Changes in Cardiac Function During a Swallow Exercise Program in Patients with Coronary Artery Disease

Research regarding risks of swallow treatment suggests that patients with coronary artery disease (CAD) experience changes in heart rate/rhythm when completing the supraglottic swallow and super-supraglottic swallow. The current study evaluated cardiac function during multiple swallowing exercises in patients with dysphagia and CAD. Eligible patients had CAD and confirmed pharyngeal dysphagia from VFS and sufficient cognitive ability to follow direction. The protocol included an a priori concealed randomized order of seven swallowing exercises (supraglottic swallow, super-supraglottic swallow, Mendelsohn and Masako maneuvers, effortful swallow with and without breath hold, and jaw opening exercise). Objective measures of heart rate/rhythm, oxygen saturation, and blood pressure were compared before vs after the overall session and each exercise using the Wilcoxon signed-rank test, and McNemar's and Cochran's Q tests with alpha at 0.05 and power at 0.80. Participants were 20 adults (15 male), aged 28-88 (median 76.5 years). 90% were intubated during their hospital stay (44% > 1 intubation) and 20% suffered post-op stroke. Severe dysphagia, marked by NPO status, occurred in 30% of patients. Sessions were 26 min long (mean; SD = 2.29). With few exceptions, objective measures were stable pre vs post overall and after each exercise. Potential vulnerability was noted with increased heart rate after the super-supraglottic swallow and increased arrhythmias after the effortful swallow (p < 0.05 for both). The order that swallowing exercises were completed did not significantly impact cardiovascular function. Telemetry and pulse oximetry proved to be feasible tools to monitor for subtle changes in cardiovascular function during completion of swallowing exercises.

Cohort profile: the ESC EURObservational Research Programme Non-ST-segment elevation myocardial infraction (NSTEMI) Registry

AIMS

The European Society of Cardiology (ESC) EURObservational Research Programme (EORP) Non-ST-segment elevation myocardial infarction (NSTEMI) Registry aims to identify international patterns in NSTEMI management in clinical practice and outcomes against the 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without ST-segment-elevation.

METHODS AND RESULTS

Consecutively hospitalised adult NSTEMI patients (n = 3620) were enrolled between 11 March 2019 and 6 March 2021, and individual patient data prospectively collected at 287 centres in 59 participating countries during a two-week enrolment period per centre. The registry collected data relating to baseline characteristics, major outcomes (in-hospital death, acute heart failure, cardiogenic shock, bleeding, stroke/transient ischaemic attack, and 30-day mortality) and guideline-recommended NSTEMI care interventions: electrocardiogram pre- or in-hospital, pre-hospitalization receipt of aspirin, echocardiography, coronary angiography, referral to cardiac rehabilitation, smoking cessation advice, dietary advice, and prescription on discharge of aspirin, P2Y12 inhibition, angiotensin converting enzyme inhibitor (ACEi)/angiotensin receptor blocker (ARB), beta-blocker, and statin.

CONCLUSION

The EORP NSTEMI Registry is an international, prospective registry of care and outcomes of patients treated for NSTEMI, which will provide unique insights into the contemporary management of hospitalised NSTEMI patients, compliance with ESC 2015 NSTEMI Guidelines, and identify potential barriers to optimal management of this common clinical presentation associated with significant morbidity and mortality.

Outcomes of very high-power short-duration ablation using 90w for pulmonary vein isolation in patients with atrial fibrillation: a real world observation study

Introduction

Pulmonary vein isolation (PVI) ablation is the established gold standard therapy for patients with symptomatic drug refractory atrial fibrillation (AF). Advancements in radiofrequency (RF) ablation, have led to the development of the novel contact force-sensing temperature-controlled very high-power short-duration (vHPSD) RF ablation. This setting delivers 90W for up to 4 seconds with a constant irrigation flow rate of 8ml/min. The aim of this study was to compare procedural outcomes and safety with conventional radiofrequency ablation.

Methods

An observational study was conducted with patients who underwent first time PVI ablation from 2019 to 2021. The cohort was divided in to: 1) vHPSD ablation – QMODE+ via QDOT MICRO catheter, 2) QMODE via QDOT MICRO catheter and 3) Conventional power-controlled RF (PCRF) ablation via THERMOCOOOL SMARRTOUCH SF (STSF) catheter. The QMODE+ vHPSD ablation group was prospectively recruited while the QMODE and PCRF group were retrospectively collected. Primary outcomes were procedural success, PVI duration, ablation duration and incidence of perioperative adverse events. Secondary outcomes were intraprocedural morphine and midazolam requirement.

Results

A total of 155 patients were included in the study with 80, 30 and 45 patients in the QMODE+ (vHPSD), QMODE and PCRF, respectively. PVI was successfully attained in all patients. QMODE+ (vHPSD) demonstrated significantly reduced time required for PVI and total energy application in comparison to the QMODE and PCRF groups (68.3±3.30 vs. 92.9±4.86 vs. 93.6±4.34 min, P&lt;0.0001; 9.7±0.452 vs. 33.9±0.452 vs. 36.0±1.56 min, P&lt;0.0001, respectively) (Figure 1). Intravenous morphine and midazolam requirement was lower in the QMODE+ (vHPSD) group compared to the QMODE and PCRF groups (10.3±0.45 vs. 16.1±0.935 vs. 15.3±0.686 mg, P&lt;0.0001; 4.05±0.402 vs. 8.63±1.07 vs. 8.58±0.821 mg, P&lt;0.0001) (Figure 2). QMODE+ (vHPSD) observed a non-significant reduction in fluoroscopy time compared to QMODE and PCRF. One cardiac tamponade were observed in both the QMODE+ (vHPSD) and QMODE group while the PCRF group exhibited an embolic stoke and two pericardial effusions that did not require drainage.

Conclusion

In this study, QMODE+ (vHPSD) demonstrated a comparable safety profile to the other treatment arms. Procedural duration and energy application time was substantially reduced while a non-significant reduction was observed for fluoroscopy time for QMODE+. Furthermore, sedation requirement was reduced and thus potentially conveyed greater patient tolerability of the procedure when conducted with QMODE+.

Notwithstanding the limitations of observational study design, these preliminary findings are promising with respect to periprocedural outcomes and safety of QMODE+. Longer term outcomes with respect to maintenance of sinus rhythm and symptomatic burden will be essential to assessing the overall efficacy of this novel technology.

Funding Acknowledgement

Type of funding sources: None.

Atrial fibrillation virtual ward: reshaping the future of AF care

Background

Atrial fibrillation (AF) hospital admissions represent significant AF related treatment costs nationally. In the year 2019–2020 our hospital reported 1,333 admissions with a primary diagnosis of AF, with a 10% annual increase. A virtual ambulatory AF ward providing multidisciplinary care with remote hospital-level monitoring could reshape the future model of AF management.

Methods

An AF virtual ward was implemented at our UK tertiary centre, as a proof-of-concept model of care. Patients admitted with a primary diagnosis of AF satisfying the AF virtual ward (AFVW) entry criteria (i.e., haemodynamically stable, HR &lt;140 bpm with other acute conditions excluded) were given access to a single lead ECG recording device, a Bluetooth integrated blood pressure machine and pulse oximeter with instruction to record daily ECGs, blood pressure readings, oxygen saturations and fill an online AF symptom questionnaire via a smart phone or electronic tablet. Data were uploaded to an integrated digital platform for review by the clinical team who undertook twice daily virtual ward rounds. Medication adjustment was arranged through the hospital pharmacy. Data was collected prospectively for patients admitted to the AF virtual ward between 31 January and 11 March 2022. Outcomes included length of hospital stay, admission avoidance and re-admissions. Re-admission avoidance was assessed using the index admission criteria as a parameter for re-admission likelihood. Patients' satisfaction was assessed using the NHS family and friends' test (FFT).

Results

Over the 6-week period a total of 14 patients were enrolled. One patient was unable to be onboarded because of technology related anxiety with 13 patients onboarded to the virtual ward, 30.7% (n=4) did not have smart phones and were provided with electronic tablets. The age on admission was 64±10 years (mean±SD) with the oldest at 78 years of age. All patients were in AF with a mean heart rate of 122±24 bpm, and 38.5% (n=5) were discharged from the virtual ward in sinus rhythm. One patient was onboarded directly from pacemaker clinic and hence hospital admission was completely avoided, and 5 re-admissions were avoided for 3 patients. One patient required brief readmission due to persistent tachycardia requiring acute cardioversion. The FFT yielded 100% positive responses among patients.

Conclusion

This proof-of-concept is a first real world experience of a virtual ward for hospital patients with fast AF. It demonstrates a promising new telemedicine-based care model and with clear appetite among both patients and health professionals. This model of care has the potential to reduce the financial and backlog pressures caused by AF admissions without compromising patients' care or safety. Work is ongoing to further confirm the safety and cost-effectiveness upon further progress in a larger patient cohort.

Funding Acknowledgement

Type of funding sources: None.

Impact of omitting post-transplant minidose-methotrexate doses in allogeneic hematopoietic cell transplantation

Given prophylactic methotrexate (MTX) is often held in the setting of toxicity we investigated the impact of omitting minidose-MTX dose(s). Outcomes were compared between patients who had 1-3 doses omitted and those who received all four planned doses of minidose-MTX. Of 370 consecutive patients, 50 had MTX dose(s) omitted. When MTX was omitted, initial management was mycophenolate mofetil (MMF; 36/50 patients) with or without corticosteroids (14/50 patients). Rates of grade 3-4 acute GVHD were similar between groups. Omission of minidose-MTX resulted in an increased risk of chronic GVHD (cGVHD; HR 2.27; p = .024) and decreased overall survival (HR 1.61; p = .024). However, other transplant-related outcomes were comparable. In summary, omission of minidose-MTX doses was not associated with an increased risk of acute GVHD when an alternative was added (e.g. MMF ± corticosteroids). This did not abrogate the increased risk of cGVHD or decreased overall survival.

OP0249 CHARACTERISTICS ASSOCIATED WITH POOR COVID-19 OUTCOMES IN PEOPLE WITH PSORIASIS AND SPONDYLOARTHRITIS: DATA FROM THE COVID-19 PsoProtect AND GLOBAL RHEUMATOLOGY ALLIANCE PHYSICIAN-REPORTED REGISTRIES

Background

Some factors associated with severe COVID-19 outcomes have been identified in patients with psoriasis (PsO) and inflammatory/autoimmune rheumatic diseases, namely older age, male sex, comorbidity burden, higher disease activity, and certain medications such as rituximab. However, information about specificities of patients with PsO, psoriatic arthritis (PsA) and axial spondyloarthritis (axSpA), including disease modifying anti-rheumatic drugs (DMARDs) specifically licensed for these conditions, such as IL-17 inhibitors (IL-17i), IL-23/IL-12 + 23 inhibitors (IL-23/IL-12 + 23i), and apremilast, is lacking.

Objectives

To determine characteristics associated with severe COVID-19 outcomes in people with PsO, PsA and axSpA.

Methods

This study was a pooled analysis of data from two physician-reported registries: the Psoriasis Patient Registry for Outcomes, Therapy and Epidemiology of COVID-19 Infection (PsoProtect), comprising patients with PsO/PsA, and the COVID-19 Global Rheumatology Alliance (GRA) registry, comprising patients with PsA/axSpA. Data from the beginning of the pandemic up to 25 October, 2021 were included. An ordinal severity outcome was defined as: 1) not hospitalised, 2) hospitalised without death, and 3) death. A multivariable ordinal logistic regression model was constructed to assess the relationship between COVID-19 severity and demographic characteristics (age, sex, time period of infection), comorbidities (hypertension, other cardiovascular disease [CVD], chronic obstructive lung disease [COPD], asthma, other chronic lung disease, chronic kidney disease, cancer, smoking, obesity, diabetes mellitus [DM]), rheumatic/skin disease (PsO, PsA, axSpA), physician-reported disease activity, and medication exposure (methotrexate, leflunomide, sulfasalazine, TNFi, IL17i, IL-23/IL-12 + 23i, Janus kinase inhibitors (JAKi), apremilast, glucocorticoids [GC] and NSAIDs). Age-adjustment was performed employing four-knot restricted cubic splines. Country-adjustment was performed using random effects.

Results

A total of 5008 individuals with PsO (n=921), PsA (n=2263) and axSpA (n=1824) were included. Mean age was 50 years (SD 13.5) and 51.8% were male. Hospitalisation (without death) was observed in 14.6% of cases and 1.8% died. In the multivariable model, the following variables were associated with severe COVID-19 outcomes: older age (Figure 1), male sex (OR 1.53, 95%CI 1.29-1.82), CVD (hypertension alone: 1.26, 1.02-1.56; other CVD alone: 1.89, 1.22-2.94; vs no hypertension and no other CVD), COPD or asthma (1.75, 1.32-2.32), other lung disease (2.56, 1.66-3.97), chronic kidney disease (2.32, 1.50-3.59), obesity and DM (obesity alone: 1.36, 1.07-1.71; DM alone: 1.85, 1.39-2.47; obesity and DM: 1.89, 1.34-2.67; vs no obesity and no DM), higher disease activity and GC intake (remission/low disease activity and GC intake: 1.96, 1.36-2.82; moderate/severe disease activity and no GC intake: 1.35, 1.05-1.72; moderate/severe disease activity and GC intake 2.30, 1.41-3.74; vs remission/low disease activity and no GC intake). Conversely, the following variables were associated with less severe COVID-19 outcomes: time period after 15 June 2020 (16 June 2020-31 December 2020: 0.42, 0.34-0.51; 1 January 2021 onwards: 0.52, 0.41-0.67; vs time period until 15 June 2020), a diagnosis of PsO (without arthritis) (0.49, 0.37-0.65; vs PsA), and exposure to TNFi (0.58, 0.45-0.75; vs no DMARDs), IL17i (0.63, 0.45-0.88; vs no DMARDs), IL-23/IL-12 + 23i (0.68, 0.46-0.997; vs no DMARDs) and NSAIDs (0.77, 0.60-0.98; vs no NSAIDs).

Conclusion

More severe COVID-19 outcomes in PsO, PsA and axSpA are largely driven by demographic factors (age, sex), comorbidities, and active disease. None of the DMARDs typically used in PsO, PsA and axSpA, were associated with severe COVID-19 outcomes, including IL-17i, IL-23/IL-12 + 23i, JAKi and apremilast.

Acknowledgements

We thank all the contributors to the COVID-19 PsoProtect, GRA and EULAR Registries.

Disclosure of Interests

None declared

Assessment of Thorax Finite Element Model Response for Behind Armor Blunt Trauma Impact Loading Using an Epidemiological Database

Nonperforating ballistic impacts on thoracic armor can cause blunt injuries, known as behind-armor blunt trauma (BABT). To evaluate the potential for this injury, the back face deformation (BFD) imprinted into a clay backing is measured; however, the link between BFD and potential for injury is uncertain. Computational human body models (HBMs) have the potential to provide an improved understanding of BABT injury risk to inform armor design but require assessment with relevant loading scenarios. In this study, a methodology was developed to apply BABT loading to a computational thorax model, enhanced with refined finite element mesh and high-deformation rate mechanical properties. The model was assessed using an epidemiological BABT survivor database. BABT impact boundary conditions for 10 cases from the database were recreated using experimentally measured deformation for specific armor/projectile combinations, and applied to the thorax model using a novel prescribed displacement methodology. The computational thorax model demonstrated numerical stability under BABT impact conditions. The predicted number of rib fractures, the magnitude of pulmonary contusion, and injury rank, increased with armor BFD, back face velocity, and input energy to the thorax. In three of the 10 cases, the model overpredicted the number of rib fractures, attributed to impact location positional sensitivity and limited details from the database. The integration of an HBM with the BABT loading method predicted rib fractures and injury ranks that were in good agreement with available medical records, providing a potential tool for future armor evaluation and injury assessment.

Clinical phenotype and management of individuals with mosaic monosomy X with Y chromosome material stratified by genital phenotype

Individuals mosaic for monosomy X and a cell line with Y chromosome material can have genitalia that appear phenotypical female, male, or ambiguous. Those with this karyotype and typical female genitalia are diagnosed with Turner syndrome; however, this definition specifically excludes those with genitalia other than typical female. There is limited information on whether medical and neurodevelopmental risks are similar among individuals with monosomy X and Y chromosome material across genital phenotypes. This multicenter retrospective study compared comorbidities and clinical management in individuals with monosomy X and Y material and male/ambiguous genitalia to those with typical female genitalia. Electronic medical records for all patients with monosomy X and Y material (n = 76) at two large U.S. pediatric centers were abstracted for predetermined data and outcomes. Logistic regression was used to compare the two phenotypic groups adjusting for site and duration of follow-up. The male/ambiguous genitalia group was just as likely to have congenital heart disease (RR 1.0, 95%CI [0.5-1.9]), autoimmune disease (RR 0.6 [0.2-1.3]), and neurodevelopmental disorders (RR 1.4 [0.8-1.2]) as those with female genitalia. Despite similar risks, they were less likely to receive screening and counseling. In conclusion, individuals with monosomy X and Y chromosome material have similar medical and neurodevelopmental risks relative to individuals with Turner syndrome regardless of genitalia, but there are notable differences in clinical management.

Observation of Magnon Polarization

We measure the mode-resolved direction of the precessional motion of the magnetic order, i.e., magnon polarization, via the chiral term of inelastic polarized neutron scattering spectra. The magnon polarization is a unique and unambiguous signature of magnets and is important in spintronics, affecting thermodynamic properties such as the magnitude and sign of the spin Seebeck effect. However, it has never been directly measured in any material until this work. The observation of both signs of magnon polarization in Y_{3}Fe_{5}O_{12} also gives direct proof of its ferrimagnetic nature. The experiments agree very well with atomistic simulations of the scattering cross section.

Clinical characteristics including cardiovascular and metabolic risk factors in adolescents with psoriasis

BACKGROUND

Clinical studies on psoriasis in adolescents have mainly been performed in patients with severe psoriasis. Population-based studies of clinical characteristics and risk factors for later cardiovascular and metabolic disease in children and adolescents are lacking.

OBJECTIVES

To examine the clinical characteristics of adolescents with psoriasis nested in a general population cohort. Furthermore, to investigate cardiovascular and metabolic risk factors in the adolescents with psoriasis compared to parentally predisposed and non-predisposed adolescents without psoriasis from the same birth cohort.

METHODS

We identified adolescents with and without psoriasis using a nationwide general population birth cohort in Denmark. A clinical examination included skin inspection and scoring of psoriasis severity, completion of a questionnaire on psoriasis and comorbidities, physical measurements, and blood sampling. Participants also completed self-administered questionnaires on quality of life and mental health.

RESULTS

We included 81 adolescents with psoriasis and 234 controls (110 with genetic predisposition for psoriasis and 124 without predisposition). Median age was 15.6 (13.5-18.5) years, and in those with active psoriasis, median Psoriasis Area and Severity Index score was 1.2 (0.1-11.4). The scalp was the most common site of psoriasis, both at debut and at time of examination. Diaper rash in infancy was more frequent in the psoriasis group. No significant differences regarding quality of life, anxiety and depression were found. More adolescents with psoriasis were obese (8.6% vs. 1.7%, P = 0.008), and physical measures of abdominal obesity were also significantly higher. HbA1c was significantly higher (31.55 vs. 30.81 mmol/mol, P = 0.048), while no differences were found for blood pressure, lipids or high-sensitivity C-reactive protein. In a subgroup analysis, this was evident in the non-predisposed psoriasis-free controls only.

CONCLUSIONS

Overall, adolescents with psoriasis from this general population had mild disease. Still, early markers of cardiovascular and metabolic disease were elevated.

The importance of clinical documentation improvement for Australian hospitals

Clinical documentation improvement (CDI) is a recent initiative gaining increased momentum in Australia. The benefits surrounding its success internationally include improved quality and patient safety outcomes and increased reimbursement. The premise of CDI is simple: engage clinicians to improve the clinical documentation in the medical record in “real time” so that it is fit for reporting, analysis and reimbursement. Every country has differing healthcare systems and this article has focused on validating the relevancy of CDI for the Australian healthcare environment.

Diagnosis of death using neurological criteria in adult patients on extracorporeal membrane oxygenation: Development of UK guidance

The diagnosis of death using neurological criteria is an important legal method of establishing death in the UK. The safety of the diagnosis lies in the exclusion of conditions which may mask the diagnosis and the testing of the fundamental reflexes of the brainstem including the apnoea reflex. Extracorporeal membrane oxygenation for cardiac or respiratory support can impact upon these tests, both through drug sequestration in the circuit and also through the ability to undertake the apnoea test. Until recently, there has been no nationally accepted guidance regarding the conduct of the tests to undertake the diagnosis of death using neurological criteria for a patient on extracorporeal membrane oxygenation. This article considers both the background to and the process of guideline development.

Identical and Nonidentical Twins: Risk and Factors Involved in Development of Islet Autoimmunity and Type 1 Diabetes

OBJECTIVE

There are variable reports of risk of concordance for progression to islet autoantibodies and type 1 diabetes in identical twins after one twin is diagnosed. We examined development of positive autoantibodies and type 1 diabetes and the effects of genetic factors and common environment on autoantibody positivity in identical twins, nonidentical twins, and full siblings.

RESEARCH DESIGN AND METHODS

Subjects from the TrialNet Pathway to Prevention Study (N = 48,026) were screened from 2004 to 2015 for islet autoantibodies (GAD antibody [GADA], insulinoma-associated antigen 2 [IA-2A], and autoantibodies against insulin [IAA]). Of these subjects, 17,226 (157 identical twins, 283 nonidentical twins, and 16,786 full siblings) were followed for autoantibody positivity or type 1 diabetes for a median of 2.1 years.

RESULTS

At screening, identical twins were more likely to have positive GADA, IA-2A, and IAA than nonidentical twins or full siblings (all P < 0.0001). Younger age, male sex, and genetic factors were significant factors for expression of IA-2A, IAA, one or more positive autoantibodies, and two or more positive autoantibodies (all P ≤ 0.03). Initially autoantibody-positive identical twins had a 69% risk of diabetes by 3 years compared with 1.5% for initially autoantibody-negative identical twins. In nonidentical twins, type 1 diabetes risk by 3 years was 72% for initially multiple autoantibody-positive, 13% for single autoantibody-positive, and 0% for initially autoantibody-negative nonidentical twins. Full siblings had a 3-year type 1 diabetes risk of 47% for multiple autoantibody-positive, 12% for single autoantibody-positive, and 0.5% for initially autoantibody-negative subjects.

CONCLUSIONS

Risk of type 1 diabetes at 3 years is high for initially multiple and single autoantibody-positive identical twins and multiple autoantibody-positive nonidentical twins. Genetic predisposition, age, and male sex are significant risk factors for development of positive autoantibodies in twins.

Screening for Atrial Fibrillation in Zambia’s Western Province

BACKGROUND: The prevalence of atrial fibrillation (AF) is increasing in sub-Saharan Africa and contributes to significant morbidity and mortality from stroke and other cardiovascular diseases. Case finding in some areas of the country, such as in rural Zambia is especially challenging with limited availability of ambulatory electrocardiogram monitoring devices. Moreover, there is very little qualitative research exploring Zambian patients&rsquo; experiences living with AF. AIMS: The two-fold purpose of this study was i) to explore the use of a screening tool for detecting AF in Western Province, Zambia and ii) to understand the patient experience of living with AF. SETTING: Mongu and Limulunga Districts in the Western Province of Zambia. METHODS: Mixed methods. Convenience sampling for both quantitative and qualitative arms of the study was used to recruit participants attending public &lsquo;Health Checks.&rsquo; Quantitative data were collected by means of an interview-administered survey and qualitative data were obtained through individual interviews. RESULTS: An irregular manual pulse was found in 12.6% (n=33) of Zambians who attended the Health Checks and two participants were confirmed to have AF. Zambians with an irregular pulse had a significantly higher prevalence of hypertension and were significantly less sedentary than those without pulse irregularities. Two themes emerged from the interview with two patients diagnosed with AF: symptoms and healthcare access. CONCLUSION: Hypertension continues to be a problem in adult Zambians and is an independent risk factor for stroke and, when diagnosed in conjunction with AF, further compounds stroke risk. Access to screening and diagnostic care for AF is essential, especially in currently underserved rural areas. In addition, participants presented with unique risk factors, such as consolidated periods of exercise, that require further research to determine context and seasonal variation so as to improve education and prevention strategies.

A Type 1 Diabetes Genetic Risk Score Predicts Progression of Islet Autoimmunity and Development of Type 1 Diabetes in Individuals at Risk

OBJECTIVE

We tested the ability of a type 1 diabetes (T1D) genetic risk score (GRS) to predict progression of islet autoimmunity and T1D in at-risk individuals.

RESEARCH DESIGN AND METHODS

We studied the 1,244 TrialNet Pathway to Prevention study participants (T1D patients' relatives without diabetes and with one or more positive autoantibodies) who were genotyped with Illumina ImmunoChip (median [range] age at initial autoantibody determination 11.1 years [1.2-51.8], 48% male, 80.5% non-Hispanic white, median follow-up 5.4 years). Of 291 participants with a single positive autoantibody at screening, 157 converted to multiple autoantibody positivity and 55 developed diabetes. Of 953 participants with multiple positive autoantibodies at screening, 419 developed diabetes. We calculated the T1D GRS from 30 T1D-associated single nucleotide polymorphisms. We used multivariable Cox regression models, time-dependent receiver operating characteristic curves, and area under the curve (AUC) measures to evaluate prognostic utility of T1D GRS, age, sex, Diabetes Prevention Trial-Type 1 (DPT-1) Risk Score, positive autoantibody number or type, HLA DR3/DR4-DQ8 status, and race/ethnicity. We used recursive partitioning analyses to identify cut points in continuous variables.

RESULTS

Higher T1D GRS significantly increased the rate of progression to T1D adjusting for DPT-1 Risk Score, age, number of positive autoantibodies, sex, and ethnicity (hazard ratio [HR] 1.29 for a 0.05 increase, 95% CI 1.06-1.6; P = 0.011). Progression to T1D was best predicted by a combined model with GRS, number of positive autoantibodies, DPT-1 Risk Score, and age (7-year time-integrated AUC = 0.79, 5-year AUC = 0.73). Higher GRS was significantly associated with increased progression rate from single to multiple positive autoantibodies after adjusting for age, autoantibody type, ethnicity, and sex (HR 2.27 for GRS >0.295, 95% CI 1.47-3.51; P = 0.0002).

CONCLUSIONS

The T1D GRS independently predicts progression to T1D and improves prediction along T1D stages in autoantibody-positive relatives.

Invasive pulmonary aspergillosis is associated with adverse clinical outcomes in critically ill patients receiving veno-venous extracorporeal membrane oxygenation

To identify the incidence, risk factors and impact on long-term survival of invasive pulmonary aspergillosis (IPA) and Aspergillus colonisation in patients receiving vv-extracorporeal membrane oxygenation (ECMO). A retrospective evaluation was performed of patients receiving vv-ECMO at a tertiary hospital in Manchester (UK) between January 2012 and December 2016. Data collected included epidemiological data, microbiological cultures, radiographic findings and outcomes. Cases were classified as proven IPA, putative IPA or Aspergillus colonisation according to a validated clinical algorithm. One hundred thirty-four patients were supported with vv-ECMO, median age of 45.5 years (range 16.4-73.4). Ten (7%) patients had putative IPA and nine (7%) had Aspergillus colonisation. Half of the patients with putative IPA lacked classical host risk factors for IPA. The median number of days on ECMO prior to Aspergillus isolation was 5 days. Immunosuppression and influenza A infection were significantly associated with developing IPA in a logistic regression model. Cox regression model demonstrates a three times greater hazard of death associated with IPA. Overall 6-month mortality rate was 38%. Patients with putative IPA and colonised patients had a 6-month mortality rate of 80 and 11%, respectively. Immunosuppression and influenza A infection are independent risk factors for IPA. IPA, but not Aspergillus colonisation, is associated with high long-term mortality in patients supported with vv-ECMO.

Valuing and understanding fish populations in the Anthropocene: key questions to address

Research on the values of fish populations and fisheries has primarily focused on bio-economic aspects; a more nuanced and multidimensional perspective is mostly neglected. Although a range of social aspects is increasingly being considered in fisheries research, there is still no clear understanding as to how to include these additional values within management policies nor is there a cogent appreciation of the major knowledge gaps that should be tackled by future research. This paper results from a workshop held during the 50th anniversary symposium of the Fisheries Society of the British Isles at the University of Exeter, UK, in July 2017. Here, we aim to highlight the current knowledge gaps on the values of fish populations and fisheries thus directing future research. To this end, we present eight questions that are deeply relevant to understanding the values of fish populations and fisheries. These can be applied to all habitats and fisheries, including freshwater, estuarine and marine.

Genetic architecture of acne vulgaris

Acne vulgaris is a ubiquitary skin disease characterized by chronic inflammation of the pilosebaceous unit resulting from bacterial colonization of hair follicles by Propionibacterium acnes, androgen-induced increased sebum production, altered keratinization and inflammation. Here, we review our current understanding of the genetic architecture of this intriguing disease. We analysed genomewide association studies (GWAS) and candidate genes studies for acne vulgaris. Moreover, we included GWAS studies for the associated disease polycystic ovary syndrome (PCOS). Overall, the available data revealed sixteen genetic loci flagged by single nucleotide polymorphisms (SNPs), none of which has been confirmed yet by independent studies. Moreover, a GWAS for PCOS identified 21 susceptible loci. The genetic architecture is complex which has been revealed by GWAS. Further and larger studies in different populations are required to confirm or disprove results from candidate gene studies as well to identify signals that may overlap between different populations. Finally, studies on rare genetic variants in acne and associated diseases like PCOS may deepen our understanding of its pathogenesis.

The role of IL-23 and the IL-23/TH 17 immune axis in the pathogenesis and treatment of psoriasis

Psoriasis is a chronic, immune‐mediated disease affecting more than 100 million people worldwide and up to 2.2% of the UK population. The aetiology of psoriasis is thought to originate from an interplay of genetic, environmental, infectious and lifestyle factors. The manner in which genetic and environmental factors interact to contribute to the molecular disease mechanisms has remained elusive. However, the interleukin 23 (IL‐23)/T‐helper 17 (T_H17) immune axis has been identified as a major immune pathway in psoriasis disease pathogenesis. Central to this pathway is the cytokine IL‐23, a heterodimer composed of a p40 subunit also found in IL‐12 and a p19 subunit exclusive to IL‐23. IL‐23 is important for maintaining T_H17 responses, and levels of IL‐23 are elevated in psoriatic skin compared with non‐lesional skin. A number of agents that specifically inhibit IL‐23p19 are currently in development for the treatment of moderate‐to‐severe plaque psoriasis, with recent clinical trials demonstrating efficacy with a good safety and tolerability profile. These data support the role of this cytokine in the pathogenesis of psoriasis. A better understanding of the IL‐23/T_H17 immune axis is vital and will promote the development of additional targets for psoriasis and other inflammatory diseases that share similar genetic aetiology and pathogenetic pathways.

A European subset analysis from the population-based Multinational Assessment of Psoriasis and Psoriatic Arthritis shows country-specific features: results from psoriasis patients in Spain

Background

The Multinational Assessment of Psoriasis and Psoriatic Arthritis (MAPP) survey data were not analysed to account for cultural and healthcare system differences across European countries (EC).

Objective

To utilize MAPP data to characterize psoriasis in Spanish patients, including severity assessment and Dermatology Life Quality Index (DLQI).

Methods

The MAPP survey was conducted between June and August 2012. This analysis included 1700 patients with self‐reported psoriasis (without psoriatic arthritis) from France (n = 349), Germany (n = 311), Italy (n = 359), Spain (n = 354) and the United Kingdom (n = 327).

Results

Patients from Spain vs. other EC self‐reported higher mean body mass index (26.9 vs. 25.6, P ≤ 0.001), lower prevalence of depression (6% vs. 12%, P = 0.002) and higher mean self‐perceived psoriasis severity at its worst (5.92 vs. 5.33, P < 0.001) despite lower estimated body‐surface‐area involvement. Overall, patients from Spain vs. other EC had lower mean global DLQI scores (4.70 vs. 6.06, P = 0.001) and lower mean scores for each DLQI dimension [all P < 0.001, except leisure (P = 0.002), treatment (P = 0.002), and work and school (P = 0.005)]. Higher DLQI values were inversely associated with age and directly correlated with perceived severity. Palmoplantar, nail and scalp psoriasis were reported less frequently in Spanish patients (P = 0.026) and were associated with higher DLQI values (P < 0.01). Spanish patients were more likely to have seen multiple healthcare providers (HCPs; P < 0.001) and achieve therapeutic goals (P < 0.001), but current treatments were similar to patients in other EC.

Conclusions

In the MAPP survey, Spanish patients differed from other EC in several characteristics, including comorbidities, extent and distribution of psoriasis lesions, perception of severity and impact on quality of life. Their perception of psoriasis severity was higher despite a lower estimated extent, and DLQI scores were significantly lower. Spanish patients had more HCP visits and a higher rate of therapeutic goal achievement. These differences might be attributed to cultural factors, phenotypical variation and differences in HCP access.