis, Pfizer, Roche, and UCB, Grant/research support from: AbbVie, Amgen, Biogen, Fresenius, GSK, Hexal, Novartis, and Pfizer, Florian Haas Consultant of: AbbVie, Celgene, Novartis, and Pfizer, Grant/research support from: AbbVie, BMS, Celgene, Chugai, MSD, Novartis, Pfizer, Roche, and Sanofi Genzyme, Elke Riechers Consultant of: AbbVie, Chugai, Novartis, and UCB, Grant/research support from: AbbVie, Chugai, Lilly, Janssen, Novartis, Pfizer, Roche, and UCB, Ulrich Prothmann Grant/research support from: AbbVie, Amgen, Bristol-Myers Squibb, Chugai, Glaxo Smith Kline, Novartis, Pfizer, Roche, Sanofi, SOBI, and UCB, Daniela Adolf Shareholder of: Employee of StatConsult and may own stock or options, Employee of: Employee of StatConsult, Carsten Holland Shareholder of: Employee of AbbVie and may own stock or options, Employee of: Employee of AbbVie, Alexander Roessler Shareholder of: Employee of AbbVie and may own stock or options, Employee of: Employee of AbbVie, Kirsten Famulla Shareholder of: Employee of AbbVie and may own stock or options, Employee of: Employee of AbbVie, Konrad Götz Shareholder of: Employee of AbbVie and may own stock or options, Employee of: Employee of AbbVie, Klaus Krueger Grant/research support from: AbbVie, Biogen, BMS, Celltrion, Gilead, Hexal, Janssen, Lilly, Medac, MSD, Novartis, Pfizer, Roche, and UCB

POS0598 PERSISTING PAIN IN RHEUMATOID ARTHRITIS: DO WE NEED TO RECONSIDER OUR IDEA OF PAIN ALLEVIATION DESPITE ANTI-INFLAMMATORY TREATMENT?

Background

Pain significantly impacts life of patients with rheumatoid arthritis (RA) (1). Besides articular pain due to systemic inflammation, neuropathic pain (NeP) represents another challenge that can pose a considerable burden on the life of patients (2).

Objectives

To investigate persisting pain in RA patients and to analyse NeP along with patient-reported outcomes (PROs).

Methods

PAIN-CONTROL is a prospective, non-interventional study in rheumatology centres in Germany. Inclusion criteria were fulfilment of the 2010 ACR/EULAR RA classification criteria, disease duration ≤ 8 yrs, DAS28 > 3.2, SJC > 3, CRP normal or above reference range, and pain rating ≥ 50 (0-100 VAS). Eligible subjects had to be scheduled for escalation of anti-inflammatory treatment according to national guidelines. At wk 24 subjects were allocated to three subgroups given DAS28-CRP change and VAS pain: i) reference group: VAS pain < 50 with either DAS28 improvement > 1.2 or DAS28 ≤ 3.2, ii) non-responders: DAS28 improvement ≤ 1.2 and DAS28 > 3.2 with or without pain alleviation, iii) persisting pain: VAS pain ≥ 50 with either DAS28 improvement > 1.2 or DAS28 ≤ 3.2. For groups 1 and 2 end of study was at week 24, patients with persisting pain continued until wk 48. Patients were assessed for NeP using a score of ≥ 19 in the painDETECT questionnaire (PD-Q) (3). Pain-related PROs, i.e. the Rheumatoid Arthritis Impact of Disease Questionnaire (RAID) and the Patient Health Questionnaire (PHQ-9), were analysed along with demographic background information (1,4). Descriptive results are presented as mean (SD) or mean (SD) | Nvalid, as well as n (%) or n (%) | Nvalid, respectively.

Results

567 subjects were analysed with the following distribution: Reference group 337 (59.4%), non-responders 102 (18.0%), and persisting pain 128 (22.6%), of which 115 patients were available at wk 48. Subgroups showed similar demographic baseline characteristics but differed in PROs (Table 1). Until wk 24, proportion of patients with NeP indication decreased in the reference group (-19.8%) and slightly in non-responders (-6.0%) and persisting pain group (-9.5%). Non-responders showed the highest NeP proportion at wk 24 (35.0%) (Table 1). Of 115 patients with persisting pain at wk 24, 47 (40.9%) tested NeP negative at wk 48, 21 (18.3%) tested unclear, 28 (24.3%) were missing and 19 (16.5%) tested positive. Of the latter 9 patients (47.4%) still had persisting pain at week 48, while this was the case for 14 patients (29.8%) in the former group. 49 (42.6%) of 115 patients with severe persisting pain at wk 24 reported pain alleviation at wk 48 and fulfillment of reference group criteria. RAID and PHQ-9 scores improved in the reference group but only slightly in the other two subgroups.

Table 1.

Demographic background and PROs

CharacteristicReference group(N = 337)Non-responders(N = 102)Persisting pain(N = 128)Gender (f/m)233 (69.1%) /65 (63.7%) /87 (68.0%) /104 (30.9%)37 (36.3%)41 (32.0%)Age57.1 (13.2) | 33759.9 (12.0) | 10257.1 (13.0) | 128Disease duration (yrs)2.5 (2.6) | 3372.7 (2.8) | 1022.5 (2.5) | 128PD-Q (≥ 19) (Bl)82 (28.6%) | 28732 (41.0%) | 7840 (36.0%) | 111PD-Q (≥ 19) (wk 24)21 (8.8%) | 23928 (35.0%) | 8027 (26.5%) | 102PD-Q (Bl)14.0 (6.8) | 28715.5 (7.1) | 7815.5 (6.5) | 111PD-Q (wk 24)8.8 (5.8) | 23914.8 (6.7) | 8013.8 (7.2) | 102RAID (Bl)5.8 (2.0) | 3326.0 (1.9) | 1006.6 (1.7) | 125RAID (wk 24)2.4 (1.8) | 3215.4 (1.9) | 975.1 (1.9) | 123PHQ-9 (Bl)7.3 (5.1) | 3288.4 (5.4) | 987.9 (5.1) | 123PHQ-9 (wk 24)3.8 (3.5) | 3187.3 (4.5) | 956.6 (4.5) | 122

Conclusion

NeP is common among RA non-responders to anti-inflammatory treatment and in patients with persisting pain, meriting a routine NeP screening to more adequately address persisting pain in these patients. However, even late improvements (after 24 wks) regarding persisting pain seem likely during anti-inflammatory treatment.

References

[1]Gossec L, Ann Rheum Dis. 2011 Jun;70(6):935–42.

[2]Noda K, Mod Rheumatol. 2020 Sep;30(5):828–34.

[3]Freynhagen R, Curr Med Res Opin. 2006 Oct;22(10):1911–20.

[4]Kroenke K, J Gen Intern Med. 2001 Sep;16(9):606–13.

Acknowledgements

Statistical analysis was provided under lead of Dr. Daniela Adolf of StatConsult GmbH, which was funded by AbbVie.

Medical writing support was provided by Dr. Matthias Englbrecht of Statscoach, which was funded by AbbVie.

Disclosure of Interests

Christoph Baerwald Speakers bureau: Prof. Christoph G. Baerwald has served as consultant to AbbVie and has received research funding and speaker fees from AbbVie., Consultant of: Prof. Christoph G. Baerwald has served as consultant to AbbVie and has received research funding and speaker fees from AbbVie., Grant/research support from: Prof. Christoph G. Baerwald has served as consultant to AbbVie and has received research funding and speaker fees from AbbVie., Edgar Stemmler Shareholder of: Dr. Edgar Stemmler is employee of AbbVie and may own AbbVie stock., Employee of: Dr. Edgar Stemmler is employee of AbbVie and may own AbbVie stock., Sixten Gnuechtel Shareholder of: Dr. Sixten Gnüchtel is employee of AbbVie and may own AbbVie stock., Employee of: Dr. Sixten Gnüchtel is employee of AbbVie and may own AbbVie stock., Katharina Jeromin Shareholder of: Dr. Katharina Jeromin is employee of AbbVie and may own AbbVie stock, Employee of: Dr. Katharina Jeromin is employee of AbbVie and may own AbbVie stock, Carsten Holland Shareholder of: Dr. Carsten Holland is employee of AbbVie and may own AbbVie stock, Employee of: Dr. Carsten Holland is employee of AbbVie and may own AbbVie stock, björn fritz Shareholder of: Dr. Björn Fritz is employee of AbbVie and may own AbbVie stock., Employee of: Dr. Björn Fritz is employee of AbbVie and may own AbbVie stock., Daniela Adolf Consultant of: Dr. Daniela Adolf is an employee of StatConsult GmbH.

Statistical analysis was provided under lead of Dr. Daniela Adolf of StatConsult GmbH, which was funded by AbbVie, Peter C. Taylor Speakers bureau: Peter C. Taylor has served as consultant to AbbVie and has received speaker fees from AbbVie, Consultant of: Peter C. Taylor has served as consultant to AbbVie and has received speaker fees from AbbVie, Ralf Baron Speakers bureau: Prof. Ralf Baron has served as consultant to AbbVie and has received speaker fees from AbbVie., Consultant of: Prof. Ralf Baron has served as consultant to AbbVie and has received speaker fees from AbbVie.

159 BARRIERS AND FACILITATORS TO IMPLEMENTING NON-PHARMACOLOGICAL STRATEGIES TO MANAGE RESPONSIVE BEHAVIOURS OF NURSING HOME RESIDENTS WITH DEMENTIA

Background

Many nursing home residents with dementia exhibit responsive behaviours including agitation and aggression. Psychotropic drugs are often prescribed to manage responsive behaviours but increase the rate of falls, strokes and death in residents with dementia. Therefore, the aim of this research is to conceptualise the barriers and facilitators to implementing non-pharmacological strategies to manage responsive behaviours.

Methods

Twenty-five interviews were conducted with nursing home managers, nurses and healthcare assistants from twenty-one private and voluntary nursing homes. Reflexive thematic analysis was used to conceptualise the barriers and facilitators to implementing non-pharmacological strategies to manage responsive behaviours. Ethical approval was obtained from the University Research Ethics Committee (Ref. FHMREC20091). All participants provided written informed consent.

Results

Three themes were constructed conceptualising the barriers and facilitators to taking a non-pharmacological approach to manage responsive behaviours. Strong leadership, specialised training in gerontology or dementia care and retention of staff long term supported the development of trusting relationships with residents. Treating residents with dementia with love and respect while providing meaningful activities enhanced resident’s self-esteem, facilitating a non-pharmacological approach to managing responsive behaviours. In addition, the engagement of families in residents’ care was found to be a powerful facilitator. However, sub-optimal teamwork between nurses and healthcare assistants and a lack of multidisciplinary collaboration posed barriers to taking a non-pharmacological approach to behaviour management. Furthermore, most healthcare assistants perceived that they were not valued, this also had a detrimental impact on residents’ care.

Conclusion

Conceptualisation of the barriers and facilitators to taking a non-pharmacological approach to manage responsive behaviours enables formulation of recommendations to address these barriers. These recommendations will assist in the development of dementia policy including the national dementia strategy, to implement sustainable non-pharmacological strategies to manage responsive behaviours of nursing home residents with dementia.

AB0255 BASELINE CHARACTERISTICS OF PATIENTS WITH RHEUMATOID ARTHRITIS TREATED WITH UPADACITINIB IN GERMAN REAL-WORLD PRACTICE: RESULTS FROM THE POST-MARKETING OBSERVATIONAL UPwArds STUDY

Background:

The efficacy and safety of upadacitinib (UPA), a selective Janus kinase inhibitor, has been evaluated in the SELECT rheumatoid arthritis (RA) clinical program,1–6 but its real-world effectiveness remains to be investigated. The UPwArds study will assess the association of C-reactive protein (CRP) level with remission and other efficacy outcomes in patients with RA treated with UPA in German real-world practice.

Objectives:

To describe the baseline characteristics of patients enrolled in the UPwArds study.

Methods:

The prospective, open-label, multicenter, non-interventional, post-marketing UPwArds study included adult patients with moderate-to-severe RA (swollen joint count [SJC28] ≥3 and inadequate response or intolerance to ≥1 disease-modifying antirheumatic drug [DMARD]). Patients were treated with UPA 15 mg once daily, as monotherapy or in combination with methotrexate (MTX; 50:50 mono:combo enrollment planned), according to the German label. Variables assessed included medical history (disease duration, previous RA therapy, and vaccination status), CRP level, and disease activity (disease activity score [DAS28(CRP)], tender joint count [TJC28], and SJC28). There was no recruitment restriction regarding CRP level. This descriptive interim analysis reports patient baseline characteristics after enrollment was complete. All data were analyzed as observed, with no imputation of missing data.

Results:

533 patients (UPA monotherapy: 257 [48%]; UPA plus MTX: 276 [52%]) were included. Mean patient age was 58 years; mean disease duration was 9 years (Table 1). Despite having active RA, almost half the population (44%; n=237) did not have elevated CRP at the start of UPA treatment. Mean DAS28(CRP) was 4.6; mean TJC28 and SJC28 were 7.7 and 5.6, respectively. Overall, 39% of patients had not been treated with any biologic (b) DMARD or targeted synthetic (ts) DMARD before enrollment; 25% and 36% had previously been treated with 1 or ≥2 bDMARDs or tsDMARDs, respectively (Figure 1). 8.7% of patients had previously received a herpes zoster vaccination (8.1% Shingrix; 0.6% Zostavax).

Conclusion:

In German clinical practice, the population of patients with RA in the UPwArds study was predominantly treatment-refractory. Half of these patients had no elevated CRP despite active disease; future analyses will assess the impact of CRP on efficacy outcomes.

References:

[1]Smolen JS, et al. Lancet 2019;393:2303–11;

[2]Burmester GR, et al. Lancet 2018;391:2503–12;

[3]Genovese MC, et al. Lancet 2018;391:2513–24;

[4]van Vollenhoven R, et al. Arthritis Rheumatol 2020;72:1607–20;

[5]Fleischmann R, et al. Arthritis Rheumatol 2019;71:1788–800;

[6]Rubbert-Roth A, et al. N Engl J Med 2020;383:1511–21.

Table 1.

Baseline characteristics

Age, yearsUPAUPA + MTXTotal57.7 (13.2)n=25758.1 (11.4)n=27657.9 (12.3)n=533Disease duration, years9.4 (8.3)8.5 (7.7)9.0 (8.0)n=253n=272n=525CRP, mg/dL1.3 (1.9)1.1 (1.7)1.2 (1.8)n=257n=276n=533CRP >ULN, n (%)137 (53.3)159 (57.6)296 (55.5)n=257n=276n=533TJC287.4 (6.0)7.9 (6.4)7.7 (6.2)n=257n=276n=533SJC285.5 (3.7)5.6 (4.1)5.6 (3.9)n=257n=276n=533Patient’s Global Assessment6.2 (1.9)6.3 (1.8)6.3 (1.8)n=257n=276n=533Physician’s Global Assessment5.8 (1.5)5.9 (1.6)5.9 (1.6)n=257n=276n=533DAS28(CRP)4.6 (1.0)4.6 (1.0)4.6 (1.0)n=257n=276n=533DAS28(ESR)4.8 (1.1)4.9 (1.2)4.9 (1.1)n=224n=239n=463CDAI24.9 (10.2)25.7 (10.8)25.4 (10.5)n=257n=276n=533SDAI26.2 (10.5)26.9 (11.3)26.6 (10.9)n=257n=276n=533RAID5.7 (2.0)5.7 (2.0)5.7 (2.0)n=255n=275n=530Pain (RAID-1)6.2 (2.2)6.1 (2.3)6.2 (2.2)n=255n=275n=530SF-12 Physical Component Summary32.6 (8.5)33.9 (8.6)33.3 (8.6)n=245n=262n=507SF-12 Mental Component Summary42.4 (11.6)42.6 (11.3)42.5 (11.5)n=245n=262n=507HAQ-DI1.3 (0.7)1.3 (0.6)1.3 (0.6)n=250n=270n=520PHQ-98.9 (5.3)8.6 (5.3)8.7 (5.3)n=252n=272n=524Erosions, n (%)87 (33.9)95 (34.4)182 (34.1)n=257n=276n=533

Data are mean (SD), n unless otherwise stated

Acknowledgements:

AbbVie funded this study; contributed to its design; participated in data collection, analysis, and interpretation of the data; and in the writing, review, and approval of the abstract. AbbVie and the authors thank all study investigators for their contributions and the patients who participated in this study. No honoraria or payments were made for authorship. Medical writing support was provided by Grant Thomas Kirkpatrick, MSc, of 2 the Nth (Cheshire, UK), and was funded by AbbVie.

Disclosure of Interests:

Torsten Witte Grant/research support from: AbbVie, Amgen, Bristol-Myers Squibb, Celgene, Chugai, Gilead, Janssen, Lilly, MSD, Mylan, Novartis, Pfizer, Roche, and UCB., Uta Kiltz Consultant of: AbbVie, Biocad, Eli Lilly and Company, Grünenthal, Hexal, Janssen, MSD, Novartis, Pfizer, Roche, and UCB, Grant/research support from: AbbVie, Amgen, Biogen, Fresenius, GSK, Hexal, Novartis, and Pfizer, Florian Haas Consultant of: AbbVie, Celgene, Novartis, and Pfizer, Grant/research support from: AbbVie, BMS, Celgene, Chugai, MSD, Novartis, Pfizer, Roche, and Sanofi Genzyme, Elke Riechers Consultant of: AbbVie, Chugai, Novartis, and UCB, Grant/research support from: AbbVie, Chugai, Lilly, Janssen, Novartis, Pfizer, Roche, and UCB, Ulrich Prothmann Grant/research support from: AbbVie, Amgen, Bristol-Myers Squibb, Chugai, Glaxo Smith Kline, Novartis, Pfizer, Roche, Sanofi, SOBI, and UCB, Daniela Adolf Employee of: Employee of StatConsult and may own stock or options, Carsten Holland Employee of: Employee of AbbVie and may own stock or options, Rouven Hecht Employee of: Employee of AbbVie and may own stock or options, Alexander Roessler Employee of: Employee of AbbVie and may own stock or options, Kirsten Famulla Employee of: Employee of AbbVie and may own stock or options, Klaus Krueger Grant/research support from: AbbVie, Biogen, BMS, Celltrion, Gilead, Hexal, Janssen, Lilly, Medac, MSD, Novartis, Pfizer, Roche, and UCB.

Uptake and efficacy of bilateral risk reducing surgery in unaffected female BRCA1 and BRCA2 carriers

BACKGROUND

Women testing positive for BRCA1/2 pathogenic variants have high lifetime risks of breast cancer (BC) and ovarian cancer. The effectiveness of risk reducing surgery (RRS) has been demonstrated in numerous previous studies. We evaluated long-term uptake, timing and effectiveness of risk reducing mastectomy (RRM) and bilateral salpingo-oophorectomy (RRSO) in healthy BRCA1/2 carriers.

METHODS

Women were prospectively followed up from positive genetic test (GT) result to censor date. χ² testing compared categorical variables; Cox regression model estimated HRs and 95% CI for BC/ovarian cancer cases associated with RRS, and impact on all-cause mortality; Kaplan-Meier curves estimated cumulative RRS uptake. The annual cancer incidence was estimated by women-years at risk.

RESULTS

In total, 887 women were included in this analysis. Mean follow-up was 6.26 years (range=0.01-24.3; total=4685.4 women-years). RRS was performed in 512 women, 73 before GT. Overall RRM uptake was 57.9% and RRSO uptake was 78.6%. The median time from GT to RRM was 18.4 months, and from GT to RRSO-10.0 months. Annual BC incidence in the study population was 1.28%. Relative BC risk reduction (RRM versus non-RRM) was 94%. Risk reduction of ovarian cancer (RRSO versus non-RRSO) was 100%.

CONCLUSION

Over a 24-year period, we observed an increasing number of women opting for RRS. We showed that the timing of RRS remains suboptimal, especially in women undergoing RRSO. Both RRM and RRSO showed a significant effect on relevant cancer risk reduction. However, there was no statistically significant RRSO protective effect on BC.

Specialist oncological surgery for removal of the ovaries and fallopian tubes in BRCA1 and BRCA2 pathogenic variant carriers may reduce primary peritoneal cancer risk to very low levels

Risk‐reducing bilateral salpingo‐oophorectomy (RRBSO) is highly effective for the prevention of high‐grade serous ovarian cancer (HGSOC) in BRCA1/2 pathogenic variant carriers (PVCs), but does not completely eliminate future risk of primary peritoneal cancer (PPC). The requirement to completely remove fallopian tubes at RRBSO and carefully exclude occult cancer/serous tubal intraepithelial carcinoma (STIC) lesions may not have been appreciated historically. We calculated rates of HGSOC and PPC in confirmed BRCA1/2 PVCs registered on the regional database in those who did (cases) and did not (controls) undergo RRBSO after genetic testing. Expected annual rates of ovarian/peritoneal cancer were 1% for BRCA1 ≥ 35 years and 0.5% for BRCA2 ≥ 45 years. Follow‐up before 35/45 years was “risk free” and lead time excluded RRBSO <35 years and <45 years for BRCA1 and BRCA2, respectively. Women were followed from personal mutation report (controls) or RRBSO (cases) to death, ovarian/peritoneal cancer or last follow‐up, whichever was sooner. In total, 891 cases (BRCA1 = 468, BRCA2 = 423) and 1302 controls had follow‐up ≥35 years (BRCA1 = 736) and ≥45 years (BRCA2 = 566), respectively, over a total of 7261.1 risk eligible years (mean = 8.15 years). Twenty‐one occult ovarian cancers were found at RRBSO (2.4%), 16 at stage 1. Post RRBSO, 56.97 ovarian/peritoneal cancers were expected but only 3 were observed (HR = 0.053; 95% CI = 0.013‐0.14), with combined Kaplan‐Meier analysis HR = 0.029 (95% CI = 0.009‐0.100, P < .001). Risk reduction was greater in specialist (HR = 0.03; 95% CI = 0.001‐0.13) compared to non‐specialist centres (HR = 0.11; 95% CI = 0.02‐0.37) (P = .07). In controls, 23.35 ovarian/peritoneal cancers were expected with 32 observed (HR = 1.37; 95% CI = 0.95‐1.91). RRBSO <35/<45 years reduces the risk of ovarian/peritoneal cancer by 95% in BRCA1/2 PVCs and may be greater in specialist centres.

What's new?

Women who carry genetic variants in BRCA1/2 that are linked to high‐grade serous ovarian cancer are advised to undergo risk‐reducing prophylactic bilateral salpingo‐oophorectomy (RRBSO). RRBSO, however, is associated with a significant residual risk of primary peritoneal cancer (PPC). Here, the rate of PPC following prophylactic surgery for high‐grade serous ovarian cancer was investigated among 2,193 BRCA1/2 mutation carriers who had undergone RRBSO. Estimates indicate that prophylactic surgery reduced the overall risk of PPC by 95 percent, a far greater reduction than previously described. Residual risk was lowest when RRBSO was carried out at specialist centers compared to non‐specialist centers.

British Gynaecological Cancer Society (BGCS) cervical cancer guidelines: Recommendations for practice

Cervix cancer in many countries is declining and screening programmes and immunisation will reduce the incidence in the next few decades. This guideline attempts to cover management of invasive disease reflecting diagnosis and imaging including new imaging and sentinel lymph node biopsies. Smaller volume disease is usually managed surgically whereas advanced disease is treated with (chemo)- radiation. It also includes discussion of fertility sparing procedures. Practices are changing frequently for all aspects of care usually in attempts to reduce complications and improve quality of life. The management of advanced disease is treated by chemotherapy and the use of newer agents is also discussed. Other sections discuss specialist situations such as cancer in pregnancy, rare cervical tumours, late effects and supportive measures and fertility preserving approaches.

SAT0272 THE VALUE OF CLINICAL AND LABORATORY FEATURES TO PREDICT EXTENT OF LARGE VESSEL VASCULITIS ON PET CT

Background:

Giant cell arteritis (GCA) is an idiopathic vasculitis affecting large and medium-sized vessels. The pattern of arterial involvement is heterogeneous with two overlapping categories recognised: classical cranial GCA and extra-cranial GCA (or large vessel vasculitis – LVV) that predominantly affects the aorta and its proximal branches. Although LVV is present in around 80% of patients with cranial GCA, and around one third will develop large vessel complications, there are no guidelines for which patients should be screened for it (1). We sought to investigate whether clinical and laboratory features were a useful guide to the severity of LVV on FDG PET-CT.

Objectives:

To retrospectively analyse whether baseline patient characteristics are able to predict the extent of large vessel vasculitis on PET-CT.

Methods:

Clinical data for 65 patients referred for a PET-CT scan by Rheumatology at the Freeman Hospital, Newcastle between January 2015 and May 2018 were retrospectively analysed. The most recent full blood count and inflammatory markers prior to the scan were used. Scans were reviewed by a consultant radiologist and trainee. The arterial network was split in to ten potentially involved territories (aortic arch, thoracic aorta, abdominal aorta, iliac vessels, axillary, brachiocephalic, subclavian, carotid, vertebral and femoral arteries. Both the value of highest standardised uptake value (SUV max) and the territory affected was recorded for each positive scan.

Results:

In the period analysed 65 PET-CT scans were requested, mostly (77%) as baseline investigations for symptoms with LVV in the differential diagnosis. Of these 22 (34%) were positive for LVV and in that group the majority of patients (64%) were female. In those with a negative scan, 47.5% were on concurrent steroid treatment compared to 9% with a positive scan. Regression analysis suggested that the number of systemic features (weight loss, pyrexia, polymyalgia) was weakly correlated with the number of affected territories (p=0.04). In contrast there was no correlation between laboratory tests ((CRP (p=0.91), ESR (p=0.46), Hb (p=0.44), platelets (p=0.74)) and the number of territories affected. The aortic arch (47%) was most commonly the territory with the highest degree of FDG uptake (SUV max) followed by the abdominal aorta (21%) and thoracic (10%) and femoral arteries (10%). There was no correlation between SUV max and laboratory tests ((CRP (p=0.55), ESR (p=0.89), Hb (p=0.82), platelets (p=0.17)) or the number of systemic features (p=0.7). There was no significant difference in the number of territories affected between those on steroid treatment at the time of the scan and steroid-naïve patients, albeit the number of positive scans in those on steroid treatment was low (n=5).

Conclusion:

These results suggest that clinical and laboratory features are a poor guide to predicting the maximal severity and extent of disease on FDG PET-CT.

References:

[1]Koster MJ, Matteson EL, Warrington KJ. Large-vessel giant cell arteritis: diagnosis, monitoring and management. Rheumatology (Oxford). 2018;57(suppl_2):ii32-ii42.

Disclosure of Interests:

None declared

Tumor Suppression in Asymptomatic Postmenopausal Endometrial Polyps

BACKGROUND/AIM

To investigate tumor suppression as an indicator of malignization potential within endometrial polyps in asymptomatic postmenopausal women.

MATERIALS AND METHODS

Immunohistochemical studies of the phosphatase and tensin homolog (PTEN) were performed. Cases included 52 benign postmenopausal polyps, 19 endometrioid carcinomas with coexisting benign polyps, and 12 polyps with foci of carcinoma. Controls included 31 atrophic endometria and 32 benign premenopausal polyps. PTEN was scored by quantitative methods according to staining intensity.

RESULTS

The mean epithelial and stromal PTEN H-score in postmenopausal benign endometrial polyps (193.8 and 123.2, respectively) was significantly higher than that in the atrophic endometrium (135.5 and 90.2, p=0.008), and premenopausal benign endometrial polyps (100.7 and 198.7, p<0.001). Significant difference between postmenopausal endometrial polyps and endometrial carcinoma was noticed in the epithelial compartment (193.8 vs. 65.7, respectively, p<0.001).

CONCLUSION

Asymptomatic benign postmenopausal polyps have a distinctively high tumor suppression compared with endometrial cancer, suggesting low malignization potential.

Role of Microtearing Turbulence in DIII-D High Bootstrap Current Fraction Plasmas

We report on the first direct comparisons of microtearing turbulence simulations to experimental measurements in a representative high bootstrap current fraction (f_{BS}) plasma. Previous studies of high f_{BS} plasmas carried out in DIII-D with large radius internal transport barriers (ITBs) have found that, while the ion energy transport is accurately reproduced by neoclassical theory, the electron transport remains anomalous and not well described by existing quasilinear transport models. A key feature of these plasmas is the large value of the normalized pressure gradient, which is shown to completely stabilize conventional drift-wave and kinetic ballooning mode instabilities in the ITB, but destabilizes the microtearing mode. Nonlinear gyrokinetic simulations of the ITB region performed with the cgyro code demonstrate that the microtearing modes are robustly unstable and capable of driving electron energy transport levels comparable to experimental levels for input parameters consistent with the experimental measurements. These simulations uniformly predict that the microtearing mode fluctuation and flux spectra extend to significantly shorter wavelengths than the range of linear instability, representing significantly different nonlinear dynamics and saturation mechanisms than conventional drift-wave turbulence, which is also consistent with the fundamental tearing nature of the instability. The predicted transport levels are found to be most sensitive to the magnetic shear, rather than the temperature gradients more typically identified as driving turbulent plasma transport.

Proliferation in Postmenopausal Endometrial Polyps-A Potential for Malignant Transformation

Background and objectives: Endometrial polyps in asymptomatic postmenopausal women are often incidentally found, yet only 1.51% of them are malignant. Their potential for malignant transformation has not been adequately addressed. The aim of this study was to investigate the proliferation within endometrial polyps as one of the indicators of their malignization potential in asymptomatic postmenopausal women. Materials and Methods: Immunohistochemical studies of Ki-67 were performed. Cases included 52 benign postmenopausal polyps, 19 endometrioid carcinoma with coexisting benign polyps, 12 polyps with foci of carcinoma and 4 cases of polyps, which later developed carcinoma. The control group included 31 atrophic endometria and 32 benign premenopausal polyps. Ki-67 was scored in either 10 or 20 “hot spot” fields, as percentage of positively stained cells. Results: The median epithelial Ki-67 score in postmenopausal benign polyps (4.7%) was significantly higher than in atrophic endometria (2.41%, p < 0.0001) and significantly lower than in premenopausal benign polyps (11.4%, p = 0.003) and endometrial cancer (8.3%, p < 0.0001). Where endometrial polyps were found in association with endometrial carcinoma, Ki-67 was significantly higher in cancer (p < 0.0001). No significant difference was found between Ki-67 scores of cancer focus and of the polyps tissue itself, respectively 2.8% and 4.55%, p = 0.37. Ki-67 expression, where polyps were resected and women later developed cancer, was not significantly different (p = 0.199). Conclusion: Polyps from asymptomatic postmenopausal women showed significantly more proliferation in both epithelial and stromal components than inactive atrophic endometria but less than premenopausal benign polyps and/or endometrial cancer. Benign postmenopausal endometrial polyps exhibit low proliferative activity, suggesting low malignant potential and may not require resection in asymptomatic women.

Comparison of Clinical Outcomes Following Patients' First and Second Concussions

Purpose

The objective of this study was to examine differences in self-reported symptoms, neurocognitive performance, and vestibular-ocular insufficiencies between patients’ first and second concussions. A secondary purpose was to explore the role of risk factors on recovery.

Methods

We conducted a retrospective medical chart review of 73 (32-M/41-F) patients aged 15.69 (SD=1.67) years from a concussion specialty clinic with two separate concussions (84.9% of 1st and 79.5% of 2nd sport-related) that occurred between August 2010 and April 2018. Clinical outcomes included the PCSS, ImPACT, and the Vestibular/Ocular Motor Screening (VOMS). A series of paired samples t-tests were used to compare clinical outcomes along with chi-square analyses for risk factor associations.

Results

Verbal memory scores were higher following the second (M=80.67, SD=15.3) (M=76.32, SD=15.65) (t[73]=–2.18, p=.03) concussion. Visual motor processing speed was faster following the second concussion (M=35.04, SD= 7.90) (M=31.35, SD=7.63) (t[73]=–5.72, p<.001). There were no other significant differences observed. Recovery time was similar for the first (61.07, SD=58.41.5) and second (67.91 SD=70.10) respectively, t(70)=–.91, p=.37. There was no relationship between any risk factors, and recovery time for either injury with the exception a significant association between gender and recovery time (>21 days) with the 1st injury for females (χ2, N=73)=10.58, p=.001.

Conclusion

Findings suggest that a second concussion does not result in more pronounced symptoms, worse neurocognitive performance, or increased deficits on vestibular/ocular performance and/or longer recovery time. The only significant risk factor to a recovery over 21 days included gender.

Reliability and Factors Associated with False Positives on the Vestibular/Ocular Motor Screening (VOMS) Tool in US Military Personnel

Purpose

The US Military recently added the Vestibular/Ocular Motor Screening (VOMS) to the Military Acute Concussion Evaluation-2 (MACE-2). However, there are no published data on the VOMS in US military personnel. The purpose of this study was to examine the reliability of the VOMS and factors associated with false positives in healthy US Army Special Operations (USASOC) personnel.

Methods

206 healthy USASOC military personnel aged 18–40 completed VOMS between March 2018 – January 2019. Analyses included internal consistency, false-positive rates, intraclass correlation coefficients (ICC), chi-square analyses with odds ratios (OR), and independent samples t-tests. VOMS clinical cut-off scores (2+ on any symptom, >5cm for NPC) were used to determine false positives.

Results

Reliability for the VOMS symptom items (Cronbach alpha=.98, ICC=.90) and NPC distance (Cronbach’s alpha=.98, ICC=.93) were high. False positive rates ranged from 10.2% (smooth pursuits) to 16.9% (NPC distance). Concussion history was associated with a 2.5 fold increase for one or more VOMS items above cut-offs (p=.01). Participants with at least one VOMS item above cut-offs were deployed nearly 6 months longer on average than those without (p=.04).

Conclusion

The findings indicate that VOMS is reliable in US military personnel with few false positives. False positives were associated with concussion history and longer deployment history, which should be considered by military medical providers when administering and interpreting VOMS in this population. Moving forward, researchers should examine the stability of VOMS and its ability to identify mTBI in this population.

Incremental Validity of Components of the Vestibular/Ocular Motor Screening for Concussion

Purpose

The Vestibular/Ocular Motor Screening (VOMS) tool for concussion evaluates symptom provocation (in a fixed order) across the following neuromotor tasks: smooth pursuits (SP), saccades-horizontal (Sac-H), saccades-vertical (Sac-V), near point of convergence (NPC), vestibular-ocular reflex-horizontal (VOR-H), vestibular-ocular reflex-vertical (VOR-V), and visual motion sensitivity (VMS). The current study evaluates the incremental validity of each VOMS component in consecutive order.

Methods

Retrospective record review of 193 subjects (49% male) aged 10–22 years old diagnosed with concussion (sport and non-sport injuries) and demonstrated an abnormal VOMS (defined by symptom provocation >2 or NPC >5cm) at initial evaluation in a specialty concussion clinic. Hierarchical regression was performed with VOMS total score (range: 0-320) as the dependent variable and each VOMS component as predictors in seven consecutive steps.

Results

The model was significant (p<.001) at each step; the final model including all seven VOMS components in order (SP, Sac-H, Sac-V, NPC, VOR-H, VOR-V, and VMS) was significant, F(7,185)= 6.87, p<.001 and accounted for 20.6% of the variance in total VOMS score. The only significant predictors in the final model included: SP (p=.01), NPC (p=.04), and VOR-H (p=.04).

Conclusion

Provocation of symptoms on SP, NPC, and VOR-H are the best predictors of total VOMS score. NPC and VOR-H symptom provocation provide unique value to vestibular screening beyond symptom provocation on SP and after completion of all other VOMS components. This information may be clinically useful when vestibular screening must be expedited (e.g., highly symptomatic patient, sideline assessment).

Building Bridges for Innovation in Ageing: Synergies between Action Groups of the EIP on AHA

The Strategic Implementation Plan of the European Innovation Partnership on Active and Healthy Ageing (EIP on AHA) proposed six Action Groups. After almost three years of activity, many achievements have been obtained through commitments or collaborative work of the Action Groups. However, they have often worked in silos and, consequently, synergies between Action Groups have been proposed to strengthen the triple win of the EIP on AHA. The paper presents the methodology and current status of the Task Force on EIP on AHA synergies. Synergies are in line with the Action Groups' new Renovated Action Plan (2016-2018) to ensure that their future objectives are coherent and fully connected. The outcomes and impact of synergies are using the Monitoring and Assessment Framework for the EIP on AHA (MAFEIP). Eight proposals for synergies have been approved by the Task Force: Five cross-cutting synergies which can be used for all current and future synergies as they consider overarching domains (appropriate polypharmacy, citizen empowerment, teaching and coaching on AHA, deployment of synergies to EU regions, Responsible Research and Innovation), and three cross-cutting synergies focussing on current Action Group activities (falls, frailty, integrated care and chronic respiratory diseases).

Combined numerical and experimental biomechanical characterization of soft collagen hydrogel substrate

This work presents a combined experimental-numerical framework for the biomechanical characterization of highly hydrated collagen hydrogels, namely with 0.20, 0.30 and 0.40% (by weight) of collagen concentration. Collagen is the most abundant protein in the extracellular matrix of animals and humans. Its intrinsic biocompatibility makes collagen a promising substrate for embedding cells within a highly hydrated environment mimicking natural soft tissues. Cell behaviour is greatly influenced by the mechanical properties of the surrounding matrix, but the biomechanical characterization of collagen hydrogels has been challenging up to now, since they present non-linear poro-viscoelastic properties. Combining the stiffness outcomes from rheological experiments with relevant literature data on collagen permeability, poroelastic finite element (FE) models were developed. Comparison between experimental confined compression tests available in the literature and analogous FE stress relaxation curves showed a close agreement throughout the tests. This framework allowed establishing that the dynamic shear modulus of the collagen hydrogels is between 0.0097 ± 0.018 kPa for the 0.20% concentration and 0.0601 ± 0.044 kPa for the 0.40% concentration. The Poisson's ratio values for such conditions lie within the range of 0.495-0.485 for 0.20% and 0.480-0.470 for 0.40%, respectively, showing that rheology is sensitive enough to detect these small changes in collagen concentration and thus allowing to link rheology results with the confined compression tests. In conclusion, this integrated approach allows for accurate constitutive modelling of collagen hydrogels. This framework sets the grounds for the characterization of related hydrogels and to the use of this collagen parameterization in more complex multiscale models.

The Role of More Sensitive Helminth Diagnostics in Mass Drug Administration Campaigns: Elimination and Health Impacts

Diagnostics play a crucial role in determining treatment protocols and evaluating success of mass drug administration (MDA) programmes used to control soil-transmitted helminths (STHs). The current diagnostic, Kato-Katz, relies on inexpensive, reusable materials and can be used in the field, but only trained microscopists can read slides. This diagnostic always underestimates the true prevalence of infection, and the accuracy worsens as the true prevalence falls. We investigate how more sensitive diagnostics would impact on the management and life cycle of MDA programmes, including number of mass treatment rounds, health impact, number of unnecessary treatments and probability of elimination. We use an individual-based model of STH transmission within the current World Health Organization (WHO) treatment guidelines which records individual disability-adjusted life years (DALY) lost. We focus on Ascaris lumbricoides due to the availability of high-quality data on existing diagnostics. We show that the effect of improving the sensitivity of diagnostics is principally determined by the precontrol prevalence in the community. Communities at low true prevalence (<30%) and high true prevalence (>70%) do not benefit greatly from improved diagnostics. Communities with intermediate prevalence benefit greatly from increased chemotherapy application, both in terms of reduced DALY loss and increased probability of elimination. Our results suggest that programmes should be extended beyond school-age children, especially in high prevalence communities. Finally, we argue against using apparent or measured prevalence as an uncorrected proxy for true prevalence.

Horses and cows might teach us about human knees

Our comparative study of the knees of horses and cows (paraphrased as highly evolved joggers and as domesticated couch-potatoes, respectively) demonstrates significant differences in the posterior sections of bovine and equine tibial cartilage, which are consistent with specialisation for gait. These insights were possible using a novel analytical measuring technique based on the shearing of small biopsy samples, called dynamic shear analysis. We assert that this technique could provide a powerful new tool to precisely quantify the pathology of osteoarthritis for the medical field.

Perioperative nutrition interventions for women with ovarian cancer

BACKGROUND

Women with ovarian cancer have been shown to be at significant risk of malnutrition with incidence rates described as being between 28% to 67%. Nutrition interventions may improve clinical outcomes positively, nutritional status or quality of life measures in this patient group.

OBJECTIVES

This review was conducted to assess the effects of nutrition interventions during the perioperative period for women with ovarian cancer.

SEARCH METHODS

Electronic searches were conducted of the Cochrane Gynaecological Cancer Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL 2012, Issue 7), Medline (1946 to July week 4 2012), Embase (1980 to 2012 week 31), DARE (to 7th August 2012) AMED (1985 to April 2012), BNI (1992 to April 2012), CINAHL (to April 2012). We also searched trials databases, conference proceedings and related citation lists. Reference listings were handsearched. No restrictions were applied on language or date.

SELECTION CRITERIA

Randomised controlled trials (RCTs) in which women 18 years and over with any stage of ovarian cancer, including recurrent cancer, were in the perioperative phase of treatment and received any type of nutrition intervention.

DATA COLLECTION AND ANALYSIS

Titles and abstracts were screened by two review authors with study selection discussed by a team. Pairs of review authors worked independently on data collection and compared findings.

MAIN RESULTS

A total of 4092 titles were screened and 14 full text reports reviewed; a single small study met the inclusion criteria. In the included RCT, 40 women (35 with ovarian cancer) had extensive elective surgery including bowel resection for treatment of gynaecological malignancy. Randomisation was made to either early oral feeding (oral fluids in the first 24 hours, solid foods on the following day) or to a 'traditional' feeding regimen where oral fluids and foods were delayed until there was evidence of bowel function. Most women in the early feeding group (14/18) were able to resume eating solid food one day after surgery. This resulted in a significantly shorter hospital stay with no increase in postoperative complications or change in quality of life measures in comparison with the women on the 'traditional' feeding regimen. The incidence of nausea and vomiting during the postoperative stay was similar in both groups and was noted in slightly more than half of the women. Overall survival was evaluated until 30 days following discharge from hospital; in this period, there was one death of a woman who had been in the 'traditional oral feeding' group, cause of death was not noted. We assessed risk of bias and found no high risk of bias was identified in the methodology and reporting of the included study, although there was an increased risk of bias due to the small size of the study in which not all of the women had ovarian cancer.

AUTHORS' CONCLUSIONS

Although women with ovarian cancer have been shown to be at risk of malnutrition, there is a lack of evidence derived from RCTs evaluating the identification, assessment and treatment of malnutrition during the perioperative phase of treatment. There is evidence from one small study that some women with ovarian cancer undergoing surgery with associated bowel resection may safely commence oral fluids within 24 hours of surgery and solid foods on the following day. Further research is required, including a RCT, to generate guidance concerning the treatment of malnutrition in this patient group.

Endoscopic ultrasound-guided fine needle aspiration training: evaluation of a new porcine lymphadenopathy model for in vivo hands-on teaching and training, and review of the literature

BACKGROUND AND STUDY AIMS

Adequate training is required to achieve successful endoscopic ultrasound (EUS)-guided fine-needle aspiration (EUS-FNA). Of the variety of training models currently available, none offers verisimilitude to the tactile feel of puncturing a human lymph node. The aim of the current study was to evaluate a new porcine lymph node model for EUS-FNA training and to evaluate its impact on trainees' performance in patients compared with the literature of other models available.

METHODS

Two trainees each performed EUS-FNA of 96 lymph nodes in 18 animals with induced lymphadenopathy (mean 1.6 cm [range 0.9-3.5 cm]). Accuracy, speed, adequacy of sampling, and trainees' performance pre- and post-training were measured. Using a questionnaire, data were gathered regarding the effect of training and comfort level in patients. Results were compared with those in the literature.

RESULTS

Trainees progressed from hands-on assistance to occasional verbal guidance toward the end of animal training. There was good correlation between puncture time and number of EUS-FNA procedures performed in all but the subcarinal location (r = - 0.17). Comparison of trainee performance in patients before and after training showed a reduction in puncture time (P = 0.0014). Questionnaire analysis revealed increased confidence in echoendoscope- and needle-handling. Comparison with other published models supports these results.

CONCLUSION

Results from the literature and the current study showed that animal training improves trainee performance, confidence, and procedural comfort when returning to patient examinations. The new model produces a realistic response that is similar to EUS-FNA in patients; this experience provides a benefit to endoscopists in terms of improved performance in patients and could be considered for use in accreditation. Due to the small numbers of trainees, larger experiences are needed to confirm training efficacy.

Observation of a critical gradient threshold for electron temperature fluctuations in the DIII-D Tokamak

A critical gradient threshold has been observed for the first time in a systematic, controlled experiment for a locally measured turbulent quantity in the core of a confined high-temperature plasma. In an experiment in the DIII-D tokamak where L(T(e))(-1) = |∇T(e)|/T(e) and toroidal rotation were varied, long wavelength (k(θ)ρ(s) ≲ 0.4) electron temperature fluctuations exhibit a threshold in L(T(e))(-1): below, they change little; above, they steadily increase. The increase in δT(e)/T(e) is concurrent with increased electron heat flux and transport stiffness. Observations were insensitive to rotation. Accumulated evidence strongly enforces the identification of the experimentally observed threshold with ∇T(e)-driven trapped electron mode turbulence.

2D full wave modeling for a synthetic Doppler backscattering diagnostic

Doppler backscattering (DBS) is a plasma diagnostic used in tokamaks and other magnetic confinement devices to measure the fluctuation level of intermediate wavenumber (k(θ)ρ(s) ~ 1) density fluctuations and the lab frame propagation velocity of turbulence. Here, a synthetic DBS diagnostic is described, which has been used for comparisons between measurements in the DIII-D tokamak and predictions from nonlinear gyrokinetic simulations. To estimate the wavenumber range to which a Gaussian beam would be sensitive, a ray tracing code and a 2D finite difference, time domain full wave code are used. Experimental density profiles and magnetic geometry are used along with the experimental antenna and beam characteristics. An example of the effect of the synthetic diagnostic on the output of a nonlinear gyrokinetic simulation is presented.