CAnceR IN PreGnancy (CARING) - a retrospective study of cancer diagnosed during pregnancy in the United Kingdom

BACKGROUND

The incidence of cancer diagnosed during pregnancy is increasing. Data relating to investigation and management, as well as maternal and foetal outcomes is lacking in a United Kingdom (UK) population.

METHODS

In this retrospective study we report data from 119 patients diagnosed with cancer during pregnancy from 14 cancer centres in the UK across a five-year period (2016-2020).

RESULTS

Median age at diagnosis was 33 years, with breast, skin and haematological the most common primary sites. The majority of cases were new diagnoses (109 patients, 91.6%). Most patients were treated with radical intent (96 patients, 80.7%), however, gastrointestinal cancers were associated with a high rate of palliative intent treatment (63.6%). Intervention was commenced during pregnancy in 68 (57.1%) patients; 44 (37%) had surgery and 31 (26.1%) received chemotherapy. Live births occurred in 98 (81.7%) of the cases, with 54 (55.1%) of these delivered by caesarean section. Maternal mortality during the study period was 20.2%.

CONCLUSIONS

This is the first pan-tumour report of diagnosis, management and outcomes of cancer diagnosed during pregnancy in the UK. Our findings demonstrate proof of concept that data collection is feasible and highlight the need for further research in this cohort of patients.

Epidemiological impact of a large number of false negative SARS-CoV-2 test results in South West England during September and October 2021

During September and October 2021, a substantial number of Polymerase Chain Reaction (PCR) tests in England processed at a single laboratory were incorrectly reported as negative. We estimate the number of false negative test results issued and investigate the epidemiological impact of this incident. We estimate the number of COVID-19 cases that would have been reported had the sensitivity of the laboratory test procedure not dropped for the period 2 September to 12 October. In addition, by making comparisons between the most affected local areas and comparator populations, we estimate the number of additional infections, cases, hospitalisations and deaths that could have occurred as a result of increased transmission due to false negative test results.We estimate that around 39,000 tests may have been false negatives during this period and, as a direct result of this incident, the most affected areas in the South-West of England could have experienced between 6000 and 34,000 additional reportable cases, with a central estimate of around 24,000 additional reportable cases. Using modelled relationships between key variables, we estimate that this central estimate could have translated to approximately 55,000 additional infections.Each false negative likely led to around 1.5 additional infections. The incident is likely to have had a measurable impact on cases and infections in the affected areas in the South-West of England. IMPACT STATEMENT: These results indicate the significant negative impact of incorrect testing on COVID outcomes; and make a substantial contribution to understanding the impact of testing systems and the need to ensure high accuracy in testing and reporting of results.

Association between acetaminophen use and vitiligo in US women and men

BACKGROUND/OBJECTIVES

Exposure to chemical phenols, which can act as tyrosine analogues and result in anti-melanocyte autoimmunity, has been associated with vitiligo. Acetaminophen (N-acetyl-p-aminophenol) is an over-the-counter analgesic of phenolic origin. The risk of vitiligo with systemic exposure to acetaminophen has not yet been evaluated.

METHODS

We examined the risk of vitiligo with regular use acetaminophen in women, the Nurses' Health Study (NHS) and in men, the Health Professionals Follow-up Study (HPFS). Regular acetaminophen use was asked biennially from 1990 in NHS and from 1986 in HPFS, and the year of clinician-diagnosed vitiligo was asked retrospectively in 2012 in the cohorts.

RESULTS

In NHS, a total of 161 vitiligo cases were identified during a follow-up of 571,724 person-years; in HPFS, a total of 183 vitiligo cases were identified during a follow-up of 680,313 person-years. Regular use of acetaminophen was associated with an increased vitiligo risk in NHS but not HPFS. The multivariable relative risk (RR) was 1.52 (95% confidence interval [CI] 1.03-2.25) in NHS and 1.09 (95% CI 0.76-1.55) in HPFS. The higher risk of vitiligo was similar by duration of acetaminophen use in women; the multivariable RRs were 1.47 (95% CI 0.98-2.21) for acetaminophen use under 5 years, and 1.78 (95% CI 1.11-2.84) for acetaminophen use over 5 years.

CONCLUSIONS

Acetaminophen may be associated with a higher risk of vitiligo in women.

The KRAS-Variant and Cetuximab in HPV-Positive Oropharyngeal Cancer in NRG/RTOG 1016

PURPOSE/OBJECTIVE(S)

NRG/RTOG 1016 was a non-inferiority phase III trial comparing radiation with cisplatin versus cetuximab monotherapy for patients with HPV-positive oropharyngeal squamous cell carcinoma (SCC). The trial did not meet the non-inferiority criteria for overall survival (OS) and had significantly worse progression-free survival (PFS) and locoregional failure (LRF) in patients treated with cetuximab. Based on prior evidence that HNSCC patients with a germ-line mutation in KRAS (the KRAS-variant) had a positive response to radiation with cisplatin plus cetuximab without increased toxicity, samples from RTOG 1016 were used to test the protocol-specified hypothesis that KRAS-variant patients will have better outcomes when receiving IMRT + cetuximab monotherapy compared to IMRT + cisplatin.

MATERIALS/METHODS

The KRAS-variant was tested in 562 samples at MiraDx, a CLIA-certified laboratory. OS, PFS, LRF, and distant metastases (DM) were as defined per the RTOG 1016 protocol, and hazard ratios (HRs) were estimated by (cause-specific) Cox models. Negative binomial regression was used to model the number of treatment-related acute and late (≤ and > 180 days from end of treatment, respectively) grade 3-5 adverse events. To assess the predictive role of the KRAS-variant, all models included KRAS, assigned treatment, and their interaction, with the interaction tested at two-sided 0.05. HRs and toxicity ratios are expressed as IMRT + cetuximab / IMRT + cisplatin.

RESULTS

The prevalence of the KRAS-variant was 16% with similar patient and tumor characteristics and well-balanced treatment arms for variant and non-variant patients. Median follow-up was 8.6 years. There was no significant interaction between KRAS and treatment for OS (p = 0.99), PFS (p = 0.56), LRF (p = 0.09), or DM (p = 0.19) (Table 1). In KRAS-variant patients the mean acute and late toxicity ratios were 0.53 (95% CI 0.36, 0.80) and 1.62 (95% CI 0.57, 4.62). In non-variant patients, the mean acute and late toxicity ratios were 0.80 (95% CI 0.67, 0.95) and 0.55 (95% CI 0.35, 0.87), respectively. The interaction of KRAS and treatment was not significant for acute (p = 0.07) or late toxicity (p = 0.07).

CONCLUSION

While this study does not directly refute prior evidence that KRAS-variant patients benefit from radiation + cisplatin and cetuximab, this study does not support the hypothesis that the KRAS-variant is a predictive biomarker of improved outcome in HPV+ oropharyngeal SCC patients treated with IMRT + cetuximab alone, and suggests that for KRAS-variant patients, potential benefits in LRF and acute toxicity with cetuximab may be offset by worse DM and worse late toxicity.

Racial differences in healthcare utilization among patients with suspected or diagnosed preeclampsia: A retrospective cohort study

OBJECTIVES

To analyze healthcare resource utilization and severe maternal morbidity (SMM) in Black and White patients with preeclampsia diagnosis versus signs/symptoms.

STUDY DESIGN

This was a retrospective cohort study analyzing data from the IBM® Explorys Database between 7/31/2012-12/31/2020. Demographic, clinical, and laboratory data were extracted. Healthcare utilization and SMM were analyzed during the antepartum period (20 weeks of gestation until delivery) among Black and White patients with signs/symptoms of preeclampsia, with a diagnosis of preeclampsia, or neither (control).

MAIN OUTCOME MEASURES

Healthcare utilization and SMM in those with a preeclampsia diagnosis or signs/symptoms of preeclampsia only were compared with a control group (White patients with no preeclampsia diagnosis or signs/symptoms).

RESULTS

Data from 38,190 Black and 248,568 White patients were analyzed. Patients with preeclampsia diagnosis or signs/symptoms were more likely to visit the emergency room compared to those without diagnosis or signs/symptoms. Black patients with signs/symptoms of preeclampsia had the highest elevated risk (odds ratio [OR] = 3.4), followed by Black patients with a preeclampsia diagnosis (OR = 3.2), White patients with signs/symptoms (OR = 2.2), and White patients with a preeclampsia diagnosis (OR = 1.8). More Black patients experienced SMM (SMM rate 6.1% [Black with preeclampsia diagnosis] and 2.6% [Black with signs/symptoms]) than White patients (5.0% [White with preeclampsia diagnosis] and 2.0% [White with signs/symptoms]). SMM rates were higher for Black preeclampsia patients with severe features than for White preeclampsia patients with severe features (8.9% vs 7.3%).

CONCLUSIONS

Compared with White patients, Black patients had higher rates of antepartum emergency care and antepartum SMM.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Differences in Left Ventricular Enlargement Secondary to Chronic Volume Loading Between English Springer Spaniels and Two Similar Sporting Breeds

INTRODUCTION

English springer spaniels have larger, rounder ventricles than most other breeds. How this geometry impacts responses to volume overload remains unknown. We compared left ventricular size between English springer spaniels and two similarly sized sporting breeds (Border collies and Labrador retrievers) in naturally occurring chronic left ventricular volume loading conditions (mitral regurgitation and patent ductus arteriosus [PDA]) to examine whether differences in remodelling responses exist between these breeds.

ANIMALS, MATERIALS AND METHODS

We searched records for cases of mitral regurgitation and PDA in three breeds. We recorded age, sex, presence of congestive heart failure (CHF), body weight and specific echocardiographic variables. We compared normalised measures of left ventricular size between breeds. Cases with CHF were further examined as a separate group.

RESULTS

One-hundred-and-ninety-one dogs were included: 110 with degenerative mitral valve disease, 42 with mitral dysplasia and 39 with PDA. One third of all cases had CHF. All measures of left ventricular size were larger in English springer spaniels in mitral regurgitation cases (P<0.001), whereas PDA cases did not differ. English springer spaniels with PDA resulting in CHF had larger systolic dimensions and volumes than similarly affected non-English Springer Spaniel dogs (P=0.003).

CONCLUSIONS

English springer spaniels have greater left ventricular dimensions when exposed to chronic mitral regurgitation, compared with Border collies and Labrador retrievers, but not when exposed to volume overload from a PDA. English springer spaniels differ in their left ventricular morphology from two other sporting breeds, supporting previous studies that they have a unique cardiac morphotype.

Non-oral manifestations in adults with a clinical and molecularly confirmed diagnosis of periodontal Ehlers-Danlos syndrome

Introduction: Periodontal Ehlers-Danlos Syndrome (pEDS) is a rare autosomal dominant type of EDS characterised by severe early-onset periodontitis, lack of attached gingiva, pretibial plaques, joint hypermobility and skin hyperextensibility as per the 2017 International EDS Classification. In 2016, deleterious pathogenic heterozygous variants were identified in C1R and C1S, which encode components of the complement system. Materials and Methods: Individuals with a clinical suspicion of pEDS were clinically and molecularly assessed through the National EDS Service in London and Sheffield and in genetic services in Austria, Sweden and Australia. Transmission electron microscopy and fibroblast studies were performed in a small subset of patients. Results: A total of 21 adults from 12 families were clinically and molecularly diagnosed with pEDS, with C1R variants in all families. The age at molecular diagnosis ranged from 21-73 years (mean 45 years), male: female ratio 5:16. Features of easy bruising (90%), pretibial plaques (81%), skin fragility (71%), joint hypermobility (24%) and vocal changes (38%) were identified as well as leukodystrophy in 89% of those imaged. Discussion: This cohort highlights the clinical features of pEDS in adults and contributes several important additional clinical features as well as novel deleterious variants to current knowledge. Hypothetical pathogenic mechanisms which may help to progress understanding and management of pEDS are also discussed.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

The potential distribution of Bacillus anthracis suitability across Uganda using INLA

To reduce the veterinary, public health, environmental, and economic burden associated with anthrax outbreaks, it is vital to identify the spatial distribution of areas suitable for Bacillus anthracis, the causative agent of the disease. Bayesian approaches have previously been applied to estimate uncertainty around detected areas of B. anthracis suitability. However, conventional simulation-based techniques are often computationally demanding. To solve this computational problem, we use Integrated Nested Laplace Approximation (INLA) which can adjust for spatially structured random effects, to predict the suitability of B. anthracis across Uganda. We apply a Generalized Additive Model (GAM) within the INLA Bayesian framework to quantify the relationships between B. anthracis occurrence and the environment. We consolidate a national database of wildlife, livestock, and human anthrax case records across Uganda built across multiple sectors bridging human and animal partners using a One Health approach. The INLA framework successfully identified known areas of species suitability in Uganda, as well as suggested unknown hotspots across Northern, Eastern, and Central Uganda, which have not been previously identified by other niche models. The major risk factors for B. anthracis suitability were proximity to water bodies (0-0.3 km), increasing soil calcium (between 10 and 25 cmolc/kg), and elevation of 140-190 m. The sensitivity of the final model against the withheld evaluation dataset was 90% (181 out of 202 = 89.6%; rounded up to 90%). The prediction maps generated using this model can guide future anthrax prevention and surveillance plans by the relevant stakeholders in Uganda.

[The most serious incident-Experiences of aggression and violence in ophthalmology]

BACKGROUND

Experiences of aggression/violence influence job satisfaction and can have a long-term psychological and physical impact on employees. In the fall of 2018, the Professional Association of Ophthalmologists (BVA) and the German Ophthalmological Society (DOG) conducted a survey on experiences of aggression and violence. The first results were published in 2020. In the survey it was also possible to describe the most serious incident to date using free text fields, among others.

METHOD

All 9411 members of the DOG and BVA were given the opportunity to complete a questionnaire online in 2018 regarding aggression and violence in ophthalmology.

RESULTS

Overall, 253 of 1508 (16.8%) ophthalmologists participating in the survey reported their most serious incident, 46.8% of which were classified as moderate and 34.3% were related to verbal violence such as insults and threats. The most serious incident was experienced by 171 (67.6%) physicians in a practice setting, 71% were specialists at the time of the incident and 74.3% of the incidents occurred during regular working hours. The main causes were intercultural conflicts, long waiting times, problems with the allocation of appointments, excessive expectations, differences in treatment and basic aggressiveness. The offenders were male in 86.3% of cases, 15.8% of the incidents were reported to the police and 21 (8.3%) physicians issued a practice reprimand or house ban.

DISCUSSION

The description of the most serious incidents illustrates situations that are sometimes hard to imagine and also which incidents were considered serious. There are large subjective variations in the assessment of the incidents. Protective measures in practices and clinics are essential.

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.

POS0712 YEAR-4 OBSERVATIONAL FOLLOW-UP OF BELIMUMAB SAFETY (MORTALITY AND MALIGNANCIES) IN PATIENTS WITH SLE WHO COMPLETED A PHASE 4, 52-WEEK, RANDOMISED, DOUBLE-BLIND PLACEBO-CONTROLLED SAFETY STUDY

Background

Belimumab (BEL) is an approved systemic lupus erythematosus (SLE) treatment. Despite BEL clinical studies demonstrating a favourable benefit–risk profile, varying incidence rates of mortality and adverse events of special interest, including malignancies, require further evaluation.

Objectives

To assess long-term safety following BEL therapy.

Methods

This was a Year (Yr)-4 post-treatment follow-up of the Phase 4, double-blind, placebo (PBO)-controlled Belimumab Assessment of Safety in SLE (BASE) study (GSK Study BEL115467; NCT01705977).1 Overall, 4003 adults with active, autoantibody-positive SLE received BEL (10 mg/kg IV) or PBO, plus standard therapy (ST), for 48 weeks. Patients (pts) then entered a Yr 2–5 follow-up period in which they received physician-directed ST. All pts were contacted annually by telephone, including pts who discontinued treatment. Mortality and new malignancies (including nonmelanoma skin cancer) were the endpoints collected, and rates summarised. We present Yr-4 follow-up data by Yr-1 treatment received.

Results

Baseline characteristics for the Yr-4 follow-up population (N=3204) were similar to the Yr-1 double-blind study population (N=4003). By the Yr-4 follow-up, cumulatively 12.7% and 11.0% of pts in the BEL and PBO Yr-1 groups had received BEL as part of physician-directed care, respectively (data not shown). As shown in the Table 1, cumulative follow-up adjusted mortality rates were lower in the BEL vs PBO Yr-1 treatment group for Yrs 2 to 4. Cumulative follow-up adjusted new primary malignancy rates were lower in the BEL vs PBO Yr-1 treatment group for Yrs 2 and 3, but similar in Yr 4.

Table 1.

Yr 1 plus Yrs 2–4 post-treatment* follow-up mortality and new primary malignancy rates by Yr-1 study treatment

Pts with events per yr, n (%)Pt incidence rate per 100 pt-yrs(Cumulative rate, %)BELPBOTotalBELPBOTotalYr-1 (as-treated) populationN=2002N=2001N=4003Deaths13 (0.65)22 (1.10)35 (0.87)0.66 (0.65)1.11 (1.10)0.87New primary malignancies†9 (0.45)10 (0.50)19 (0.47)0.450.500.47Yr-2 (as-treated in Yr-1) populationN=1695N=1670N=3365Deaths9 (0.53)21 (1.26)30 (0.89)0.60 (1.10)1.18 (2.15)0.89 (1.62)New primary malignancies3 (0.18)7 (0.42)10 (0.30)0.34 (0.60)0.48 (0.85)0.41 (0.72)Yr-3 (as-treated in Yr-1) populationN=1659N=1630N=3289Deaths9 (0.54)17 (1.04)26 (0.79)0.58 (1.55)1.14 (3.00)0.86 (2.27)New primary malignancies, n (%)7 (0.42)9 (0.55)16 (0.49)0.37 (0.95)0.49 (1.25)0.43 (1.10)Yr-4 (as-treated in Yr-1) populationN=1622N=1582N=3204Deaths by MedDRA SOC14 (0.86)13 (0.82)27 (0.84)0.65 (2.25)1.07 (3.65)0.86 (2.95)Infections/infestations4 (0.25)5 (0.32)9 (0.28)Cardiac disorders2 (0.12)1 (0.06)3 (0.09)General disorders/ administration site conditions2 (0.12)2 (0.13)4 (0.12)Respiratory/thoracic/ mediastinal disorders2 (0.12)1 (0.06)3 (0.09)Nervous system disorders2 (0.12)1 (0.06)3 (0.09)Other‡2 (0.12)3 (0.18)5 (0.15)New primary malignancies10 (0.62)5 (0.32)15 (0.47)0.43 (1.45)0.44 (1.45)0.43 (1.45)

*Pts in the post-treatment follow-up period are no longer receiving study treatment. †Includes nonmelanoma skin cancer.

‡Contains 1 event for 5 distinct pts of each of renal/urinary disorders, and neoplasms (BEL); musculoskeletal/connective tissue disorders, injury/poisoning/procedural complications, and vascular disorders (PBO).

MedDRA, Medical Dictionary for Regulatory Activities; SOC, system organ class

Conclusion

Post-treatment Yr-4 follow-up results in BASE, the largest double-blind trial in pts with SLE to date, support the safety of BEL therapy, with no new BEL safety concerns identified in this analysis.

References

[1]Sheikh SZ, et al. Lancet Rheumatol 2020;3:e122–30

Acknowledgements

This analysis was funded by GlaxoSmithKline (GSK). Medical writing support was provided by Lulu Hill, MPharmacol, Fishawack Indicia Ltd. UK, part of Fishawack Health, and was funded by GSK.

Disclosure of Interests

Saira Sheikh Consultant of: GSK, Grant/research support from: Pfizer, Morton Scheinberg Consultant of: GSK, Pfizer, Alnylam, AbbVie, PTC Therapeutics, James Cheng-Chung Wei Consultant of: TSH Biopharm, AbbVie, BMS, Celgene, Chugai, Eisai, Janssen, Novartis, Pfizer, Sanofi-Aventis, and UCB Pharma, Grant/research support from: AbbVie, Amgen, Astellas, BMS, Celgene, Eli Lilly, Gilead, Janssen, Novartis, Pfizer, Sun and UCB Pharma, Dana Tegzová: None declared, William Stohl Consultant of: GSK, Grant/research support from: GSK, Pfizer, Gilead, RICARDO ACAYABA DE TOLEDO Speakers bureau: AbbVie, Janssen, UCB, Novartis, Celltrion, Consultant of: AbbVie, Janssen, Novartis, UCB, Grant/research support from: Pfizer, AbbVie, Novartis, GSK, Tamara Mucenic Speakers bureau: Novartis, Janssen, BMS, AbbVie, Pfizer, Roche, Grant/research support from: GSK, Janssen, Roche, Eli Lilly, Gilead, UCB, Mauricio R Abello Banfi: None declared, Kathleen Maksimowicz-McKinnon Grant/research support from: Chemocentryx, Carlos Abud-Mendoza Speakers bureau: GSK, Lilly, Pfizer, Sandra Navarra Speakers bureau: Pfizer, Novartis, Johnson & Johnson, Consultant of: Biogen, Boehringer Ingelheim, Grant/research support from: Astellas, Mercedes García Speakers bureau: GSK, Janssen, Pfizer, Ignacio Garcia-De La Torre: None declared, Andrew Liu Shareholder of: GSK, Employee of: GSK, Abhishek Roy Employee of: GSK, Paul Wilde Shareholder of: GSK, Employee of: GSK, Sofia Fernandes Shareholder of: GSK, Employee of: GSK, Julia Harris Shareholder of: GSK, Employee of: GSK, David Roth Shareholder of: GSK, Employee of: GSK

POS0183 THE EFFECT OF BELIMUMAB ON SRI-4 RESPONSE IN MULTIPLE SUBGROUPS OF PATIENTS WITH SYSTEMIC LUPUS ERYTHEMATOSUS: RESULTS OF A LARGE INTEGRATED ANALYSIS

Background

Belimumab (BEL) is approved for the treatment of active autoantibody-positive systemic lupus erythematosus (SLE).1 Four Phase 3 studies have consistently demonstrated greater SLE Responder Index (SRI) response rates with BEL vs placebo (PBO).2-5 This robust dataset allows for additional exploration of the onset of efficacy of BEL and response rates by patient (pt) characteristics.

Objectives

To perform a post hoc analysis evaluating the effect of BEL on SRI-4 response across a large, pooled population and pt subgroups.

Methods

The Belimumab Summary of Lupus Efficacy (Be-SLE) integrated analysis evaluated data from adults with SLE from 5 double-blind, PBO-controlled BEL trials: BLISS-76, BLISS-52, BLISS-NEA, BLISS-SC, and EMBRACE.2-6 Pts were randomised to BEL (monthly intravenous 10 mg/kg or weekly subcutaneous 200 mg) or PBO, plus standard therapy. Data were collected every 4 weeks (wks) from baseline (BL) to Wk 52. The SRI-4 response rate (a composite measure that includes ≥4-point reduction in Safety of Estrogens in Lupus Erythematosus National Assessment - SLE Disease Activity Index [SELENA-SLEDAI] score, stable Physician Global Assessment [PGA] increase of <0.3, and no new British Isles Lupus Assessment Group [BILAG] 1A/2B organ domain scores) by visit and time to first SRI-4 response maintained through Wk 52 were determined for both treatment groups. SRI-4 response rates at Wk 52 were evaluated by BL characteristic subgroups: SELENA-SLEDAI score; SLE International Collaborating Clinics/American College of Rheumatology Damage Index (SDI) score; disease duration; biomarker levels (anti-dsDNA, complement [C]3/C4); glucocorticoid (GC), immunosuppressant (IS), and antimalarial (AM) use.

Results

Overall, 3086 pts were included (BEL, n=1869; PBO, n=1217). Most were female (94.4%); mean (standard deviation [SD]) age was 37.0 (11.6) years. Mean (SD) SLE duration was 6.4 (6.4) years.

At Wk 52, in the overall population, significantly more BEL vs PBO pts were SRI-4 responders (Figure 1). A significantly greater proportion of SRI-4 responders was observed with BEL vs PBO as early as Wk 8 (38.4% vs 33.3%; odds ratio, OR [95% confidence interval, CI] 1.25 [1.07, 1.46]; p=0.0060), which continued to increase to Wk 52 (54.8% vs 41.6%; OR [95% CI] 1.70 [1.46, 1.98]; p<0.0001). At Wk 52, more BEL vs PBO pts had a 4-point reduction in SELENA-SLEDAI (56.3% vs 43.1%; OR [95% CI] 1.71 [1.47, 2.00]; p<0.0001), no worsening in PGA (76.6% vs 67.9%; OR [95% CI] 1.52 [1.28, 1.79]; p<0.0001), and no new BILAG 1A/2B organ domain scores (77.1% vs 69.4%; OR [95% CI] 1.47 [1.25, 1.74]; p<0.0001). Pts on BEL were 52% more likely to experience an SRI-4 response that was maintained through Wk 52 (hazard ratio, HR [95% CI] 1.52 [1.36, 1.69]; p<0.0001).

Figure 1.

SRI-4 response at Wk 52 in the overall population and by BL characteristic subgroups.

*OR (95% CI) and p-value are from a logistic regression model for BEL vs PBO comparison with covariates of treatment group, study and BL SELENA-SLEDAI score (≤9 vs ≥10)

SRI-4 response rates were significantly higher with BEL vs PBO in most subgroups, with the highest response rates observed in pts with SELENA-SLEDAI score of ≥10, low C3 and/or C4 + anti-dsDNA ≥30 IU/ml, and low C3 and/or C4 at BL (Figure 1).

Conclusion

Significantly more pts receiving BEL had SRI-4 response rates that occurred from Wk 8 and were maintained through Wk 52 compared with pts receiving PBO. The efficacy of BEL was consistent across multiple pt subgroups, with higher response rates in pts with SELENA-SLEDAI scores of ≥10, low C3 and/or C4 + anti-dsDNA ≥30 IU/ml and low C3 and/or C4 at BL. These results further substantiate the benefits of BEL in the treatment of adults with SLE.

References

[1]GlaxoSmithKline. Benlysta US prescribing information. 2021

[2]Furie R, et al. Arthritis Rheumatol 2011;63(12):3918–30

[3]Navarra SV, et al. Lancet 2011;377(9767):721–31

[4]Stohl W, et al. Arthritis Rheum 2017;69(5):1016–27

[5]Zhang F, et al. Ann Rheum Dis 2018;77(3):355–63

[6] Ginzler E, et al. Arthritis Rheum 2021; doi: 10.1002/art.41900

Acknowledgements

This analysis was funded by GlaxoSmithKline (GSK). Medical writing support was provided by Lulu Hill, MPharmacol, Fishawack Indicia Ltd. UK, part of Fishawack Health, and was funded by GSK.

Disclosure of Interests

Michelle A Petri Consultant of: GSK, Grant/research support from: GSK, George Bertsias Speakers bureau: Pfizer, Aenorasis, UCB, Novartis, Lilly, SOBI, Consultant of: Novartis, GSK, AstraZeneca, Grant/research support from: GSK, Pfizer, Mark Daniels Shareholder of: GSK, Employee of: GSK, Norma Lynn Fox Shareholder of: GSK, Employee of: GSK, Bevra H. Hahn Consultant of: UCB, GSK, Anne Hammer Shareholder of: GSK, Employee of: GSK, Julia Harris Shareholder of: GSK, Employee of: GSK, Holly Quasny Shareholder of: GSK, Employee of: GSK, Chiara Tani Speakers bureau: GSK, AstraZeneca, Anca Askanase Consultant of: AstraZeneca, Aurinia Pharmaceuticals Inc., Amgen, AbbVie Inc., BMS, GSK, Grant/research support from: AstraZeneca, Eli Lilly and Company, GSK, Idorsia Pharmaceuticals Ltd, Janssen Pharmaceuticals, Pfizer

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

A fully automatic system to assess foot collapse on lateral weight-bearing foot radiographs: A pilot study

BACKGROUND

Foot collapse is primarily diagnosed and monitored using lateral weight-bearing foot x-ray images. There are several well-validated measurements which aid assessment. However, these are subject to inter- and intra-user variability.

OBJECTIVE

To develop and validate a software system for the fully automatic assessment of radiographic changes associated with foot collapse; automatically generating measurements for calcaneal tilt, cuboid height and Meary's angle.

METHODS

This retrospective study was approved by the Health Research Authority (IRAS 244852). The system was developed using lateral weight-bearing foot x-ray images, and evaluated against manual measurements from five clinical experts. The system has two main components: (i) a Random Forest-based point-finder to outline the bones of interest; and (ii) a geometry-calculator to generate the measurements based on the point positions from the point-finder. The performance of the point-finder was assessed using the point-to-point error (i.e. the mean absolute distance between each found point and the equivalent ground truth point, averaged over all points per image). For assessing the performance of the geometry-calculator, linear mixed models were fitted to estimate clinical inter-observer agreement and to compare the performance of the software system to that of the clinical experts.

RESULTS

A total of 200 images were collected from 79 subjects (mean age: 56.4 years ±12.9 SD, 30/49 females/males). There was good agreement among all clinical experts with intraclass correlation estimates between 0.78 and 0.86. The point-finder achieved a median point-to-point error of 2.2 mm. There was no significant difference between the clinical and automatically generated measurements using the point-finder points, suggesting that the fully automatically obtained measurements are in agreement with the manually obtained measurements.

CONCLUSIONS

The proposed system can be used to support and automate radiographic image assessment for diagnosing and managing foot collapse, saving clinician time, and improving patient outcomes.

Pancreatic Gangliocytic Praganglioma: A Rare Case and Literature Review

Introduction/Objective

Gangliocytic paraganglioma, GP is a morphologically distinct tumor first reported by Dahl in 1957, most often in second portion of duodenum near ampulla of Vater. GP mostly present as single tumors, but occasionally may be multiple, when seen in association with Von Recklinghausen disease and carcinoid tumors. Rare cases have been reported at other sites in gastrointestinal tract including esophagus, pylorus, jejunum and extra- gastrointestinal tract in the nasopharynx, thymus, lung and ovary. Pancreatic GP is extremely rare with five cases reported till date.

Methods/Case Report

A 42- year- old male presented with abdominal pain. Physical exam showed no abnormalities. The significant findings on labs were raised amylase levels in the range of 1262 U and mild hyperglycemia with blood glucose of 178mg/dl. CA 19-9 was found to be 8.0 U/ml. Coronal CT Abdomen showed hypodense well circumscribed nodule 1.5 cm in body of pancreas. Gross specimen of pancreas showed a circumscribed 1.5 cm nodule in body of Pancreas.The microscopic sections of pancreatic mass show epithelioid appearing neuroendocrine cells in nests, with spindle shaped schwann cells or sustentacular cells in periphery, and scattered ganglion cells. The immunohistochemical staining positive for synaptophysin in epithelioid cells, S100 in spindled schwann cells and CK in epithelioid cells and Ganglion cells. Based on the microscopic findings, a diagnosis of Gangliocytic Paraganglioma, GP arising in Pancreas was made.

Results (if a Case Study enter NA)

NA

Conclusion

Pancreatic GP, are often misdiagnosed as Pancreatic Neuro endocrine tumors, Grade1. The accurate differentiation and precise diagnosis is crucial for appropriate clinical management. WHO classification of 2010, classifies gangliocytic paragangliomas as benign. Duodenal GP has a benign behavior with lymph node metastasis in only 5-7% cases, and no evidence of distant metastasis. In comparison, Pancreatic GP show an more aggressive behavior with lymph node metastasis observed in 2/6 cases and one case with sternal bone metastasis, emphasizing the importance of the primary location of origin of GP as prognostic factor. Our understanding is limited due to the scarcity of literature; more published data shall be instrumental in further explaining the clinical behavior of this rare entity.

Staphylococcus caledonicus sp. nov. and Staphylococcus canis sp. nov. isolated from healthy domestic dogs

Two strains, H8/1^T and H16/1A^T, of Gram-stain-positive, coagulase-negative staphylococci were isolated from separate healthy domestic dogs in Scotland. Both strains were genome sequenced and their inferred DNA–DNA hybridisation indicates that H8/1^T and H16/1A^T represent two novel species of the genus Staphylococcus. On the basis of the results of genome sequence analysis (genome blast distance phylogeny and single nucleotide polymorphism analysis) H8/1^T is most closely related to Staphylococcus devriesei and H16/1A^T most closely related to Staphylococcus felis. Also, average nucleotide identity distinguished H8/1^T and H16/1A^T from S. devriesei and S. felis as did minor phenotypic differences. On the basis of these results, it is proposed that H8/1^T and H16/1A^T represent novel species with the respective names Staphylococcus caledonicus and Staphylococcus canis. The type strain of S. caledonicus is H8/1^T (=NCTC 14452^T=CCUG 74789^T). The type strain of S. canis is H16/1A^T (=NCTC 14451^T=CCUG 74790^T)

AB0288 SAFETY OF BELIMUMAB IN PATIENTS WITH ACTIVE SYSTEMIC LUPUS ERYTHEMATOSUS: YEAR 2 FOLLOW-UP OF A LARGE PHASE 4, RANDOMISED, DOUBLE-BLIND, PLACEBO-CONTROLLED STUDY

Background:

Belimumab (BEL), a recombinant human monoclonal antibody that inhibits B-lymphocyte stimulator (BLyS), is approved for the treatment of systemic lupus erythematosus (SLE). Clinical studies have yielded varying incidence rates of mortality and adverse events of special interest, such as malignancies, thereby necessitating large-scale, long-term assessment following BEL exposure.

Objectives:

To assess all-cause mortality and new primary malignancies during post-treatment Year 2 follow-up in adult patients with active, autoantibody-positive SLE who received intravenous (IV) BEL or placebo (PBO), plus standard therapy in the 52-week double-blind treatment period of the ongoing BASE trial.1

Methods:

This was a post-treatment follow-up of the Phase 4, double-blind study (BASE1; GSK Study BEL115467; NCT01705977), which randomised 4019 adults with active SLE and receiving standard therapy to BEL (10 mg/kg IV) or PBO on Days 0, 14, 28, and monthly thereafter until Week 48. All patients (including those who discontinued BEL before the end-of-treatment phase) were contacted by phone annually (+/-30-day time window). Rates of mortality and new primary malignancy are summarised for Year 2 follow-up, presented by the treatment received during the 52-week double-blind treatment period (Year 1).

Results:

Baseline patient characteristics and disease activity collected at the start of the study, evaluated in patients with Year 2 follow-up were similar to the overall Year 1 study population. Cumulatively by Year 2 follow-up, 10.7% and 9.5% of patients had been exposed to commercial BEL in the BEL and PBO groups, respectively. Cumulative follow-up adjusted mortality and malignancy rates (per 100 patient years) were lower in the BEL vs PBO Year 1 treatment group (Table 1).

Conclusion:

Year 2 follow-up results of BASE, the largest clinical trial of SLE to date,1 provide continued support for the BEL safety profile. No new BEL safety concerns were identified in patients with active, autoantibody-positive SLE receiving standard therapy.

Funding: GSK

References:

[1]Sheikh SZ, et al. Lancet Rheum. 2020 (ePub ahead of print) doi.org/10.1016/S2665-9913(20)30355-6

Table 1.

Year 2 post-treatment* follow-up mortality and new primary malignancy rates by study treatment during Year 1

BELPBOTotalYear 1 as-treated populationN=2002N=2001N=4003Year 1 deaths, n (%)13 (0.65)22 (1.10)35 (0.87)Year 1 new primary malignancies, n (%)9 (0.45)10 (0.50)19 (0.47)Year 2 (as-treated in Year 1) populationN=1681N=1666N=3347Year 2 deaths by MedDRA SOC, n (%)9 (0.54)21 (1.26)30 (0.90)Cardiac disorders2 (0.12)6 (0.36)8 (0.24)Infections and infestations4 (0.24)2 (0.12)6 (0.18)Uncoded1 (0.06)3 (0.18)4 (0.12)General disorders/administration site conditions1 (0.06)2 (0.12)3 (0.09)Gastrointestinal disorders1 (0.06)1 (0.06)2 (0.06)Neoplasms02 (0.12)2 (0.06)Other05 (0.30)†5 (0.15)Cumulative deaths by Year 2 follow-up, n (%)22 (1.10)43 (2.15)65 (1.62)Incidence rate per 100 patient years0.601.180.89Year 2 new primary malignancies by MedDRA SOC, n (%)3 (0.18)4 (0.24)7 (0.21)Neoplasms2 (0.12)4 (0.24)6 (0.18)Hepatobiliary disorders1 (0.06)01 (0.03)Cumulative malignancies by Year 2 follow-up, n (%)12 (0.60)14 (0.70)26 (0.65)Patient incidence rate per 100 patient years0.340.400.37

*Patients in the post-treatment follow-up period are no longer receiving study treatment; †1 event/patient: blood/lymphatic system, musculoskeletal/connective tissue, nervous system, psychiatric, and renal/urinary disorders.

MedDRA, Medical Dictionary for Regulatory Activities; SOC, system organ class.

Acknowledgements:

Medical writing assistance was provided by Katalin Bartus, PhD, Fishawack Indicia Ltd., UK, part of Fishawack Health, and was funded by GSK.

Disclosure of Interests:

Saira Sheikh Grant/research support from: Pfizer, Morton Scheinberg Consultant of: GSK, Pfizer, Alnylam, AbbVie, PTC Therapeutics, James Cheng-Chung Wei Consultant of: TSH Biopharm, AbbVie, BMS, Celgene, Chugai, Eisai, Janssen, Novartis, Pfizer, Sanofi-Aventis and UCB pharma, Grant/research support from: AbbVie, Amgen, Astellas, BMS, Celgene, Eli Lilly, Gilead, Janssen, Novartis, Pfizer Sun and UCB, Dana Tegzová: None declared, William Stohl Consultant of: GSK, Grant/research support from: GSK, Pfizer, Gilead, Tamara Mucenic Speakers bureau: Novartis, Janssen, BMS, AbbVie, Pfizer, Roche, Grant/research support from: GSK, Janssen, Roche, Eli Lilly, Gilead, UCB, Raj Punwaney Shareholder of: GSK, Employee of: GSK, Regina Kurrasch Shareholder of: GSK, Employee of: GSK, Julia Harris Shareholder of: GSK, Employee of: GSK, Saima Muzaffar Shareholder of: GSK, Employee of: GSK, Sofia Fernandes Shareholder of: GSK, Employee of: GSK, Norma Lynn Fox Shareholder of: GSK, Employee of: GSK, Andrew Liu Shareholder of: GSK, Employee of: GSK, Holly Quasny Shareholder of: GSK, Employee of: GSK, David Roth Shareholder of: GSK, Employee of: GSK

Calibrating a chief complaint list for low resource settings: a methodologic case study

BACKGROUND

The chief or presenting complaint is the reason for seeking health care, often in the patient's own words. In limited resource settings, a diagnosis-based approach to quantifying burden of disease is not possible, partly due to limited availability of an established lexicon or coding system. Our group worked with colleagues from the African Federation of Emergency Medicine building on the existing literature to create a pilot symptom list representing an attempt to standardize undifferentiated chief complaints in emergency and acute care settings. An ideal list for any setting is one that strikes a balance between ease of use and length, while covering the vast majority of diseases with enough detail to permit epidemiologic surveillance and make informed decisions about resource needs.

METHODS

This study was incorporated as a part of a larger prospective observational study on human immunodeficiency virus testing in Emergency Departments in South Africa. The pilot symptom list was used for chief complaint coding in three Emergency Departments. Data was collected on 3357 patients using paper case report forms. Chief complaint terms were reviewed by two study team members to determine the frequency of concordance between the coded chief complaint term and the selected symptom(s) from the pilot symptom list.

RESULTS

Overall, 3537 patients' chief complaints were reviewed, of which 640 were identified as 'potential mismatches.' When considering the 191 confirmed mismatches (29.8%), the Delphi process identified 6 (3.1%) false mismatches and 185 (96.9%) true mismatches. Significant chief-complaint clustering was identified with 9 sets of complaints frequently selected together for the same patient. "Pain" was used 2076 times for 58.7% of all patients. A combination of user feedback and expert-panel modified Delphi analysis of mismatched complaints and clustered complaints resulted in several substantial changes to the pilot symptom list.

CONCLUSIONS

This study presented a systematic methodology for calibrating a chief complaint list for the local context. Our revised list removed/reworded symptoms that frequently clustered together or were misinterpreted by health professionals. Recommendations for additions, modifications, and/or deletions from the pilot chief complaint list we believe will improve the functionality of the list in low resource environments.

P10: LYMPH NODE YIELD IS NOT A RELIABLE PROGNOSTIC MARKER IN ANTERIOR RESECTION AND ABDOMINOPERINEAL RESECTION FOLLOWING NEOADJUVANT THERAPY FOR RECTAL CANCER

Introduction

International guidelines recommend a minimum lymph node yield (LNY) of ≥12 for oncological resection in colorectal cancer (CRC). Neoadjuvant chemoradiotherapy (NACRT) decreases LNY, which questions its ability to provide accurate prognostic information. The consensus of this significance remains undetermined. This study aimed to investigate the significance of LNY on recurrence and survival following anterior resection and abdominoperineal resection with or without NACRT for rectal cancer.

Method

Prospectively collected data on patients diagnosed with rectal cancer in a tertiary referral centre was interrogated retrospectively. Patients were divided into primary surgery and NACRT groups. Univariable analysis was performed using Fisher's exact test, t-test, and x2 test, while multivariable analysis utilised a multiple regression model. Disease recurrence and survival was analysed with logrank test for Kaplan-Meier curves.

Result

148 patients were included [56.1% (n=83) receiving NACRT]. The median LNY of the primary surgery group was 14 [interquartile range (IQR) 11-19] and for the NACRT group was 12 (IQR 8-14) (p &lt;0.001). Disease recurrence was similar in both primary surgery and NACRT groups. There was a significant decrease in overall mortality in NACRT patients (p = 0.03), but there was no significant difference observed in recurrence or mortality amongst LNYs of &lt;8, 8-11, and ≥12.

Conclusion

LNY less than 12 was not a negative prognostic indicator following NACRT and surgery for rectal cancer.

Take-home message

A lymph node yield of less than 12 is not a negative prognostic indicator in rectal cancer patients who receive neoadjuvant chemotherapy.

Development of a shared decision-making tool in vitiligo: an international study

BACKGROUND

Shared decision-making tools (SDMt) are visual tools developed to promote joint medical decisions between physicians and patients. There is a paucity of such tools in dermatology.

OBJECTIVES

To develop and validate a SDMt for use in specialized consultation for vitiligo.

METHODS

A prospective cross-sectional study was carried out from March 2019 to March 2020. We first conducted a qualitative study of topics discussed by patients and clinicians during therapeutic decision-making in the setting of a specialized consultation for vitiligo using an anchored-theory method, which allowed conceptualization of the SDMt. The usefulness of the SDMt was evaluated by a working group of multidisciplinary health workers and patients with vitiligo. Consensus on the final tool was obtained through an e-Delphi method.

RESULTS

We recruited 30 patients with vitiligo for the qualitative study, which identified 91 topics related to therapeutic decision-making. Hierarchical clustering analysis confirmed the distribution of these topics in two subgroups (general treatment goals and priorities, and topics specific to each treatment). The consensus of a multidisciplinary group was used to develop the SDMt. The tool was comprised of eight A5 cards, which addressed face repigmentation; body repigmentation (limited area); body repigmentation (extended area); partial or complete depigmentation; coping with the disease; stabilization of disease; maintaining repigmentation; and disease information. Cognitive interviews confirmed the satisfaction, readability and usefulness of the SDMt. The SDMt was then translated and culturally validated in English.

CONCLUSIONS

We developed a tool for shared decision-making in nonsegmental vitiligo, which we translated and cross-culturally validated in a US patient population with vitiligo to ensure its generalizability.

UK food and nutrition security during and after the COVID-19 pandemic

The COVID‐19 pandemic is a major shock to society in terms of health and economy that is affecting both UK and global food and nutrition security. It is adding to the ‘perfect storm’ of threats to society from climate change, biodiversity loss and ecosystem degradation, at a time of considerable change, rising nationalism and breakdown in international collaboration. In the UK, the situation is further complicated due to Brexit. The UK COVID‐19Food andNutritionSecurity project, lasting one year, is funded by the Economic and Social Research Council and is assessing the ongoing impact of COVID‐19 on the four pillars of food and nutrition security: access, availability, utilisation and stability. It examines the food system, how it is responding, and potential knock on effects on the UK’s food and nutrition security, both in terms of the cascading risks from the pandemic and other threats. The study provides an opportunity to place the initial lessons being learnt from the on‐going responses to the pandemic in respect of food and nutrition security in the context of other long‐term challenges such as climate change and biodiversity loss.

Characterisation and control of the biosolids storage environment: Implications for E. coli dynamics

E. coli survival in biosolids storage may present a risk of non-compliance with guidelines designed to ensure a quality product safe for agricultural use. The storage environment may affect E. coli survival but presently, storage characteristics are not well profiled. Typically biosolids storage environments are not actively controlled or monitored to support increased product quality or improved microbial compliance. This two-phased study aimed to identify the environmental factors that control bacterial concentrations through a long term, controlled monitoring study (phase 1) and a field-scale demonstration trial modifying precursors to bacterial growth (phase 2). Digested and dewatered biosolids were stored in operational-scale stockpiles to elucidate factors controlling E. coli dynamics. E. coli concentrations, stockpile dry solids, temperature, redox and ambient weather data were monitored. Results from ANCOVA analysis showed statistically significant (p < 0.05) E. coli reductions across storage periods with greater die-off in summer months. Stockpile temperature had a statistically significant effect on E. coli survival. A 4.5 Log reduction was measured in summer (maximum temperature 31 °C). In the phase 2 modification trials, covered stockpiles were able to maintain a temperature >25 °C for a 28 day period and achieved a 3.7 Log E. coli reduction. In winter months E. coli suppression was limited with concentrations >6 Log₁₀ CFU g^-1 DS maintained. The ANCOVA analysis has identified the significant role that physical environmental factors, such as stockpile temperature, has on E. coli dynamics and the opportunities for control.

Two-dimensional echocardiographic estimates of left ventricular volumes obtained in different views in dogs provide similar measurements but are not interchangeable

INTRODUCTION

Little information exists regarding the interchangeability of left ventricular volume estimates using a monoplane Simpson's Method of Discs on images obtained from the left apical four-chamber and right parasternal long axis four-chamber views. We examined if volume estimates obtained from these views were interchangeable.

ANIMALS

A total of 224 dogs: 86 healthy, 96 with mitral valve disease, 42 with various cardiac pathologies.

MATERIALS AND METHODS

Investigators obtained right parasternal long-axis and left apical four-chamber views from each dog and used manufacturer-supplied software to estimate left ventricular volumes in diastole and systole using Simpson's Method of Discs. Estimates based on linear measurements (diameter cubed, 0.67∗diameter cubed, and Teichholz) were also calculated. Reproducibility for each view, and agreement between the estimates obtained with each view, and those calculated from linear dimensions, were examined using Limits of Agreement. Reference intervals for volumes indexed to bodyweight and body surface area were calculated.

RESULTS

Neither method proved very reproducible. Although no bias was detected, the agreement between volumes indexed to bodyweight and body surface area was insufficient to recommend interchangeability. Estimates based on Teichholz and diameter cubed methods overestimated volumes; however, those based on 0.67∗diameter cubed performed reasonably.

CONCLUSIONS

Monoplane volume estimates from the left apical and right parasternal long axis four-chamber views are similar but not interchangeable. Clinicians can perform crude estimates of left ventricular volume using the equation 0.67∗diameter cubed.

Assessing the benefits and usefulness of Schwartz Centre rounds in second-year medical students using clinical educator-facilitated group work session: not just "a facilitated moan"!

BACKGROUND

An experiential curriculum exposing medical students to the clinic early has many benefits but comes with the emotional stress this environment engenders. Schwartz rounds (SR) are an effective means to combat emotional stress and increasingly used in UK and USA hospitals. Recent studies show that the SR format may also provide benefits for medical students. This study aimed to investigate whether the guidance of SR in second year medical students provides the same benefits as to healthcare professionals.

METHODS

SR assessment involved 83 s year MBChB students in facilitated groupwork sessions. Topics discussed were "change and resilience" and "duty of candour". Students completed a Likert Scale questionnaire evaluating outcomes proffered by the Point of Care Foundation in collaboration with the Schwartz Foundation, with freeform feedback.

RESULTS

There was an 86% completion rate with 25% providing written feedback. Participants were more likely to agree than disagree that SR were beneficial. SR effectiveness in enhancing students' working relationship awareness and skills was strongly correlated with understanding the purpose of, and engagement with, the SR (P < 0.001). Similarly, engagement with the SR was strongly correlated with self-reporting of enhanced patient-centredness (P < 0.001). Freeform feedback could be grouped into five themes that revolved around understanding of the SR and engagement with the process. Many positive comments regarded the SR as a forum not only to "learn experientially" but to so in a "safe environment". Many negative comments stemmed from students not seeing any benefits of engagement with the SR, in that sharing experiences was "unbeneficial", "empathy is inherent and not learnt", or that sharing emotional problems is simply "moaning".

CONCLUSION

SRs are an effective way of fostering empathy and understanding towards patients and colleagues. However, for the students to benefit fully from the SR it is necessary for them to engage and understand the process. Therefore, for the successful implementation of SR into pre-clinical medical education, it is important to help students realise that SR are not merely a "facilitated whinge".