Outcome and feasibility of radiotherapy bridging in large B-cell lymphoma patients receiving CD19 CAR T in the UK

Radiotherapy (RT) has potential synergistic effects with chimeric antigen receptor (CAR) T but is not widely used as bridging therapy due to logistical challenges and lack of standardised protocols. We analysed RT bridging in a multicentre national cohort of large B-cell lymphoma patients approved for 3L axicabtagene ciloleucel or tisagenlecleucel across 12 UK centres. Of 763 approved patients, 722 were leukapheresed, 717 had data available on bridging therapy. 169/717 (24%) received RT bridging, 129 as single modality and 40 as combined modality treatment (CMT). Of 169 patients, 65.7% had advanced stage, 36.9% bulky disease, 86.5% elevated LDH, 41.7% international prognostic index (IPI) ≥3 and 15.2% double/triple hit at the time of approval. Use of RT bridging varied from 11% to 32% between centres and increased over time. Vein-to-vein time and infusion rate did not differ between bridging modalities. RT-bridged patients had favourable outcomes with 1-year progression-free survival (PFS) of 56% for single modality and 47% for CMT (1-year PFS 43% for systemic bridging). This is the largest cohort of LBCL patients receiving RT bridging prior to CAR T reported to date. Our results show that RT bridging can be safely and effectively used even in advanced stage and high-risk disease, with low dropout rates and excellent outcomes.

Dynamics of magnetization at infinite temperature in a Heisenberg spin chain

Understanding universal aspects of quantum dynamics is an unresolved problem in statistical mechanics. In particular, the spin dynamics of the one-dimensional Heisenberg model were conjectured as to belong to the Kardar-Parisi-Zhang (KPZ) universality class based on the scaling of the infinite-temperature spin-spin correlation function. In a chain of 46 superconducting qubits, we studied the probability distribution of the magnetization transferred across the chain's center, [Formula: see text]. The first two moments of [Formula: see text] show superdiffusive behavior, a hallmark of KPZ universality. However, the third and fourth moments ruled out the KPZ conjecture and allow for evaluating other theories. Our results highlight the importance of studying higher moments in determining dynamic universality classes and provide insights into universal behavior in quantum systems.

Stable quantum-correlated many-body states through engineered dissipation

Engineered dissipative reservoirs have the potential to steer many-body quantum systems toward correlated steady states useful for quantum simulation of high-temperature superconductivity or quantum magnetism. Using up to 49 superconducting qubits, we prepared low-energy states of the transverse-field Ising model through coupling to dissipative auxiliary qubits. In one dimension, we observed long-range quantum correlations and a ground-state fidelity of 0.86 for 18 qubits at the critical point. In two dimensions, we found mutual information that extends beyond nearest neighbors. Lastly, by coupling the system to auxiliaries emulating reservoirs with different chemical potentials, we explored transport in the quantum Heisenberg model. Our results establish engineered dissipation as a scalable alternative to unitary evolution for preparing entangled many-body states on noisy quantum processors.

Development and external validation of a machine learning model for prediction of survival in undifferentiated pleomorphic sarcoma

PURPOSE

Machine learning (ML) algorithms to predict cancer survival have recently been reported for a number of sarcoma subtypes, but none have investigated undifferentiated pleomorphic sarcoma (UPS). ML is a powerful tool that has the potential to better prognosticate UPS.

METHODS

The Surveillance, Epidemiology, and End Results (SEER) database was queried for cases of histologically confirmed undifferentiated pleomorphic sarcoma (UPS) (n = 665). Patient, tumor, and treatment characteristics were recorded, and ML models were developed to predict 1-, 3-, and 5-year survival. The best performing ML model was externally validated using an institutional cohort of UPS patients (n = 151).

RESULTS

All ML models performed best at the 1-year time point and worst at the 5-year time point. On internal validation within the SEER cohort, the best models had c-statistics of 0.67-0.69 at the 5-year time point. The Multi-Layer Perceptron Neural Network (MLP) model was the best performing model and used for external validation. Similarly, the MLP model performed best at 1-year and worst at 5-year on external validation with c-statistics of 0.85 and 0.81, respectively. The MLP model was well calibrated on external validation. The MLP model has been made publicly available at https://rachar.shinyapps.io/ups_app/ .

CONCLUSION

Machine learning models perform well for survival prediction in UPS, though this sarcoma subtype may be more difficult to prognosticate than other subtypes. Future studies are needed to further validate the machine learning approach for UPS prognostication.

The diagnostic Accuracy of Visual versus automated dipstick proteinuria testing in Pregnancy: A systematic review and Meta-Analysis

OBJECTIVE

To evaluate the diagnostic accuracy of point-of-care (POC) tests for detecting proteinuria in pregnant women.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

MEDLINE and EMBASE databases were searched from inception to 13 November 2020.

ELIGIBILITY CRITERIA AND DATA ANALYSIS

Included studies measured the sensitivity and specificity ofPOC proteinuria testing compared to laboratory reference standards (protein-creatinine ratio (PCR), 24-hour urine collection). Bivariate meta-analyses determined pooled sensitivity and specificity. Random-effects inverse-variance model determinedheterogeneity.

MAIN OUTCOME MEASURES

The primary outcome was overall sensitivity and specificity, stratified by method of POC testing and reference standard. Secondary outcomes were sensitivity and specificity within thesubgroupstest brand, reference standard, and hypertension status.

RESULTS

1078 studies were identified, 17 studies comprising 23 comparisons were included. The meta-analysis included 13 studies with 19 comparisons. Pooled sensitivity and specificity of visual dipsticks against PCR was 72 % (95 % CI: 56 % to 84 %) and 92 % (95 % CI: 76 % to 98 %), respectively. Pooled sensitivity and specificity of visual dipsticks against 24-hour collection was 69 % (55 % to 80 %) and 70 % (51 % to 84 %), respectively. Pooled sensitivity and specificity for automated readers against PCR was 73 % (53 % to 86 %) and 91 % (83 % to 95 %), respectively. Pooled sensitivity and specificity of automated readers against 24-hour collection was 65 % (42 % to 83 %) and 82 % (46 % to 96 %), respectively.

CONCLUSION

Visual dipsticks have comparable accuracy to automated readers, yet are notadequate as a rule-out test for proteinuria. Proteinuria POC testing maybe beneficial inantenatal care when repeatfollow-up tests are performed. PROSPERO Registration Number: CRD42021231914.

Improved outcomes of large B-cell lymphoma patients treated with CD19 CAR T in the UK over time

The success of CD19 Chimeric antigen receptor (CAR) T-cell therapy in large B-cell lymphoma (LBCL) has been partially offset by toxicity and logistical challenges, which off-the-shelf agents like CD20xCD3 bispecific antibodies might potentially overcome. However, when using CAR T outcomes as the 'standard-of-care comparator̕ for relapsed/refractory (r/r) LBCL, a potential learning curve with implementing a novel, complex therapy like CAR T needs to be considered. To address this, we analysed 726 UK patients intended to be treated with CD19 CAR T for r/r LBCL and compared outcomes between the first year of the national CAR T programme (Era 1; 2019) and the more recent treatment era (Era 2; 2020-2022). We identified significant improvements for Era 2 versus Era 1 in dropout rate (17% vs. 27%, p = 0.001), progression-free survival (1-year PFS 50% vs. 32%, p < 0.001) and overall survival (1-year OS 60% vs. 40%, p < 0.001). We also observed increased use of bridging therapy, improvement in bridging outcomes, more tocilizumab/corticosteroid use, reduced high-grade cytokine release syndrome (4% vs. 9%, p = 0.01) and intensive care unit admissions (20% vs. 32%, p = 0.001). Our results demonstrate significant improvement in CAR T outcomes over time, highlighting the importance of using up-to-date clinical data when comparing CAR T against new treatment options for r/r LBCL.

Real-time x-ray abnormality alerts for emergency departments using a radiographer comment model - a multisite pilot study

INTRODUCTION

The timely communication of clinically significant image appearances to Emergency Department (ED) referrers is necessary for optimum patient care. Australian reliance on verbal communication only is time-limited, open to misinterpretation and lacks transparency. A combined radiographer alert and comment model was designed to reliably communicate image abnormalities to ED referrers in real-time.

METHODS

A multidisciplinary steering group designed the model for all ED general imaging. Protocols were developed to document radiographer comments (critical, urgent and clinically significant) in patients' medical records. Critical findings were communicated directly to ED. Five NSW hospitals varying in size, complexity and population demographics piloted the model between three to twelve months during 2021-2022. Site auditors compared comments with the radiology report and designated each as True Positive (TP), False Positive (FP), indeterminate and clinically significant. Indeterminate cases were analysed by an external radiologist. Inter-observer consensus was obtained for all classifications via two independent auditors. The Positive Predictive Value (PPV), or precision of the comment, was calculated for each site.

RESULTS

Radiographers (n = 69) provided comments for 1102 cases. The pooled average PPV for TP was 0.96; (0.947-0.971; 95% CI). The weighted mean error (FP comments) was 3.9%; (2.9% - 5.3%.; 95% CI).

CONCLUSION

The Radiographer Comment model provided consistent levels of commenting precision and reproducibility across a range of sites with a pooled average PPV (0.96). The False Positive rate or weighted mean error (FP) of 3.9% (2.9% - 5.3%.; 95% CI) was low.

IMPLICATIONS FOR FUTURE PRACTICE

A strategic, interprofessional approach in the implementation of an image alert combined with a Radiographer Comment can be adapted across a variety of hospital settings for ED and other departments.

The use of eye-tracking technology as a tool to evaluate social cognition in people with an intellectual disability: a systematic review and meta-analysis

BACKGROUND

Relatively little is known about social cognition in people with intellectual disability (ID), and how this may support understanding of co-occurring autism. A limitation of previous research is that traditional social-cognitive tasks place a demand on domain-general cognition and language abilities. These tasks are not suitable for people with ID and lack the sensitivity to detect subtle social-cognitive processes. In autism research, eye-tracking technology has offered an effective method of evaluating social cognition-indicating associations between visual social attention and autism characteristics. The present systematic review synthesised research which has used eye-tracking technology to study social cognition in ID. A meta-analysis was used to explore whether visual attention on socially salient regions (SSRs) of stimuli during these tasks correlated with degree of autism characteristics presented on clinical assessment tools.

METHOD

Searches were conducted using four databases, research mailing lists, and citation tracking. Following in-depth screening and exclusion of studies with low methodological quality, 49 articles were included in the review. A correlational meta-analysis was run on Pearson's r values obtained from twelve studies, reporting the relationship between visual attention on SSRs and autism characteristics.

RESULTS AND CONCLUSIONS

Eye-tracking technology was used to measure different social-cognitive abilities across a range of syndromic and non-syndromic ID groups. Restricted scan paths and eye-region avoidance appeared to impact people's ability to make explicit inferences about mental states and social cues. Readiness to attend to social stimuli also varied depending on social content and degree of familiarity. A meta-analysis using a random effects model revealed a significant negative correlation (r = -.28, [95% CI -.47, -.08]) between visual attention on SSRs and autism characteristics across ID groups. Together, these findings highlight how eye-tracking can be used as an accessible tool to measure more subtle social-cognitive processes, which appear to reflect variability in observable behaviour. Further research is needed to be able to explore additional covariates (e.g. ID severity, ADHD, anxiety) which may be related to visual attention on SSRs, to different degrees within syndromic and non-syndromic ID groups, in order to determine the specificity of the association with autism characteristics.

Deconvolving microbial and environmental controls on marine sedimentary pyrite sulfur isotope ratios

Reconstructions of past environmental conditions and biological activity are often based on bulk stable isotope proxies, which are inherently open to multiple interpretations. This is particularly true of the sulfur isotopic composition of sedimentary pyrite (δ34Spyr), which is used to reconstruct ocean-atmosphere oxidation state and track the evolution of several microbial metabolic pathways. We present a microanalytical approach to deconvolving the multiple signals that influence δ34Spyr, yielding both the unambiguous determination of microbial isotopic fractionation (εmic) and new information about depositional conditions. We applied this approach to recent glacial-interglacial sediments, which feature over 70‰ variations in bulk δ34Spyr across these environmental transitions. Despite profound environmental change, εmic remained essentially invariant throughout this interval and the observed range in δ34Spyr was instead driven by climate-induced variations in sedimentation.

Single fathers' experiences of using egg donation and surrogacy to start a family

STUDY QUESTION

What are the experiences of single men using egg donation and surrogacy as a route to parenthood?

SUMMARY ANSWER

The fathers mainly had a positive relationship with the surrogate and simultaneously exercised agency, and experienced challenges, during the process of surrogacy.

WHAT IS KNOWN ALREADY

Little is known about single men's experiences of egg donation and surrogacy arrangements. Studies have focused on single men's decision-making processes about the use of surrogacy and family functioning once these families are formed. Questions remain about how fathers experience and navigate the process of surrogacy as a single man.

STUDY DESIGN, SIZE, DURATION

The study is an international, in-depth qualitative study of fathers who chose to begin a family and parent alone. Data were collected between 2018 and 2021 as part of a larger study of solo fathers with different routes to parenthood. The present study reports on 21 fathers who used surrogacy and egg donation to begin their family. The average age of the fathers was 44 years, the fathers had young children aged 6 years or younger, and lived in countries across Australia, Europe, and North America.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Purposive sampling was used to recruit participants. In-depth semi-structured interviews were conducted. Interview topics included fathers' experiences of the process of using egg donation and surrogacy, and navigating the relationship with the surrogate. The audio-recorded interviews lasted around 2 hours and were subsequently transcribed verbatim.

MAIN RESULTS AND THE ROLE OF CHANCE

Data were analysed using reflexive thematic analysis and qualitative content analysis. Most of the fathers chose an identifiable egg donor. Regarding the relationship with the surrogate, many fathers had remained in contact with her, but to differing degrees, and they generally reported positive relationships. Thematic analysis led to the identification of three themes relating to the fathers' experiences of choosing surrogacy as a single man: the ability to make choices; challenges and constraints; and special relationship.

LIMITATIONS, REASONS FOR CAUTION

Due to the variation between different countries regarding laws on surrogacy, contextual factors may have impacted on the experiences of single fathers, and the sample size was small. However, the research provides new insights into an area with little academic literature.

WIDER IMPLICATIONS OF THE FINDINGS

Given the growing trend of single men having children through surrogacy, the findings suggest that this new path to parenthood can be both rewarding and challenging. Single men may benefit from tailored support and counselling to help them navigate the surrogacy journey.

STUDY FUNDING/COMPETING INTEREST(S)

This study was funded by the Wellcome Trust (grant number 208013/Z/17/Z). The authors have no conflicts of interest to declare.

TRIAL REGISTRATION NUMBER

n/a.

Measurement-induced entanglement and teleportation on a noisy quantum processor

Measurement has a special role in quantum theory1: by collapsing the wavefunction, it can enable phenomena such as teleportation2 and thereby alter the 'arrow of time' that constrains unitary evolution. When integrated in many-body dynamics, measurements can lead to emergent patterns of quantum information in space-time3-10 that go beyond the established paradigms for characterizing phases, either in or out of equilibrium11-13. For present-day noisy intermediate-scale quantum (NISQ) processors14, the experimental realization of such physics can be problematic because of hardware limitations and the stochastic nature of quantum measurement. Here we address these experimental challenges and study measurement-induced quantum information phases on up to 70 superconducting qubits. By leveraging the interchangeability of space and time, we use a duality mapping9,15-17 to avoid mid-circuit measurement and access different manifestations of the underlying phases, from entanglement scaling3,4 to measurement-induced teleportation18. We obtain finite-sized signatures of a phase transition with a decoding protocol that correlates the experimental measurement with classical simulation data. The phases display remarkably different sensitivity to noise, and we use this disparity to turn an inherent hardware limitation into a useful diagnostic. Our work demonstrates an approach to realizing measurement-induced physics at scales that are at the limits of current NISQ processors.

Nursing, midwifery, and allied health professions research capacities and cultures: a survey of staff within a university and acute healthcare organisation

BACKGROUND

There is an increasing focus on the development of research capacity and culture in Nursing, Midwifery and Allied Health Professions (NMAHP). However, better understanding of the existing research success and skills, motivators, barriers, and development needs of NMAHP professionals is required to inform this development. This study sought to identify such factors within a university and an acute healthcare organisation.

METHODS

An online survey, incorporating the Research Capacity and Culture tool, was administered to NMAHP professionals and students at a university and an acute healthcare organisation in the United Kingdom. Ratings of success/skill levels of teams and individuals were compared between professional groups using Mann-Whitney U tests. Motivators, barriers, and development needs were reported using descriptive statistics. Descriptive thematic analysis was used for open-ended text responses.

RESULTS

A total of 416 responses were received (N&M n = 223, AHP n = 133, Other n = 60). N&M respondents were more positive than their AHP counterparts about the success/skill levels of their teams. There were no significant differences between N&M and AHP in their ratings of individual successes/skills. Finding and critically reviewing relevant literature were identified as specific individual strengths; with weaknesses in securing research funding, submitting ethics applications, writing for publication, and advising less experienced researchers. The main motivators for research were to develop skills, increased job satisfaction, and career advancement; whilst barriers included lack of time for research and other work roles taking priority. Key support needs identified included mentorship (for teams and individuals) and in-service training. Open-ended questions generated main themes of 'Employment & staffing', 'Professional services support', 'Clinical & academic management', 'Training & development', 'Partnerships' and 'Operating principles'. Two cross-cutting themes described issues common to multiple main themes: 'Adequate working time for research' and 'Participating in research as an individual learning journey'.

CONCLUSIONS

Rich information was generated to inform the development of strategies to enhance research capacity and culture in NMAHP. Much of this can be generic but some nuances may be required to address some specific differences between professional groups, particularly related to perceived team success/skills and priorities identified for support and development.

Non-Abelian braiding of graph vertices in a superconducting processor

Indistinguishability of particles is a fundamental principle of quantum mechanics¹. For all elementary and quasiparticles observed to date-including fermions, bosons and Abelian anyons-this principle guarantees that the braiding of identical particles leaves the system unchanged^2,3. However, in two spatial dimensions, an intriguing possibility exists: braiding of non-Abelian anyons causes rotations in a space of topologically degenerate wavefunctions^4-8. Hence, it can change the observables of the system without violating the principle of indistinguishability. Despite the well-developed mathematical description of non-Abelian anyons and numerous theoretical proposals^9-22, the experimental observation of their exchange statistics has remained elusive for decades. Controllable many-body quantum states generated on quantum processors offer another path for exploring these fundamental phenomena. Whereas efforts on conventional solid-state platforms typically involve Hamiltonian dynamics of quasiparticles, superconducting quantum processors allow for directly manipulating the many-body wavefunction by means of unitary gates. Building on predictions that stabilizer codes can host projective non-Abelian Ising anyons^9,10, we implement a generalized stabilizer code and unitary protocol²³ to create and braid them. This allows us to experimentally verify the fusion rules of the anyons and braid them to realize their statistics. We then study the prospect of using the anyons for quantum computation and use braiding to create an entangled state of anyons encoding three logical qubits. Our work provides new insights about non-Abelian braiding and, through the future inclusion of error correction to achieve topological protection, could open a path towards fault-tolerant quantum computing.

Exploring the benefits of nature-based interventions in socio-economically deprived communities: a narrative review of the evidence to date

AIM

Socio-economic deprivation encompasses the relative disadvantage experienced by individuals or communities in relation to financial, material or social resources. Nature-based interventions (NBIs) are a public health approach that promote sustainable, healthy communities through engagement with nature and show potential to address inequalities experienced by socio-economically deprived communities. This narrative review aims to identify and evaluate the benefits of NBIs in socio-economically deprived communities.

METHOD

A systematic literature search of six electronic publication databases (APA PsycInfo, CENTRAL, CDSR, CINAHL, Medline and Web of Science) was conducted on 5 February 2021 and repeated on 30 August 2022. In total, 3852 records were identified and 18 experimental studies (published between 2015 and 2022) were included in this review.

RESULTS

Interventions including therapeutic horticulture, care farming, green exercise and wilderness arts and craft were evaluated in the literature. Key benefits were observed for cost savings, diet diversity, food security, anthropometric outcomes, mental health outcomes, nature visits, physical activity and physical health. Age, gender, ethnicity, level of engagement and perception of environment safety influenced the effectiveness of the interventions.

CONCLUSION

Results demonstrate there are clear benefits of NBIs on economic, environmental, health and social outcomes. Further research including qualitative analyses, more stringent experimental designs and use of standardised outcome measures is recommended.

"But not the music": psychopathic traits and difficulties recognising and resonating with the emotion in music

Recognising and responding appropriately to emotions is critical to adaptive psychological functioning. Psychopathic traits (e.g. callous, manipulative, impulsive, antisocial) are related to differences in recognition and response when emotion is conveyed through facial expressions and language. Use of emotional music stimuli represents a promising approach to improve our understanding of the specific emotion processing difficulties underlying psychopathic traits because it decouples recognition of emotion from cues directly conveyed by other people (e.g. facial signals). In Experiment 1, participants listened to clips of emotional music and identified the emotional content (Sample 1, N = 196) or reported on their feelings elicited by the music (Sample 2, N = 197). Participants accurately recognised (t(195) = 32.78, p < .001, d = 4.69) and reported feelings consistent with (t(196) = 7.84, p < .001, d = 1.12) the emotion conveyed in the music. However, psychopathic traits were associated with reduced emotion recognition accuracy (F(1, 191) = 19.39, p < .001) and reduced likelihood of feeling the emotion (F(1, 193) = 35.45, p < .001), particularly for fearful music. In Experiment 2, we replicated findings for broad difficulties with emotion recognition (Sample 3, N = 179) and emotional resonance (Sample 4, N = 199) associated with psychopathic traits. Results offer new insight into emotion recognition and response difficulties that are associated with psychopathic traits.

CAR T in patients with large B-cell lymphoma not fit for autologous transplant

Large B-cell lymphoma (LBCL) patients with comorbidities and/or advanced age are increasingly considered for treatment with CD19 CAR T, but data on the clinical benefit of CAR T in the less fit patient population are still limited. We analysed outcomes of consecutive patients approved for treatment with axicabtagene ciloleucel (axi-cel) or tisagenlecleucel (tisa-cel) by the UK National CAR T Clinical Panel, according to fitness for autologous stem cell transplant (ASCT). 81/404 (20%) of approved patients were deemed unfit for ASCT. Unfit patients were more likely to receive tisa-cel versus axi-cel (52% vs. 48%) compared to 20% versus 80% in ASCT-fit patients; p < 0.0001. The drop-out rate from approval to infusion was significantly higher in the ASCT-unfit group (34.6% vs. 23.5%; p = 0.042). Among infused patients, response rate, progression-free and overall survival were similar in both cohorts. CAR T was well-tolerated in ASCT-unfit patients with an incidence of grade ≥3 cytokine release syndrome and neurotoxicity of 2% and 11%, respectively. Results from this multicentre real-world cohort demonstrate that CD19 CAR T can be safely delivered in carefully selected older patients and patients with comorbidities who are not deemed suitable for transplant.

'I know it's not normal but it's normal to me, and that's all that matters': experiences of young adults conceived through egg donation, sperm donation, and surrogacy

STUDY QUESTION

What are thoughts and feelings of young adults born following egg donation, sperm donation, and surrogacy?

SUMMARY ANSWER

Young adults felt either unconcerned or positive about the method of their conception.

WHAT IS KNOWN ALREADY

Much of what we know about adults born to heterosexual couples following anonymous donation has come from samples of donor conceived people who had found out about their origins during adulthood. There have been no studies of how young adults born through surrogacy feel about their conception and towards their surrogate.

STUDY DESIGN, SIZE, DURATION

Thirty-five young adults were interviewed as part of the seventh phase of a larger multi-method, multi-informant longitudinal study of assisted conception families in the UK. Adults were conceived using either egg donation, sperm donation, gestational surrogacy, or genetic surrogacy and were raised in households headed by heterosexual couples.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Participants had a mean age of 20 years and were born following traditional surrogacy (n = 10), gestational surrogacy (n = 5), egg donation (n = 11), or sperm donation (n = 9). All young adults born following sperm donation and most (n = 10) born from egg donation had an anonymous donor. In all surrogacy arrangements, the parents had met the surrogate prior to treatment. The majority of young adults were told about their conception by the age of 4 years. Participants were interviewed over the internet using a semi-structured interview. Interviews were transcribed verbatim and analysed using qualitative content analysis to understand young adults' thoughts and experiences related to their conception and whether they were interested in meeting their donor or surrogate.

MAIN RESULTS AND THE ROLE OF CHANCE

Fourteen (40%) young adults felt their conception made them feel special or unique, with the remainder feeling either neutral or unconcerned (n = 21, 60%). A higher proportion of young adults conceived using egg donation (n = 8, 73%) felt unique/special compared to young adults born following sperm donation and surrogacy. For 10 of the young adults, their feelings about their conception had changed over time, with most becoming more positive (n = 9, 26%). For most young adults (n = 22, 63%), conception was rarely or infrequently discussed with others. However, when it was, these conversations were largely conducted with ease. Most (n = 25, 71%) did not know other individuals born through the same method of conception as themselves, and the vast majority (n = 34, 97%) were not members of any support groups. For the 25 young adults not in contact with their donor or surrogate, 11 wished to meet them, 8 did not want to have contact, and 6 were unsure. Young adults in contact with their donor or surrogate had varying levels of closeness to them. Only one young adult had searched for the identity of their donor.

LIMITATIONS, REASONS FOR CAUTION

Of the 47 young adults invited to participate in the present study, 35 agreed to take part resulting in a response rate of 74%. It is therefore not known how those who did not take part felt about their conception. Given that the families reported here had been taking part in this longitudinal study from when the target child was aged 1 year, they may have been more likely to discuss the child's conception than other families. The study also utilized self-report measures, which may have been prone to social desirability, with donor conceived young adults wanting to present their experiences in a positive light.

WIDER IMPLICATIONS OF THE FINDINGS

The findings suggest that young adults born through surrogacy and donor conception do not feel negatively about their birth and this may be a consequence of the young age at which they found out about their conception. Although some young adults said they wished to meet their donor, this did not necessarily mean they were actively searching for them.

STUDY FUNDING/COMPETING INTEREST(S)

The study was funded by the Wellcome Trust [grant number 208013/Z/17/Z]. The authors have no conflicts of interest to declare.

TRIAL REGISTRATION NUMBER

N/A.

Relational Coordination as a Predictor of Job Satisfaction and Intent to Stay Among Nurses and Physicians in the Military Health System

INTRODUCTION

Job satisfaction and retention of military and civilian nurses and physicians who work in military treatment facilities (MTFs) are critical to maintaining quality of care and operational readiness. Civilian nurses and physicians working in MTFs supplement staffing for active duty military nurses and physicians and support operational readiness when military nurses and physicians deploy in wartime crises or humanitarian efforts. Decreased retention of military and civilian nurses and physicians can negatively impact operational readiness and patient care outcomes. Although several factors (e.g., burnout, pay, and leadership) influence job satisfaction and retention among nurses and physicians in both military and civilian healthcare settings, high-quality communication and relationships between nurses and physicians are associated with better job satisfaction and retention. However, little is known about how high-quality communication and relationships affect job satisfaction and retention among nurses and physicians in MTFs. Relational coordination (RC) is a process of high-quality communication supported by relationships of shared knowledge, shared goals, and mutual respect among members of the healthcare team. By strengthening RC, hospital leaders can more effectively achieve desired outcomes. The purpose of this study was to explore how RC influences job satisfaction and intent to stay among nurses, residents, and physicians in an Army hospital, and whether job satisfaction mediated the relationship between RC and intent to stay.

MATERIALS AND METHODS

We conducted an exploratory, cross-sectional study in a 138-bed MTF in the southeastern USA and invited a convenience sample of military and civilian nurses, residents, and physicians to complete a 47-item survey on RC, job satisfaction, and intent to stay. We used Pearson's correlation to explore relationships between RC, job satisfaction, and intent to stay and then employed multiple regression to explore whether RC predicts job satisfaction and intent to stay, after controlling for professional role, demographic characteristics, and other covariates. Furthermore, we explored whether job satisfaction mediates the relationship between RC and intent to stay.

RESULTS

Two hundred and eighty-nine participants completed the survey. Seventy percentage of respondents were civilian, were Caucasian (61%), and had a mean age of 40 years old. The RCs within roles (β = 0.76, P < .001) and between roles (β = 0.46, P < .001) were both positively associated with job satisfaction. RCs within roles was associated with higher intent to stay (β = 0.38, P = .005). Civilian nurses and physicians reported higher intent to stay, followed by officers and enlisted service members. Job satisfaction mediated the relationship between RC within roles and intent to stay.

CONCLUSION

Our findings suggest that RC is a powerful workplace dynamic that influences job satisfaction and intent to stay, for nurses, residents, and physicians in MTFs. Specifically, we found that RC was positively associated with job satisfaction and intent to stay and that job satisfaction mediates the relationship between RC and intent to stay. We recommend that hospital leaders in MTFs explore interventions to strengthen RC among health professionals by including relational, work process and structural interventions as part of their strategy for retaining military healthcare professionals.

Outcomes in Patients With von Willebrand Disease Receiving Recombinant von Willebrand Factor on Demand and in Surgical Settings: Chart Review

This European observational chart review assessed the efficacy/safety of recombinant von Willebrand factor (rVWF) for on-demand treatment of spontaneous/traumatic bleeds and prevention and/or treatment of surgery-related bleeding in adults with von Willebrand disease (VWD). Patients (n = 91) were enrolled at first rVWF administration (index). Data were collected for the 12 months before index and until death, loss to follow-up, or end of study (3-12 months after index). Fifteen patients reported an rVWF-treated spontaneous/traumatic bleed at index. Bleed resolution was obtained for 14 patients (unknown status, n = 1), and investigators assessed treatment satisfaction for 13 rVWF prescriptions (2 moderate, 5 good, and 6 excellent). rVWF was used to prevent/treat surgery-related bleeds at index in 76 patients. Bleed resolution was achieved in 25/58 rVWF-treated surgeries; bleed resolution was not applicable for 33 surgeries. In both groups, there were no reports of treatment-emergent adverse events after initiating rVWF, including hypersensitivity reactions, thrombotic events, and VWF inhibitor development. rVWF was shown to be effective for the on-demand treatment of spontaneous/traumatic bleeds, and for the prevention and treatment of surgical bleeds in this real-world VWD population.

Formation of robust bound states of interacting microwave photons

Systems of correlated particles appear in many fields of modern science and represent some of the most intractable computational problems in nature. The computational challenge in these systems arises when interactions become comparable to other energy scales, which makes the state of each particle depend on all other particles1. The lack of general solutions for the three-body problem and acceptable theory for strongly correlated electrons shows that our understanding of correlated systems fades when the particle number or the interaction strength increases. One of the hallmarks of interacting systems is the formation of multiparticle bound states2-9. Here we develop a high-fidelity parameterizable fSim gate and implement the periodic quantum circuit of the spin-½ XXZ model in a ring of 24 superconducting qubits. We study the propagation of these excitations and observe their bound nature for up to five photons. We devise a phase-sensitive method for constructing the few-body spectrum of the bound states and extract their pseudo-charge by introducing a synthetic flux. By introducing interactions between the ring and additional qubits, we observe an unexpected resilience of the bound states to integrability breaking. This finding goes against the idea that bound states in non-integrable systems are unstable when their energies overlap with the continuum spectrum. Our work provides experimental evidence for bound states of interacting photons and discovers their stability beyond the integrability limit.

Noise-resilient edge modes on a chain of superconducting qubits

Inherent symmetry of a quantum system may protect its otherwise fragile states. Leveraging such protection requires testing its robustness against uncontrolled environmental interactions. Using 47 superconducting qubits, we implement the one-dimensional kicked Ising model, which exhibits nonlocal Majorana edge modes (MEMs) with ℤ 2 parity symmetry. We find that any multiqubit Pauli operator overlapping with the MEMs exhibits a uniform late-time decay rate comparable to single-qubit relaxation rates, irrespective of its size or composition. This characteristic allows us to accurately reconstruct the exponentially localized spatial profiles of the MEMs. Furthermore, the MEMs are found to be resilient against certain symmetry-breaking noise owing to a prethermalization mechanism. Our work elucidates the complex interplay between noise and symmetry-protected edge modes in a solid-state environment.

The burden of end-stage osteoarthritis in Australia: a population-based study on the incidence of total knee replacement attributable to overweight/obesity

OBJECTIVES

To determine the risk of total knee replacement (TKR) for primary osteoarthritis (OA) associated with overweight/obesity in the Australian population.

METHODS

This population-based study analyzed 191,723 cases of TKR collected by the Australian Orthopaedic Association National Joint Registry and population data from the Australian Bureau of Statistics. The time-trend change in incidence of TKR relating to BMI was assessed between 2015 and 2018. The influence of obesity on the incidence of TKR in different age and gender groups was determined. The population attributable fraction (PAF) was then calculated to estimate the effect of obesity reduction on TKR incidence.

RESULTS

The greatest increase in incidence of TKR was seen in patients from obese class III. The incidence rate ratio for having a TKR for obesity class III was 28.683 at those aged 18-54 years but was 2.029 at those aged >75 years. Females in obesity class III were 1.7 times more likely to undergo TKR compared to similarly classified males. The PAFs of TKR associated with overweight or obesity was 35%, estimating 14,287 cases of TKR attributable to obesity in 2018. The proportion of TKRs could be reduced by 20% if overweight and obese population move down one category.

CONCLUSIONS

Obesity has resulted in a significant increase in the incidence of TKR in the youngest population in Australia. The impact of obesity is greatest in the young and the female population. Effective strategies to reduce the national obese population could potentially reduce 35% of the TKR, with over 10,000 cases being avoided.

Mental health and child refugees

This paper presents an overview of the importance of mental health services for unaccompanied asylum-seeking children in the United Kingdom. It reviews what mental health support appears to be available in the United Kingdom following an on-line search which took place in Spring 2021 and using information gathered through 22 interviews and focus groups with stakeholders. The latter group are defined as people working with asylum-seeking children. The primary stakeholders were local authority staff, although interviews were also conducted with local government associations (London Councils, the Local Government Association), NHS bodies and the voluntary sector. Often, further relevant stakeholders were identified during interviews. The report details the aims, methodology and context, before the findings are presented which is followed by recommendations for improving mental and social care provision for unaccompanied asylum-seeking children in the United Kingdom.

Intercostal thoracotomy for surgical attenuation of portoazygos extrahepatic portosystemic shunts in three dogs: surgical technique and short-term outcomes

CASE HISTORIES

The medical records of three dogs, presenting to the surgery department at a tertiary private referral hospital (Cork, Republic of Ireland), were retrospectively reviewed. The patients presented for investigation of a 3-day history of progressive lethargy, decreased appetite and hindlimb weakness (Case 1); brachycephalic obstructive airway syndrome and the development of abnormal licking behaviours (Case 2); and a 2-month history of increased thirst with elevated alanine aminotransferase in serum (Case 3).

CLINICAL FINDINGS

Case 1 presented with tachycardia, hindlimb paraparesis and neck pain, while Case 2 presented with facial conformation abnormalities consistent with brachycephalic obstructive airway syndrome. General physical examination and neurological assessment were within normal limits for Case 3. Baseline serum biochemistry measurements, in all three patients, indicated elevated activities of alanine aminotransferase and alkaline phosphatase, as well as elevated concentrations of resting bile acids (BA), suggestive of an extrahepatic portosystemic shunt. Abdominal computed tomography (CT) angiography was performed, for each dog, which revealed the presence of a portoazygous shunt (PAS) with final insertion into the caudal azygos vein within the thorax.

TREATMENT AND OUTCOME

Abdominal CT angiography images were used for surgical planning and a right-sided intercostal thoracotomy was performed. The location of the thoracotomy was patient-specific and located cranial to the diaphragm, either at the point of PAS insertion into the azygos vein or one rib-space caudal to the insertion, as determined by pre-operative CT images. The intercostal thoracotomy provided good visualisation of the PAS and an appropriate surgical field for placement of a thin film band around the PAS. No surgical complications or post-attenuation seizures were observed. All patients appeared comfortable on oral analgesia and were discharged from the hospital by 48 hours after surgery. All patients demonstrated a clinical improvement when reassessed 6-8 weeks after surgery, and Cases 2 and 3 demonstrated a reduction of resting BA concentrations to within normal limits. The third patient (Case 1) had a considerable reduction in the concentration of resting BA from >140 µmol/L to 20 µmol/L (reference range 0-10 µmol/L) 6-8 weeks after surgery.

CLINICAL RELEVANCE

A right-sided intercostal thoracotomy can be considered for surgical management of PAS in dogs. While both intraoperative and short-term results appear promising, further prospective studies are required before this approach can be recommended as the preferred approach for PAS attenuation.

Effect of percutaneous electrical nerve field stimulation on mechanosensitivity, sleep, and psychological comorbidities in adolescents with functional abdominal pain disorders

BACKGROUND

Percutaneous electrical nerve field stimulation (PENFS) improves symptoms in adolescents with functional abdominal pain disorders (FAPDs). However, little is known about its impact on sleep and psychological functioning. We evaluated the effects of PENFS on resting and evoked pain and nausea, sleep and psychological functioning, and long-term outcomes.

METHODS

Patient ages 11-19 years with FAPD requiring PENFS as standard care were recruited. Evoked pain was elicited by a Water Load Symptom Provocation Task (WL-SPT) before and after four weeks of treatment. Pain, gastrointestinal symptoms, sleep, somatic symptoms, and physical and psychological functioning were assessed. Actigraphy was used to measure daily sleep-wake patterns.

KEY RESULTS

Twenty patients (14.3 ± 2.2 years old) with FAPD were enrolled. Most patients were females (70%) and white (95%). During pain evoked by WL-SPT, visual analog scale (VAS) pain intensity and nausea were lower following PENFS compared with baseline (p = 0.004 and p = 0.02, respectively). After PENFS, resting VAS pain unpleasantness (p = 0.03), abdominal pain (p < 0.0001), pain catastrophizing (p = 0.0004), somatic complaints (0.01), functional disability (p = 0.04), and anxiety (p = 0.02) exhibited significant improvements, and some were sustained long-term. Self-reported sleep improved after PENFS (p's < 0.05) as well as actigraphy-derived sleep onset latency (p = 0.03).

CONCLUSIONS AND INFERENCES

We demonstrated improvements in resting and evoked pain and nausea, sleep, disability, pain catastrophizing, somatic complaints, and anxiety after four weeks of PENFS therapy. Some effects were sustained at 6-12 months post-treatment. This suggests that PENFS is a suitable alternative to pharmacologic therapy.

Embodied Interaffectivity in the Emergence and Maintenance of Group Cohesion

Group cohesion is an affect-laden construct, with a large body of research indicating its importance for success of teams. Surprisingly, it has received scant attention in collaborative learning contexts, and little is known about its development as dynamically emergent in the spontaneous, interdependent actions of actors during groupwork. This paper details an illustrative case analysis which took an embodied perspective to explore the role of interaffectivity in the emergence and maintenance of cohesion in one small group of university students who reported a highly positive and productive experience of collaborative science activities over a semester. The case analysis made visible group cohesion as unfolding and enactive in the myriad ephemeral and seemingly inconsequential microlevel behaviors that evolved into macro-temporal patterns of positive embodied interaffectivity, magnifying their visibility and collective impact. A fine-grained embodiment lens unveiled how participants cocreated collaborative affordances in actions that involved corporeal orientation as well as use of space, task, and other material artifacts. Task-related humor within routine task interaction offered the potential for establishing group cohesion in early group life, but also posed a potential threat to task-focused cohesiveness, requiring careful modulation at critical task points. Attentiveness not only to the task but importantly, to one another as interpersonal attentiveness, appeared to be a key factor in developing and maintaining group cohesion, also demonstrating collaborative learning as a process of orienting to and understanding tasks through one another. An embodiment lens highlighted mutual attentiveness in the ongoing orienter-orientee microprocesses that facilitated group orientation early in group life, and in reorienting to positive embodied interaffectivity when the group reconvened for their joint science activities in subsequent weeks.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

O-212 Single fathers by choice: experiences of surrogacy and thoughts and feelings about disclosure

Study question

What are the experiences of single men regarding (i) the process of surrogacy (ii) their relationship with the surrogate (iii) disclosing surrogacy to their child?

Summary answer

The fathers reported a variety of experiences of surrogacy and all fathers had either disclosed or intended to disclose using surrogacy to their child.

What is known already

Very little is known about single men’s experiences of surrogacy arrangements and how they think and feel about disclosing their use of surrogacy and egg donation to their child. Studies have focused on the decision-making process of using surrogacy as a single man and family functioning once these families are formed. Yet questions remain about how fathers experience and navigate the process of surrogacy as a single man and how they communicate to their child about their surrogacy story.

Study design, size, duration

The study is an international, multi-disciplinary, qualitative study of fathers who chose to begin a family and parent alone. Data were collected by two researchers between 2018 and 2021 and form part of a larger study of single fathers by choice with different routes to parenthood. The present study reports on twenty-one fathers who used surrogacy and egg donation to begin their family. The children were aged between 0-6 years.

Participants/materials, setting, methods

Purposive sampling was used to recruit participants. In-depth semi-structured interviews were conducted with the single fathers. The interview topics covered fathers’ motivations for pursuing single parenthood, experiences of the process of using egg donation and surrogacy, surrogacy arrangements including location, navigating the relationship with the surrogate, and fathers' decisions around disclosing their route to parenthood to their child. The audio-recorded interviews mostly lasted around two hours and verbatim transcripts were produced afterwards.

Main results and the role of chance

Data were analysed using reflexive thematic analysis and qualitative content analysis. Preliminary analysis indicated that the fathers reported a variety of experiences of surrogacy and had differing experiences in terms of the length of time it took to begin the surrogacy journey and the ease with which arrangements were made. Many of the fathers had remained in contact with the surrogate, but to differing degrees. Clinics were placed as both facilitators and gatekeepers of the process, pointing to the complexities of the surrogacy process.

Regarding disclosure, it was found that the fathers thought more about when to disclose, rather than whether to disclose. All the fathers stated an intention to tell their child about their surrogacy story, but carefully considered which age was best and wanted to use child-led methods of disclosure. The fathers reported that it was hard to hide their route to parenthood and expressed a motivation to talk openly to their children about the way in which they built their family. Many fathers described either using books or creating their own book as a disclosure aid for their child.

Limitations, reasons for caution

Due to the variation between different countries regarding laws on surrogacy, the findings may not be representative of experiences of surrogacy in different contexts from the ones studied. The sample size was relatively small; however, the research provides new insights into an area with little academic literature.

Wider implications of the findings

The study findings contribute a new understanding of the experiences of single fathers who use surrogacy to begin a family. The disclosure findings largely reflect those of studies of single mothers through sperm donation showing that single parents are very likely to disclose and many disclose at an early age.

Trial registration number

N / A

AB0434 EFFICACY AND SAFETY OF OBINUTUZUMAB IN SYSTEMIC LUPUS ERYTHEMATOSUS PATIENTS WITH SECONDARY NON-RESPONSE TO RITUXIMAB

Background

Secondary inefficacy characterized by infusion reactions and anti-drug antibodies occur in 14% of SLE patients treated with repeat rituximab courses(1). Obinutuzumab is a next-generation humanized type-2 anti-CD20 therapy licensed for hematological malignancies which may overcome this issue(2).

Objectives

We set out to evaluate the clinical efficacy and safety of obinutuzumab in a cohort of rituximab resistant SLE patients.

Methods

We collated data from SLE patients receiving obinutuzumab for secondary non-response to rituximab in BILAG centres. Disease activity was assessed using BILAG-2004, SLEDAI-2K and serology before, and 6 months after, obinutuzumab 2x1000mg infusions alongside methylprednisolone 100mg. Flow cytometry where possible was carried out using a multiple gating highly sensitive strategy.

Results

All 9 patients included in the study received obinutuzumab alongside concomitant oral immunosuppression. At 6 months post-obinutuzumab, there were significant reductions in median SLEDAI-2K from 12 to 6 (p=0.014) and total BILAG-2004 score from 21 to 2 (p=0.009). Complement C3 and dsDNA titres improved significantly (both p=0.04). Non statistically significant numerical improvements were seen in C4 levels.

Of 8/9 patients receiving concomitant oral prednisolone at baseline (all >10mg/day), 5/9 had their dose reduced at 6 months; 4/8 were on 5mg/day and were in Lupus Low Disease Activity State. After obinutuzumab, 6/9 patients with peripheral B-cell data achieved complete depletion including 4/4 assessed with highly sensitive assays. 1/9 obinutuzumab non-responder required cyclophosphamide therapy. 1 unvaccinated patient died from COVID-19.

Table 1.

Baseline characteristics, disease activity and steroid doses before and after last obinutuzumab/rituximab.

PatientEthnicityDisease duration (Years)Age (Years)Total BILAG-2004 before ObiTotal BILAG-2004 after ObiSLEDAI-2K before ObiSLEDAI-2K after ObiPrednisolone before Obi (mg)Prednisolone after Obi (mg)1South Asian10.836.41821481052South Asian6.324.424212430103South Asian11.934.829110410104South Asian8.241.92116015155South Asian6.829.43221181450606White European17.537.0128881557White European16.930.01211281058Caribbean6.244.225213010159Caribbean2.621.092166105Median (Q1, Q3)NA8.2 (6, 12)34.8 (29,37)21 (12, 25)2 (1, 2)12 (10, 14)6 (4, 8)10 (10, 15)10 (5, 15)

Conclusion

Obinutuzumab appears to be effective and steroid-sparing in renal and non-renal SLE patients with secondary non-response to rituximab. Obinutuzumab was shown to be effective in patients with severe renal and non-renal disease. Therefore, in those with previous responsiveness to B-cell depletion, switching to humanised type-2 anti-CD20 therapy is a logical approach following loss off efficacy.

References

[1]Vital EM, Dass S, Buch MH, Henshaw K, Pease CT, Martin MF, et al. B cell biomarkers of rituximab responses in systemic lupus erythematosus. Arthritis Rheum [Internet]. 2011 Oct [cited 2020 Oct 12];63(10):3038–47. Available from: https://pubmed.ncbi.nlm.nih.gov/21618204/

[2]Hassan SU, Md Yusof MY, Emery P, Dass S, Vital EM. Biologic Sequencing in Systemic Lupus Erythematosus: After Secondary Non-response to Rituximab, Switching to Humanised Anti-CD20 Agent Is More Effective Than Belimumab. Front Med [Internet]. 2020 Aug 27 [cited 2020 Sep 2];7:498. Available from: https://www.frontiersin.org/article/10.3389/fmed.2020.00498/full

Disclosure of Interests

Jack Arnold: None declared, Shouvik Dass Consultant of: Roche, Abbvie, UCB & Chugai, Employee of: Honoraria from Roche, Abbvie, UCB & Chugai, Sarah Twigg: None declared, Colin Jones: None declared, Benjamin Rhodes: None declared, Peter Hewins: None declared, Mithun Chakravorty: None declared, Philip Courtney: None declared, Michael Ehrenstein Grant/research support from: GSK, Employee of: Has received honoraria from GSK, Md Yuzaiful Md Yusof: None declared, Edward Vital Employee of: Has received honoraria from Roche

POS0793 IMPROVED RELAPSE-FREE SURVIVAL WITH THE NORWICH PREDNISOLONE REGIMEN FOR GIANT CELL ARTERITIS

Background

Glucocorticoid therapy is the mainstay treatment for GCA. There is no consensus on the dose of prednisolone to be used. Prednisolone regimens used in clinical trials have reported relapse rates of 66 to 92%. The long-term follow-up of Tocilizumab and prednisolone for 1-year showed a relapse rate of 74% at 2 years. The Norwich Regimen is a bespoke prednisolone plan with an initial dose of 1mg/kg of lean body mass. It delivers 164.64 mg/kg of lean body mass in a logarithmic taper over 100 weeks. It was devised to reduce the risk of relapse and allow patients to be in control of their prednisolone reduction.

Objectives

To document drug-free survival at 150 weeks of people with GCA treated with a bespoke prednisolone taper

Methods

All patients were diagnosed by biopsy, ultrasonography or PET scan and provided with a printed prednisolone plan at diagnosis. All individuals were assessed at approximately 3-6 monthly intervals in addition to suspected relapse, toxicity or other need for course correction. Relapses were confirmed objectively using a modification of the Kerr criteria. Relapse free survival was recorded at 100 weeks. Patients were given an open invite to contact us in the event of a suspected relapse after coming off prednisolone. A notes review was done to record events at 150 weeks.

Results

150 consecutive people with objectively diagnosed GCA (mean age 74) since 10/01/2012 have completed 150 weeks since starting prednisolone. Drug-free, relapse-free survival at 100 weeks was met by 133/150 (89%). 7 individuals died and 20 relapsed. A further 5 died and 15 relapsed by week 150; 103/150 (69%) survivors were in prednisolone-free remission. Of the 12 deaths – 6 died of cancer, 1 subdural haemorrhage, 1 ischaemic bowel, 1 septicaemia, 1 general decline (aged 93). The cause of death was not available for 2 individuals who died in the community. The median time to relapse for the 35 individuals was 80 weeks (IQR 64,109).

Conclusion

We report the first results of a bespoke prednisolone taper to be used in real life. The Norwich Regimen for the treatment of GCA results in drug-free relapse-free survival of 89% at 100 weeks and 69% at 150 weeks, which is superior to all other reports published so far.

References

[1]Mukhtyar, C, Cate, H, Graham, C, Merry, P, Mills, K, and Misra, A, 2019, ‘Development of an evidence-based regimen of prednisolone to treat giant cell arteritis – the Norwich regimen’ Rheumatology Advances in Practice, Volume 3, Issue 1, 2019, rkz001, https://doi.org/10.1093/rap/rkz001

[2]Hellmich B, Agueda A, Monti S, et al2018 Update of the EULAR recommendations for the management of large vessel vasculitis Annals of the Rheumatic Diseases 2020;79:19-30.

Disclosure of Interests

None declared

POS0810 FREQUENCY OF VISUAL MANIFESTATIONS IN GIANT CELL ARTERITIS IN NORFOLK

Background

The ophthalmic features of giant cell arteritis (GCA) involve a spectrum of severity from transient symptoms to bilateral visual loss from anterior ischaemic optic neuropathy or less commonly central retinal or cilioretinal artery occlusion. Reported ocular involvement varies between 10-70%.1,2. At the Norfolk and Norwich University Hospital an interdisciplinary fast track service is provided for potential GCA patients. This report aims provides a complete picture of the frequency and nature of ocular involvement in GCA.

Objectives

350 records of consecutive patients diagnosed objectively with GCA based on biopsy or imaging were reviewed. In our centre, the hospital pathway mandates all suspected GCA cases to have a formal ophthalmology assessment including visual acuity, pupil exam and full-dilated fundus assessment. Systemic and Ophthalmic symptoms and signs were recorded.

Methods

From January 2012 to September 2021, 350 individuals were diagnosed with GCA by biopsy, ultrasonography or positron emission tomography. The mean age was 74 ± 7.7 years. 235 (67%) of patients were females. 101 (29%) presenting with GCA had visual symptoms and/or signs. 42 of them had mono-ocular and 5 had binocular loss of vision. A summary of the key visual symptoms and signs are shown in Table 1. Only 6 patients with visual symptoms did not have any symptoms commonly associated with GCA.

Table 1.

Visual Symptoms and Signs (N=350 patients)

Visual Symptoms101Blurred Vision36Loss of vision47Double Vision27Ocular SignsRight CRAO11Left CRAO110Right AION219Left AION223Right extraocular muscle weakness6Left extraocular muscle weakness4

1 Central retinal artery occlusion 2 Anterior ischaemic optic neuropathy

Results

From January 2012 to September 2021, 350 individuals were diagnosed with GCA by biopsy, ultrasonography or positron emission tomography. The mean age was 74 ± 7.7 years. 235 (67%) of patients were females. 101 (29%) presenting with GCA had visual symptoms and/or signs. 42 of them had mono-ocular and 5 had binocular loss of vision. A summary of the key visual symptoms and signs are shown in Table 1. Only 6 patients with visual symptoms did not have any extra-ocular symptoms commonly associated with GCA.

Conclusion

We report the frequency of visual involvement in one of the largest cohorts of individuals with GCA. 29% have ocular symptoms. Partial or total field loss occurred in 13% of cases. 2% of patients presented with visual manifestations as the only feature of GCA. Rarely, permanent visual loss may occur without any other manifestation of GCA.

References

[1]Ivana Vodopivec, Joseph F Rizzo, III, Ophthalmic manifestations of giant cell arteritis, Rheumatology, Volume 57, Issue suppl_2, February 2018, Pages ii63–ii72.

[2]Saleh M, Turesson C, Englund M, Merkel PA, Mohammad AJ. Visual Complications in Patients with Biopsy-proven Giant Cell Arteritis: A Population-based Study. J Rheumatol. 2016;43(8):1559-1565.

Disclosure of Interests

None declared

POS1523-HPR PATIENT SATISFACTION SURVEY OF A SPECIALIST PHARMACIST RUN RHEUMATOLOGY BIOLOGIC AND JAK INHIBITOR CLINIC

Background

Hereford Rheumatology Department, UK, treats over 850 patients on biologic disease-modifying anti-rheumatic drugs (bDMARDs) and JAK inhibitors (JAKi). The multidisciplinary team (MDT) includes a Specialist Rheumatology Pharmacist running clinics for all adult Rheumatology patients who have been identified for bDMARD or JAKi initiation or switch by their responsible Consultant. Patients can feel anxious during the pre-treatment screening process and require reassurance about medication safety. This innovative role has been a well-received asset to the Rheumatology MDT, but patients’ perceptions of the role are unknown. To our knowledge, there is no similar study within British Rheumatology practice.

Objectives

The survey aims to gauge patient satisfaction of the consultation from a pharmacist-run bDMARD and JAKi initiation and switch clinic.

Methods

A generic patient satisfaction survey was piloted with positive results. Following this, a bespoke survey was developed, specifically enquiring about patients’ perceptions of the consultation skills, clarity, education and reassurance provided by the pharmacist. A Likert scale was used where appropriate and a space for free text was included. The Trust’s Patient Experience Team was consulted to ensure clarity for patients. In consecutive weekly clinics from July 2021 to January 2022, the survey was given to all patients immediately following Specialist Rheumatology Pharmacist clinic. The majority of patients were seen face-to-face however the survey was posted to the patient if telephone consultation was necessary. Clinic staff collected the completed surveys to ensure patient anonymity.

Results

57 of 58 patients completed the survey, with 100% stating they were pleased to receive counselling from a pharmacist. Patients were asked to score their knowledge of the medication out of 10, before and after the consultation; they reported a mean increase in knowledge of 3.9/10. The remaining survey results show mostly positive feedback (Table 1).

Table 1.

Patient rating of experience in pharmacist clinic.

StatementNo answerStrongly disagreeDisagreeNeitherAgreeStrongly agreeThe pharmacist put me at ease00001146The information provided was easy for me to understand.10011342The pharmacist listened to what I had to say.0000948The pharmacist showed care and sensitivity to my Rheumatological condition.00001146The pharmacist appeared knowledgeable about the medication to be started.0000849I feel that the medication I am starting has been chosen for me as an individual.10011738I understand why we are starting the new medication.00021045I have been told about the side effects the medication could cause.00001146I feel that it is safe to start the new medication.10161534I was able to discuss my concerns and ask questions about the new medication.00001146I felt included in the decision to start or change to new medication.10021143Overall, my experience in the pharmacist clinic today was a positive one*40001043

*Statement excludes results from 4 patients who did not complete the second page of the survey.

Conclusion

The results demonstrate the high level of patient satisfaction attained from the Specialist Pharmacist clinic. A small number of patients remain sceptical about medication safety, despite discussion. Inclusion of a pharmacist is especially useful to manage the increasing number of patients starting these medications, maintaining excellent patient experience, reducing the workload for other Rheumatology staff, and ensuring a robust MDT.

References

Not applicable.

Disclosure of Interests

Claire Jones Speakers bureau: Presented to rheumatology pharmacists at King’s College hospital London, Dec 2017. Purpose: to share my role to aid their development. Paid by UCB: £1000., Consultant of: Focus group for Fresenius Kabi Sept 2021. Received £500 honorarium, Jeanette Trickey: None declared

Tailored Immersion: Implementing Personalized Components Into Virtual Reality for Veterans With Post-Traumatic Stress Disorder

Introduction

With the application of virtual reality (VR), tailored interventions can be created that mirror the traumatic experiences of veterans with post-traumatic stress disorder (PTSD). Visual elements can be mimicked, and auditory and other senses stimulated. In doing so, the degree of immersion can be adjusted to optimize the therapeutic process. Objectively measuring the sensory immersion is key to keep subjects within their personal window of tolerance. Based on this information the therapist can decide manipulate the sensory stimulation embedded in the treatment.

Objectives

The objectives of this study are to explore the different immersive design aspects of VRET that can be modified to influence the experienced presence in veterans with PTSD, and to discuss possible methods of measuring the emotional response facilitated by immersive design aspects and experienced presence.

Methods

Four design aspects are discussed: system, sensory cues, narrative and challenge. We also report on a user experiment in three veterans that informed on quality and depth of immersion.

Results

Believability of the neutral virtual environment was important for maintaining the veterans’ presence within the VR experience. The immersive design aspects that were personalized and supportive in the narrative of the veteran such as music and self-selected images appeared to have a strong influence on recall and reliving of the traumatic events.

Conclusions

Finally, in order to increase the therapeutic effect in veterans with PTSD, the highlighted design aspects should be recognized and tailored to maximize immersion in virtual reality exposure therapy.

Disclosure

No significant relationships.

Novel Hendra Virus Variant Detected by Sentinel Surveillance of Horses in Australia

We identified and isolated a novel Hendra virus (HeV) variant not detected by routine testing from a horse in Queensland, Australia, that died from acute illness with signs consistent with HeV infection. Using whole-genome sequencing and phylogenetic analysis, we determined the variant had ≈83% nt identity with prototypic HeV. In silico and in vitro comparisons of the receptor-binding protein with prototypic HeV support that the human monoclonal antibody m102.4 used for postexposure prophylaxis and current equine vaccine will be effective against this variant. An updated quantitative PCR developed for routine surveillance resulted in subsequent case detection. Genetic sequence consistency with virus detected in grey-headed flying foxes suggests the variant circulates at least among this species. Studies are needed to determine infection kinetics, pathogenicity, reservoir-species associations, viral-host coevolution, and spillover dynamics for this virus. Surveillance and biosecurity practices should be updated to acknowledge HeV spillover risk across all regions frequented by flying foxes.