Age, Gender, and Liver Enzyme Impact Hospital Stay in COVID-19 Minority Patient with Cancer in the USA: Does Race Matters in the Pandemic?

Patients with cancer are known to have a poor prognosis when infected with SARS-CoV-2 infection. We aimed in this study to assess health outcomes in COVID-19 patients with different cancers in comparison to non-cancer COVID-19 patients from different centers in the United States (US). We evaluated medical records of 1,943 COVID-19 Cancer patients from 3 hospitals admitted between December 2019 to October 2021 and compared them with non-cancer COVID-19 patients. Among 1,943 hospitalized COVID-19 patients, 18.7% (n=364) have an active or previous history of cancer. Among these 364 cancer patients, 222 were African Americans (61.7%) and 121 were Caucasians (33.2%). Cancer patients had significantly longer hospitalization compared to controls (8.24 vs 6.7 days). Overall, Lung cancer is associated with high mortality. Patients with a previous history of cancer were more prone to death (p=0.04) than active cancer patients. In univariate and multivariate analyses, predictors of death among cancer patients were male sex, older age, presence of dyspnea, elevated troponin, elevated AST (0.001) and ALT (0.05), low albumin (p=0.04) and mechanical ventilation (p=0.001). Patients with a previous history of cancer were more prone to death when compared to active cancer COVID-19 patients. Early recognition of cancer COVID-19 patients' death-associated risk factors can help determine appropriate treatment and management plans for better prognosis and outcome.

Barriers to and Recommendations for Equitable Access to Healthcare for Migrants and Refugees in Aotearoa, New Zealand: An Integrative Review

The health system in Aotearoa New Zealand is predicated on equity in access to health services as a fundamental objective yet barriers to equitable access for migrant and refugees continue to exist. There is a paucity of studies that synthesise the experiences and realities of migrants, refugees and healthcare providers that hinder access to healthcare and provide recommendations to improve services. This review synthesised these barriers and recommendations, with an aim to improve equitable access to healthcare to migrants and refugees. An integrative review of 13 peer-reviewed research studies from EBSCOhost research databases published between January 2016 and September 2022. Studies included: (i) related to Aotearoa; (ii) had a focus on equitable delivery of healthcare to migrants and refugees; and (iii) had a full English text available. The PRISMA framework guided the reporting of the review. The findings were thematically analysed and presented using a narrative empirical synthesis. The findings were organised into three broad themes: attitudinal barriers, structural barriers, and recommendations. Attitudinal barriers included the lack of culturally competent healthcare providers, discrimination by healthcare providers, and personal, social, and cultural attributes. Structural barriers referred to policies and frameworks that regulated the accessibility of health services such as the cost of healthcare, accessibility and acceptability of interpreter services, length of allocated appointments and long waiting times for an appointment, difficulties navigating the health system, and logistical barriers. Recommendations focused on promoting a sense of belonging, enabling a whole-of-society approach that brings together all sectors involved in providing health care for collective impact, and advocating for government policies to create a system that addresses the core health service access needs. This review provides rich context-specific findings on the barriers to equitable access to healthcare and proposed interventions to enhance equitable health outcomes for migrants and refugees in Aotearoa. The review contributes to relevant policy decisions and has practical implications to build responsive health systems which are inclusive, equitable and best address the health needs of populations from diverse cultural backgrounds.

Why the Post-Roe Era Requires Protecting Conscientious Provision as We Protect Conscientious Refusal in Health Care

The US Supreme Court overturned Roe v Wade in June 2022, and now each state's legislature will decide if and when its citizens will have legal access to abortion care and if and when its physicians will be criminalized for providing what is considered to be the standard of care by multiple health-related organizations. This extraordinary change in the medico-legal landscape requires reevaluation of health profession codes of ethics related to clinician conscience. This article argues that these codes must now be expanded to address 2 newly critical areas: physician advocacy to make abortion illegal and affirmative protection for "conscientious provision" in hostile environments on par with protection of conscientious refusal.

The Ethics of Access: Reframing the Need for Abortion Care as a Health Disparity

The majority of U.S. abortion patients are poor women, and Black and Hispanic women. Therefore, this article encourages bioethicists and equity advocates to consider whether the need for abortion care should be considered a health disparity, and if yes, whether framing it this way would increase the ability of poor women and women of color to get the medical care they need. In order to engage with these critical questions, bioethicists must avoid abortion exceptionalism and respect patients as moral agents. Centering the conscience of pregnant people shifts our analysis away from the ethics of the act of abortion, and toward the ethics of access to abortion care. Because the Supreme Court is on the brink of shifting the question of abortion's legality to state legislatures, this is the moment for all bioethicists to clarify and strengthen their thinking, writing, and teaching in abortion ethics.

WHO informal consultation on revision of guidelines on evaluation of similar biotherapeutic products, virtual meeting, 30 June – 2 July 2021

The WHO informal consultation was held to promote the revision of WHO guidelines on evaluation of similar biotherapeutic products (SBPs) adopted by the Expert Committee on Biological Standardization (ECBS) in 2009. It was agreed in the past consultations that the evaluation principles in the guidelines are still valid, but a review was recommended to provide more clarity and case-by-case flexibility. The opportunity was therefore taken to review the experience and identify areas where the current guidance could be more permissive without compromising its basic principles, and where additional explanation could be provided regarding the possibility of reducing the amount of data needed for regulatory approval. The meeting participants applauded the leading role taken by the WHO in providing a much-needed streamlined approach for development and evaluation of SBPs which will provide efficient and cost-effective product development and increase patient access to treatments. It was recognized that the principles as currently described in the draft WHO guidelines are based on sound science and experience gained over the last fifteen years of biosimilar approvals. However, since these guidelines when finalised will constitute the global standard for biosimilar evaluation and assist national regulatory authorities in establishing revised guidance and regulatory practice in this complex area, it was felt that further revision and clarity on certain perspectives in specific areas was necessary to dispel uncertainties arising in the current revised version. This report describes the principles in the draft guidelines, including topics discussed and consensus reached.

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WHO guidelines serve as a basis for the development of national regulatory framework for biosimilars.

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Revision of guidelines is to provide more flexibility and clarification on data required for regulatory approval.

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Revised guidelines would contribute to improving consistency on regulatory decision and patient access to treatments.

Hippocampal volume reduction is associated with direct measure of insulin resistance in adults

Hippocampal integrity is highly susceptible to metabolic dysfunction, yet its mechanisms are not well defined. We studied 126 healthy individuals aged 23-61 years. Insulin resistance (IR) was quantified by measuring steady-state plasma glucose (SSPG) concentration during the insulin suppression test. Body mass index (BMI), adiposity, fasting insulin, glucose, leptin as well as structural neuroimaing with automatic hippocampal subfield segmentation were performed. Data analysis using unsupervised machine learning (k-means clustering) identified two subgroups reflecting a pattern of more pronounced hippocampal volume reduction being concurrently associated with greater adiposity and insulin resistance; the hippocampal volume reductions were uniform across subfields. Individuals in the most deviant subgroup were predominantly women (79 versus 42 %) with higher BMI [27.9 (2.5) versus 30.5 (4.6) kg/m²], IR (SSPG concentration, [156 (61) versus 123 (70) mg/dL] and leptinemia [21.7 (17.0) versus 44.5 (30.4) μg/L]. The use of person-based modeling in healthy individuals suggests that adiposity, insulin resistance and compromised structural hippocampal integrity behave as a composite phenotype; female sex emerged as risk factor for this phenotype.

O-213 Slow day 5 development affects implantation potential of fresh transferred embryos but not birthweight once pregnancy occurs: A multi-center retrospective cohort study

Study question

Does slow development of fresh transferred day 5 embryos lead to decreased implantation potential and birthweight?

Summary answer

Slow day 5 development was associated with reduced implantation potential when transferred fresh but the subsequent birthweight of the resulting baby was not impacted.

What is known already

Slow development of in vitro cultured cleavage stage embryos is associated with reduced blastocyst development and implantation rates. There is no current consensus regarding whether to transfer fresh slow developing day 5 embryos or to extend culture for a subsequent day with potential for cryopreservation. It is therefore important to understand the true prognosis of fresh transferred day 5 embryos at less advanced developmental stages. This would provide evidence based guidelines for the decision making process in regard to embryo transfer.

Study design, size, duration

This is a retrospective multi-center cohort study, including 1213 consecutive patients undergoing autologous oocyte in vitro fertilization (IVF) treatment during 2016-2019,with fresh transfer of a single day 5 embryo (selection based on developmental stage and inner cell mass and trophectoderm morphology if blastocyst was at the ≥expanding stage). Cycle data were collected from 4 associated private clinics, with repeat cycles of same patients excluded to avoid clustering effect at statistical analysis.

Participants/materials, setting, methods

Live birth and birthweight were followed up in all 1213 fresh day 5 SETs. Multiple regression (logistic or linear) was performed to investigate association between slow day 5 development (defined as ≤ early blastocyst) and (a)live birth, (b) birthweight, and (c) gestation-adjusted birthweight (Z score) to account for gestational age, gender and compared to embryos at ≥ expanded stage. Results were expressed as adjusted odds ratio (aOR) with 95% confidence interval (CI)or coefficients (β).

Main results and the role of chance

No implantation was achieved following single fresh transfer of day 5 embryos that failed to reach early blastocyst stage (n = 76) and were transferred as ≤ morula stage. Live birth rate was significantly lower following single day 5 fresh transfer of an early blastocyst (n = 237, 16%), in comparison to expanding (n = 329, 27%, P = 0.001), expanded(n = 392, 41%, P = 0.000), and hatching/hatched blastocysts (n = 169, 44%, P = 0.000). After adjusting for potential confounding factors including; maternal age, hours post insemination at day 5 assessment, number of oocytes collected, number of 2PN embryos, and number of embryos frozen; multiple logistic regression showed significantly reduced likelihood of live birth resulting from early blastocysts in reference to those at the expanding (aOR=0.584, 0.371-0.917, P = 0.020), expanded (aOR=0.322, 0.208-0.501, P = 0.000), or hatching/hatched stages (aOR=0.255, 0.147-0.443, P = 0.000). However, multivariate linear regression indicated that early blastocysts resulting in a live birth (n = 39) did not lead to altered birthweight (β=-9.091, P = 0.904; β=-34.960, P = 0.343; β=-26.074, P = 0.414; respectively) or Z score (β = 0.045, P = 0.706; β=-0.051, P = 0.426; β=-0.028, P = 0.506; respectively) in reference to the expanding (n = 90), expanded (n = 160), or hatching/hatched stages (n = 75).

Limitations, reasons for caution

The retrospective nature of this study does not allow controlling of unknown confounders. The 4 participating clinics are associated within the same network with shared protocols, therefore, results may not be generalized to other clinics with different settings.

Wider implications of the findings

The findings suggest no clinical value of fresh day 5 transfer of embryos ≤morula stage. Although early blastocysts implant at reduced rate, assuring birthweight outcomes suggest clinical value. Future studies intend to investigate slow growing day 5 fresh transfers versus embryos that were slow growing but transferred after day 6.

Trial registration number

NA

P–191 Time-lapse videography reveals morphometric and morphokinetic differences in the pronuclei of male and female human zygotes

Study question

Do morphometric and morphokinetic profiles of pronuclei (PN) following intracytoplasmic sperm injection (ICSI) vary between male and female human zygotes?

Summary answer

Male and female zygotes displayed different PN morphometrics and morphokinetics. Additionally, variations were identified between sperm-originated (SPN) and oocyte-originated (OPN) pronuclei.

What is known already

Previous studies have investigated the use of PN-associated parameters via static observations as indicators of zygote viability, including size equality or juxtaposition. However, recent clinical application of time-lapse videography (TLV) provides a novel opportunity to assess these pronuclear events with greater accuracy and precision of morphometric and morphokinetic measurement. A number of recent TLV studies have also investigated potential live birth prediction by such PN associated measures, however whether or not there are gender associated differences in such measures which could in turn confound live birth prediction is unknown. Study design, size, duration: This retrospective cohort study included 94 consecutive autologous single day 5 transfer cycles (either fresh or frozen) performed between January 2019 and March 2020. Only ICSI cycles (maternal age <40 years) leading to a singleton live birth (43 males and 51 females) were included for analysis. All oocytes were placed in the EmbryoScope incubator for culture immediately post sperm injection with all annotation performed retrospectively by one embryologist (L-SO).

Participants/materials, setting, methods

Timings included 2nd polar body extrusion (tPb2), SPN(tSPNa)/OPN(tOPNa) appearance (differentiated by proximity to Pb2) and PN fading (tPNF). Morphometrics were evaluated at 8 (stage 1), 4 (stage 2) and 0 hour before PNF (stage 3), measuring PN area (um2), PN juxtaposition, and nucleolus precursor body (NPB) arrangement. Means ± standard deviation were compared using student t test or logistic regression as odds ratio (OR) and 95% confidence interval (CI), and proportional data by chi-squared analysis.

Main results and the role of chance

Logistic regression indicated that male zygotes had longer time intervals of tPb2_tSPNa than female zygotes (4.8±1.5 vs 4.2±1.0 h, OR = 1.442, 95% CI 1.009–2.061, p = 0.044), but not tPb2_tOPNa (4.7±1.8 vs 4.5±1.3 h, OR = 1.224, 95% CI 0.868–1.728, p = 0.250) and tPb2_tPNF (19.9±2.8 vs 19.1±2.3 h, OR = 1.136, 95% CI 0.957–1.347, p = 0.144). SPN increased in size from stage 1 through 2 to 3 (435.3±70.2, 506.7±77.3, and 556.3±86.4 um2, p = 0.000) and OPN did similarly (399.0±59.4, 464.3±65.2, and 513.8±63.5 um2, p = 0.000), with SPN being significantly larger than OPN at each stage (p < 0.05 respectively). However, relative size difference between SPN and OPN was similar between male and female zygotes at 3 stages (33.6±61.7 vs 38.6±50.8 um2, p = 0.664; 38.5±53.1 vs 45.7±71.9 um2, p = 0.585; 38.4±77.4 vs 45.8±63.9 um2, p = 0.615; respectively). More male than female zygotes reached central PN juxtaposition at stage 1 (77% vs 51%, p = 0.010), stage 2 (98% vs 86%, p = 0.048) and stage 3 (98% vs 86%, p = 0.048). Furthermore, more OPN showed aligned NPBs than in SPN at stage 1 (45% vs 29%, p = 0.023), but similar proportions at stage 2 (64% vs 50%, p = 0.056) and stage 3 (76% vs 72%, p = 0.618). There were no gender associated differences detected in NPB alignment in either SPN or OPN (p > 0.05 respectively).

Limitations, reasons for caution

The retrospective design does not allow for control of unknown confounders. Sample size is considered relatively small. PN area measurement may not truly represent volume as PN may not be perfectly spherical. Findings were based on women <40 years old so may not apply to older population.

Wider implications of the findings: These findings augment and extend previous studies investigating PN parameters via static observations. The reported variations between male and female embryos may confound live birth prediction when using pronuclei morphometrics and morphokinetics. Larger scaled studies are warranted to verify these findings.

Trial registration number

Not applicable

576 ESTABLISHING VIRTUAL MULTIDISCIPLINARY ROUND IN BELFAST TRUST NURSING HOMES: PHARMACIST, NURSING & HEALTHCARE TEAM COLLABORATION

Introduction

During the first covid surge, 25% of Belfast HSC Trust (BHSCT) care homes were affected, rising to 44% by surge 3, resulting in limited face to face access for healthcare professionals. Nursing home residents required medicine reviews post-covid infection to optimise medicines and reduce pill burden.

Method

The Care Home Nursing Support Team (CHNST), consultant pharmacist for older people and the lead care home pharmacist medicines optimisation older people (MOOP), rapidly established a multidisciplinary virtual round. Four main steps included:

An SOP was established to ensure consistent pathway for nursing home inclusion criteria and team roles. The inclusion group included residents who were furthest from their baseline including weight loss, swallowing difficulties, decreased mobility, altered sitting balance and polypharmacy.

The pharmacist developed a proforma template for completion by the nursing home staff to gather key information ahead of the round to improve efficiency eg swallow, renal function, pain, falls risk.

The care home resident was included on video link by ipad following careful consent processes. Benefits included enhanced assessment of frailty, mobility, dexterity and adherence.

Results

Conclusion

The multidisciplinary care home rounds provided an efficient means to collaborate with other professionals, while providing holistic & patient-focussed care. Plans are underway for development of an NI MOOP care home pathway.

OP0241 SERIOUS INFECTION WITH TOCILIZUMAB COMPARED TO TNF-INHIBITORS AND OTHER BDMARDS IN RHEUMATOID ARTHRITIS PATIENTS: DOES LINE OF THERAPY MATTER?

Background:

In the real-world, tocilizumab is prescribed to a population of patients different from those prescribed TNF-inhibitors, often older with longer disease duration, worse functional status and more previous b- or tsDMARDs.

Objectives:

The aim of this study was to evaluate if and how the risk of serious infection on tocilizumab and other bDMARDs differs when stratifying by line of therapy in a real-world population of rheumatoid arthritis patients.

Methods:

We included patients registered in the BSRBR-RA treated with tocilizumab, etanercept, adalimumab, infliximab, certolizumab, abatacept or rituximab, including biosimilars. Primary outcome was the occurrence of a serious infection (defined as infection requiring hospitalisation, intravenous antibiotics or resulting in death). Primary covariate of interest was line of therapy (from first to fifth line of therapy). Every change to another b- or tsDMARD was considered a new line of therapy, but not a change between a bio-original and a biosimilar.

Hazard ratios (HR) of serious infections were estimated using an inverse probability weighted Cox regression, based on a propensity score including baseline patient and disease characteristics, and adjusting for time in study (see Table). The reference group was etanercept, which included the highest number of patients. Treatment exposure was analysed without and with stratification by line of therapy.

Table.NETNTCZADAIFXCERTRTXABAN33,91610,6552,6327,8394,4301,6165,5561,188Patient-years19,1294,34214,5048,1352,72612,0091,686Infections8071926814817443374Incidence per 100 patient-years (95%CI)4.2 (3.9-4.5)4.4 (3.8-5.1)4.7 (4.4-5.1)5.9 (5.4-6.6)2.7 (2.2-3.4)3.6 (3.3-4.0)4.0 (3.2-5.1)Unadjusted HR (95%CI)Ref.1.0 (0.9-1.2)1.1 (1.0-1.2)1.4 (1.2-1.6)0.6 (0.5-0.8)0.9 (0.8-1.0)0.9 (0.7-1.2)Adjusted HR* (95% CI)All lines of therapy33,916Ref.1.2 (1.0-1.5)1.1 (1.0-1.3)1.3 (1.1-1.6)0.8 (0.6-1.0)1.0 (0.8-1.1)1.2 (0.8-1.7)1stline16,152Ref.0.9 (0.5-1.5)1.1 (1.0-1.3)1.3 (1.1-1.6)0.6 (0.5-0.9)1.6 (1.2-2.2)-2ndline10,378Ref.1.4 (1.0-2.0)1.1 (0.9-1.4)1.1 (0.7-1.6)0.9 (0.4-2.2)1.0 (0.8-1.2)0.9 (0.5-1.9)3rdline4,676Ref.1.4 (0.9-2.3)1.3 (0.8-2.2)0.9 (0.4-1.9)0.9 (0.3-2.9)0.8 (0.5-1.2)1.5 (0.7-2.9)4thline1,947Ref.1.0 (0.5-2.3)1.3 (0.4-3.7)1.4 (0.5-4.4)0.2 (0.0—2.1)1.0 (0.5.-2.2)0.9 (0.4-2.3)5thline763Ref.0.9 (0.2-3.5)2.5 (0.5-12.4)0.7 (0.1-7.1)3.3 (0.6-18.4)0.9 (0.2-3.5)0.8 (0.2-3.5)

ABA, abatacept; ADA, adalimumab; CERT, certolizumab; ETN, etanercept; HR, hazard ratio; IFX, infliximab; RTX, rituximab; TCZ, tocilizumab

*Adjusted using inverse probably weighting (with age, gender, concomitant steroids, concomitant DMARDs, comorbidities, seropositivity, smoking, disease duration, HAQ and DAS28 at baseline in the model) and time since study entry (categorised from 0 to 4, 0 starting just before or at the moment of entering study, 1 starting during the first year, 2 starting during the second year until 4 for the fourth year and more)

Results:

A total of 33,916 treatment courses were included (Table) contributing to 62,532 years of follow-up. Compared to etanercept, participants starting abatacept, tocilizumab and rituximab were older, had more previous bDMARDs, longer disease duration and more comorbidities. The crude HR of serious infections were higher with infliximab and adalimumab, lower with certolizumab and rituximab, and not significantly different for abatacept and tocilizumab compared to etanercept. After adjustment, HR of serious infections were higher with tocilizumab, adalimumab and infliximab. However, when stratified by line of therapy, HR were no longer significantly different compared to etanercept for tocilizumab, adalimumab and infliximab for most lines of therapy.

Conclusion:

Whilst initially there appears to be a difference in rates of serious infection between biologic therapies, line of therapy may be a confounding factor when comparing the risk of serious infections between bDMARDs.

Disclosure of Interests:

Kim Lauper Consultant of: Gilead-galapagos, Grant/research support from: AbbVie, Lianne Kearsley-Fleet: None declared, Rebecca Davies: None declared, Kath Watson: None declared, Mark Lunt: None declared, Kimme Hyrich Consultant of: AbbVie, Grant/research support from: Pfizer, BMS

Developing Novel Host-Based Therapies Targeting Microbicidal Responses in Macrophages and Neutrophils to Combat Bacterial Antimicrobial Resistance

Antimicrobial therapy has provided the main component of chemotherapy against bacterial pathogens. The effectiveness of this strategy has, however, been increasingly challenged by the emergence of antimicrobial resistance which now threatens the sustained utility of this approach. Humans and animals are constantly exposed to bacteria and have developed effective strategies to control pathogens involving innate and adaptive immune responses. Impaired pathogen handling by the innate immune system is a key determinant of susceptibility to bacterial infection. However, the essential components of this response, specifically those which are amenable to re-calibration to improve host defense, remain elusive despite extensive research. We provide a mini-review focusing on therapeutic targeting of microbicidal responses in macrophages and neutrophils to de-stress reliance on antimicrobial therapy. We highlight pre-clinical and clinical data pointing toward potential targets and therapies. We suggest that developing focused host-directed therapeutic strategies to enhance "pauci-inflammatory" microbial killing in myeloid phagocytes that maximizes pathogen clearance while minimizing the harmful consequences of the inflammatory response merits particular attention. We also suggest the importance of One Health approaches in developing host-based approaches through model development and comparative medicine in informing our understanding of how to deliver this strategy.

SAT0103 THE EFFECT OF BODYWEIGHT ON RESPONSE TO INTRAVENOUS OR SUBCUTANEOUS TOCILIZUMAB IN PATIENTS WITH RHEUMATOID ARTHRITIS

Background:

Tocilizumab is an IL-6 receptor humanised monoclonal antibody treatment option in rheumatoid arthritis (RA) who have not responded or are intolerant of disease modifying anti-rheumatic drugs (DMARDs) or other biologics. Tocilizumab was available initially as an intravenous (IV) preparation, dosed according to weight, and more recently as a subcutaneous (SC) preparation given at 162mg/weekly irrespective of bodyweight.

Obesity is highly prevalent in RA and there has been concern that starting or switching patients to SC tocilizumab could reduce its effectiveness in those patients with a higher body weight when compared to IV tocilizumab.

Objectives:

To investigate the relationship between bodyweight and DAS28 response at 6 months in tocilizumab naïve RA patients starting IV or SC tocilizumab.

Methods:

The study population comprised RA subjects recruited to the BSRBR-RA up to 30/11/2018 commencing IV or SC tocilizumab for the first time. Patients had to be tocilizumab naïve and have at least one six monthly study follow-up recorded after starting tocilizumab. Baseline characteristics at point of starting tocilizumab are described. Linear regression, fully adjusted for relevant confounders, was used to investigate the relationship between change in DAS28 score from baseline to six months and body weight per ten kilograms (kg), and in a separate analysis, as BMI category. Multiple imputation was used to handle missing data.

Results:

1241 patients starting tocilizumab (902 IV, 339 SC) were eligible for analysis. The median age was 59 years, majority were female, and had median disease duration of 11 years at baseline. Over seventy percent had prior biologic exposure. Median weight was 77kg for IV and 76kg for SC starters, and the majority of patients were categorised as normal weight (30% IV, 37% SC) or pre-obesity (31% IV & SC) according to BMI. Median DAS28 score was 5.8 (IV) and 5.5 (SC) at start of treatment with median improvement after 6-months of 1.50 and 2.02 units respectively. The fully adjusted linear regression model showed no association between body weight or BMI and change in DAS28 score at six months for patients starting IV or SC tocilizumab. (Table).

TableBaseline VariableIntravenous TCZ patients (n=902)Subcutaneous TCZ patients (n=339)Age, median (IQR)58 (50-67)60 (51-70)Gender, n (%) female708 (78)233 (74)Disease duration, median (IQR) years11 (4-21)11 (4-21)DAS28 score, median (IQR)5.8 (5.1-6.6)5.5 (4.7-6.5)Change in DAS28 score, median (IQR)-1.50 (-3.10 - -0.23)-2.02 (-3.72- -0.37)Weight in KGs, median (IQR)77 (64-91)76 (64-88)Change in DAS28, coefficient (95% CI)Body weight per 10kgs*0.04 (-0.01-0.09)-0.005 (-0.11-0.10)BMI category*Normal weightrefrefUnderweight-0.41 (-1.27-0.46)0.08 (-1.62-1.77)Pre-obesity-0.26 (-0.57-0.05)0.02 (-0.44-0.48)Obesity class I, II & III-0.03 (-0.35-0.29)0.08 (-0.40-0.55)

*Fully adjusted for age, gender, disease duration, baseline DAS28 score, baseline HAQ score, co-morbidities, and number of previous biologics

Conclusion:

Data from this study show that body weight does not appear to affect initial response to IV or SC tocilizumab. This is reassuring given that patients are likely to be given SC tocilizumab due to ease of administration and reduced hospital costs.

Disclosure of Interests:

Rebecca Davies: None declared, Arani Vivekanantham: None declared, Mark Lunt: None declared, Kath Watson: None declared, Kimme Hyrich Grant/research support from: Pfizer, UCB, BMS, Speakers bureau: Abbvie, James Bluett: None declared

Effects of LDL Cholesterol and Statin Use on Verbal Learning and Memory in Older Adults at Genetic Risk for Alzheimer's Disease

BACKGROUND

The apolipoprotein epsilon 4 (APOE4) allele is a well-established genetic risk factor for Alzheimer's disease (AD). However, there are mixed findings as to how the APOE4 allele modifies the effects of both higher low-density lipoprotein cholesterol (LDL) and statin use on cognitive functioning.

OBJECTIVE

This study sought to examine the effects of LDL levels and statin use on verbal learning and memory, as modified by the presence of the APOE4 allele, in a sample of cognitively unimpaired, older adults at risk for AD.

METHODS

Neuropsychological, LDL, statin use, and APOE4 data were extracted from an ongoing longitudinal study at the Banner Alzheimer's Institute in Arizona. Participants were cognitively unimpaired based on Mini-Mental State Examination scores within a normal range, aged 47-75, with a family history of probable AD in at least one first-degree relative.

RESULTS

In the whole sample, higher LDL was associated with worse immediate verbal memory in APOE4 non-carriers, but did not have an effect on immediate verbal memory in APOE4 carriers. In APOE4 non-carriers, statin use was associated with better verbal learning, but did not have an effect on verbal learning in APOE4 carriers. Among women, higher LDL in APOE4 carriers was associated with worse verbal learning than in APOE4 non-carriers, and statin use in APOE4 non-carriers was associated with better verbal learning and immediate and delayed verbal memory but worse performances on these tasks in APOE4 carriers.

CONCLUSION

LDL and statin use may have differential effects on verbal learning and/or memory depending on genetic risk for AD. Women appear to be particularly vulnerable to statin use depending on their APOE4 status.

DIFFERENTIAL EFFECTS OF STATINS ON COGNITION IN WOMEN AT RISK FOR ALZHEIMER’S DISEASE

It is well established that the apolipoprotein epsilon 4 allele (APOE4) and being female are risk factors for late onset Alzheimer’s disease (AD) and declines in verbal learning and memory are early cognitive symptoms of conversion to AD. Because of conflicting findings regarding the effects of statins on cognition, this study examined statin use with respect to verbal learning and memory by APOE4 status in a sample of cognitively unimpaired women at risk for AD. Neuropsychological, statin use, and APOE4 data were utilized as a secondary analysis from an ongoing longitudinal study at the Banner Alzheimer’s Institute in Arizona. Subjects were cognitively unimpaired women aged 47-75 with a family history of probable AD in at least one first-degree relative. Neuropsychological outcome variables included total learning, immediate memory, and delayed memory scores from the Rey Auditory Verbal Learning Test (RAVLT). Statin use was defined by use of a cholesterol lowering drug at study enrollment. APOE4 status was defined by presence of at least one APOE4 allele. Linear regression analyses were conducted to determine existence of interactions between statin use and APOE4 status on cognition. Statistically significant interactions were found between statin use and APOE4 status in RAVLT total learning and immediate memory. Statin use in women APOE4 non-carriers was associated with better verbal learning and immediate memory performances whereas statin use in women APOE4 carriers was associated with worse performances on these same tasks. Conclusions. Findings suggest that sex and APOE4 status may be important factors in consideration of statin use.

4325Change in left atrial function predicts incident atrial fibrillation: the multi-ethnic study of atherosclerosis

Background

Longitudinal change in left atrial (LA) structure and function could be helpful in predicting risk for incident AF. We used cardiac magnetic resonance (CMR) imaging to explore the relationship between change in LA structure and function and incident AF in a multi-ethnic population free of clinical cardiovascular disease at baseline.

Methods and results

In the Multi-Ethnic Study of Atherosclerosis (MESA), 2338 participants, free at baseline of clinically recognized AF and cardiovascular disease, had LA volume and function assessed with CMR imaging, at baseline (2000–02), and at Exam 4 (2005–07) or 5 (2010–12). Free of AF, 124 participants developed AF over 3.8±0.9 years (to 2015) following the second imaging. In adjusted Cox regression models, an average annualized change in all LA parameters were significantly associated with an increased risk of AF. An annual decrease of 1–SD unit in total LA emptying fractions (LAEF) was most strongly associated with risk of AF after adjusting for AF clinical risk factors, baseline LA parameters and left ventricular mass-to-volume ratio (hazard ratio per SD=1.91,95% confidence interval=1.53–2.38, P<0.001). The addition of change in total LAEF to an AF risk score improved model discrimination and reclassification (net reclassification improvement=0.107, P=0.017; integrative discrimination index=0.049, P<0.001).

Model discrimination, NRI and IDI Model: CHARGE-AF risk factors# + Baseline LA variable + ΔLA variable CHARGE-AF ΔLAVImin (mL/m2/y) ΔTotal LAEF (%/y) ΔPeak LA Strain (%/y) C-statistic (95% CI) 0.757 (0.721–0.794) 0.787 (0.749–0.824) 0.779 (0.737–0.820) 0.770 (0.732–0.808) NRI† (p-value) – 0.000 (0.991) 0.107 (0.017) 0.017 (0.634) IDI (p-value) – 0.049 (<0.001) 0.049 (<0.001) 0.018 (<0.001) Calibration chi2* (p-value) 19.3 (0.02) 11.68 (0.232) 5.751 (0.765) 3.673 (0.932) AF: atrial fibrillation; LA: left atrium; EF: emptying fractions; Δ: annual change; VImin: minimum indexed volume; CI: confidence interval; NRI: net reclassification improvement; IDI: integrative discrimination index #CHARGE-AF risk factors: age, race, height, weight, systolic and diastolic blood pressure, use of antihypertensive medication, smoking status, diabetes, MI and CHF by the second imaging. † Categories for NRI: <2.5%, 2.5%-5% and >5%. *Model calibration: Grønnesby and Borgan's modified Hosmer-Lemeshow chi-square statistic for survival analysis.

Kaplan-Meier curves of ΔTotal LAEF

Conclusion

In this multi-ethnic study population free of clinical cardiovascular disease at baseline, a greater increase in LA volumes and decrease in LA function were associated with incident AF. The addition of change in total LAEF to risk prediction models for AF improved model discrimination and reclassification of AF risk.

Acknowledgement/Funding

This research was supported by contracts HHSN2682015ehz745.01623I,N01-HC-95159-69 from the NHLBI and UL1-TR-ehz745.016240,UL1-TR-001079,R01-HL-127659 from NIH

Young African American women’s participation in an m-Health study in cardiovascular risk reduction: Feasibility, benefits, and barriers

Background:

Young black women have an increased risk of cardiovascular disease, and thus identifying innovative prevention strategies is essential. A potential preventive strategy is mobile health; however, few studies have tested this strategy in young black women.

Aim:

The purpose of this study was to assess the feasibility of a mobile health intervention through a digital application to reduce cardiovascular disease risk factors in young black women, and identify benefits and barriers to participation.

Methods:

Forty black women aged 25–45 years completed four sessions of cardiovascular disease risk reduction education and a six-month smartphone cardiovascular disease risk reduction monitoring and coaching intervention, targeting heart-healthy behavior modifications. At follow-up, women responded to a semi-qualitative online survey assessing the user-friendliness and perceived helpfulness of the intervention.

Results:

Of 40 women, 38 completed the follow-up survey. Sixty per cent of participants reported that the applications were easy or very easy to maintain, 90% reported that the application was easy or very easy to use. Over 60% observed that their family’s nutrition improved “a lot” or “a medium amount,” and many participants noted positive changes in their children’s diets. Only 8% of participants cited time or cost required to prepare healthy foods as barriers to implementing dietary changes.

Conclusions:

The m-Health intervention was feasible as a means of cardiovascular disease risk reduction for young black women. In addition, we found that targeting women provided indirect benefits for other family members, especially children. Most of the participants did not encounter systemic barriers to participation, suggesting that mobile health interventions can be effective tools to improve health behaviors in vulnerable populations.

Why We Should Stop Using the Term "Elective Abortion"

In abortion care, the term "elective" is often used as a moral judgment that determines which patients are entitled to care. Secular health care organizations that attempt to avoid controversy by allowing "therapeutic" but not "elective" abortions are using medical terminology to reinforce regressive social norms concerning motherhood and women's sexuality because what distinguishes pregnant women with medical indications for abortion is that they originally wanted to become mothers or, in cases of rape, that they did not consent to sex. Secular health care organizations should stop denying the moral agency of patients and physicians who conclude abortion is morally acceptable and should only use the word elective when billing codes require it. Regardless of reason, the proper label for all abortion is health care.

Cognitive effects of mifepristone in overweight, euthymic adults with depressive disorders

BACKGROUND

Previous studies have shown that individuals with mood disorders have a higher prevalence of both hypercortisolemia and insulin resistance. Insulin resistance is posited to contribute to the cognitive deficits observed in individuals who have depression. However, the mechanistic relationship between cortisol and insulin within the central nervous system remains to be further elucidated. This study aimed to evaluate the effects of the antiglucocorticoid agent, mifepristone, on metabolic function and cognitive performance in individuals receiving treatment for depressive disorders who were euthymic at baseline.

METHODS

Participants were administered a 600 mg/day dose of mifepristone for 28 days. Oral glucose tolerance tests (OGTTs) and cognitive assessments measuring verbal memory and executive functioning were administered at baseline and after 28 days of treatment.

RESULTS

Improvements in attention and verbal learning were associated with reduction of fasting plasma glucose (FPG) in response to mifepristone treatment.

LIMITATIONS

Limitations include the open-label design of this study and a small sample size.

CONCLUSIONS

The findings from this study suggest that improvement in fasting plasma glucose levels, upon administration of mifepristone, is associated with the improvement in early input of verbal information. Further studies are warranted in order to better evaluate the use of mifepristone or other antiglucocorticoid agents in treatment of mood disorders characterized by metabolic dysfunction.

Diabetes UK evidence-based nutrition guidelines for the prevention and management of diabetes

A summary of the latest evidence-based nutrition guidelines for the prevention and management of diabetes is presented. These guidelines are based on existing recommendations last published in 2011, and were formulated by an expert panel of specialist dietitians after a literature review of recent evidence. Recommendations have been made in terms of foods rather than nutrients wherever possible. Guidelines for education and care delivery, prevention of Type 2 diabetes, glycaemic control for Type 1 and Type 2 diabetes, cardiovascular disease risk management, management of diabetes-related complications, other considerations including comorbidities, nutrition support, pregnancy and lactation, eating disorders, micronutrients, food supplements, functional foods, commercial diabetic foods and nutritive and non-nutritive sweeteners are included. The sections on pregnancy and prevention of Type 2 diabetes have been enlarged and the weight management section modified to include considerations of remission of Type 2 diabetes. A section evaluating detailed considerations in ethnic minorities has been included as a new topic. The guidelines were graded using adapted 'GRADE' methodology and, where strong evidence was lacking, grading was not allocated. These 2018 guidelines emphasize a flexible, individualized approach to diabetes management and weight loss and highlight the emerging evidence for remission of Type 2 diabetes. The full guideline document is available at www.diabetes.org.uk/nutrition-guidelines.

Comparison of Kaposi Sarcoma Risk in Human Immunodeficiency Virus-Positive Adults Across 5 Continents: A Multiregional Multicohort Study

BACKGROUND

We compared Kaposi sarcoma (KS) risk in adults who started antiretroviral therapy (ART) across the Asia-Pacific, South Africa, Europe, Latin, and North America.

METHODS

We included cohort data of human immunodeficiency virus (HIV)-positive adults who started ART after 1995 within the framework of 2 large collaborations of observational HIV cohorts. We present incidence rates and adjusted hazard ratios (aHRs).

RESULTS

We included 208140 patients from 57 countries. Over a period of 1066572 person-years, 2046 KS cases were diagnosed. KS incidence rates per 100000 person-years were 52 in the Asia-Pacific and ranged between 180 and 280 in the other regions. KS risk was 5 times higher in South African women (aHR, 4.56; 95% confidence intervals [CI], 2.73-7.62) than in their European counterparts, and 2 times higher in South African men (2.21; 1.34-3.63). In Europe, Latin, and North America KS risk was 6 times higher in men who have sex with men (aHR, 5.95; 95% CI, 5.09-6.96) than in women. Comparing patients with current CD4 cell counts ≥700 cells/µL with those whose counts were <50 cells/µL, the KS risk was halved in South Africa (aHR, 0.53; 95% CI, .17-1.63) but reduced by ≥95% in other regions.

CONCLUSIONS

Despite important ART-related declines in KS incidence, men and women in South Africa and men who have sex with men remain at increased KS risk, likely due to high human herpesvirus 8 coinfection rates. Early ART initiation and maintenance of high CD4 cell counts are essential to further reducing KS incidence worldwide, but additional measures might be needed, especially in Southern Africa.

Use of high-density SNP data to identify patterns of diversity and signatures of selection in broiler chickens

The development of broiler chickens over the last 70 years has been accompanied by large phenotypic changes, so that the resulting genomic signatures of selection should be detectable by current statistical techniques with sufficiently dense genetic markers. Using two approaches, this study analysed high-density SNP data from a broiler chicken line to detect low-diversity genomic regions characteristic of past selection. Seven regions with zero diversity were identified across the genome. Most of these were very small and did not contain many genes. In addition, fifteen regions were identified with diversity increasing asymptotically from a low level. These regions were larger and thus generally included more genes. Several candidate genes for broiler traits were found within these 'regression regions', including IGF1, GPD2 and MTNR1AI. The results suggest that the identification of zero-diversity regions is too restrictive for characterizing regions under selection, but that regions showing patterns of diversity along the chromosome that are consistent with selective sweeps contain a number of genes that are functional candidates for involvement in broiler development. Many regions identified in this study overlap or are close to regions identified in layer chicken populations, possibly due to their shared precommercialization history or to shared selection pressures between broilers and layers.

Documenting moral agency: a qualitative analysis of abortion decision making for fetal indications

OBJECTIVES

We explored whether the decision-making process of women aborting a pregnancy for a fetal indication fit common medical ethical frameworks.

STUDY DESIGN

We applied three ethical frameworks (principlism, care ethics, and narrative ethics) in a secondary analysis of 30 qualitative interviews from women choosing 2nd trimester abortion for fetal indications.

RESULTS

All 30 women offered reasoning consistent with one or more ethical frameworks. Principlism themes included avoidance of personal suffering (autonomy), and sparing a child a poor quality of life and painful medical interventions (beneficence/non-maleficence). Care ethics reasoning included relational considerations of family needs and resources, and narrative ethics reasoning contextualized this experience into the patient's life story.

CONCLUSIONS

This population's universal application of commonly accepted medical ethical frameworks supports the position that patients choosing fetal indication abortions should be treated as moral decision-makers and given the same respect as patients making decisions about other medical procedures.

IMPLICATIONS

These findings suggest recent political efforts blocking abortion access should be reframed as attempts to undermine the moral decision-making of women.

Creativity in Medical Education: The Value of Having Medical Students Make Stuff

What is the value of having medical students engage in creative production as part of their learning? Creating something new requires medical students to take risks and even to fail--something they tend to be neither accustomed to nor comfortable with doing. "Making stuff" can help students prepare for such failures in a controlled environment that doesn't threaten their professional identities. Furthermore, doing so can facilitate students becoming resilient and creative problem-solvers who strive to find new ways to address vexing questions. Though creating something new can be fun, this is not the main outcome of interest. Rather, the principle reason we recommend devoting precious curricular time to creative endeavors is because it helps medical students become better doctors.

Reducing Staphylococcus aureus bloodstream infections associated with peripheral intravenous cannulae: successful implementation of a care bundle at a large Australian health service

BACKGROUND

Healthcare-associated Staphylococcus aureus bacteraemia (HA-SAB) results in morbidity, mortality, and increased healthcare costs, and these infections are frequently regarded as preventable.

AIM

To implement a multi-modal prevention programme for improved processes regarding peripheral intravenous cannula (PIVC) insertion and maintenance, in order to reduce PIVC-associated HA-SAB events in a large Australian health service.

METHODS

Baseline clinical practice was evaluated for a 12-month pre-intervention period. Measures to reduce HA-SAB risk were introduced between January and September 2013: staff education, improved documentation (including phlebitis scoring), and availability of standardized equipment. Post-intervention auditing was performed during the 27 months following intervention. Baseline and post-intervention HA-SAB and PIVC-associated infection rates were compared. Interrupted time-series and Bayesian change-point analyses were applied to determine the impact of interventions and timing of change.

FINDINGS

Significantly improved documentation regarding PIVC insertion and management was observed in the post-intervention period, with fewer PIVCs left in situ for ≥4 days (2.6 vs 6.9%, P<0.05). During the baseline period a total of 68 HA-SAB events occurred [1.01/10,000 occupied bed-days (OBDs)] and 24 were PIVC-associated (35% of total, rate 0.39 per 10,000 OBDs). In the post-intervention period, a total of 83 HA-SAB events occurred (0.99 per 10,000 OBDs) and 12 were PIVC-associated (14.4% of total, rate 0.14 per 10,000 OBDs). PIVC-associated SAB rates were 63% lower in the post-intervention period compared to baseline (P=0.018) with a change point observed following full bundle implementation in October 2013.

CONCLUSION

A successful multi-modal hospital-wide campaign was introduced to reduce PIVC-associated SAB rates. Evaluation of cost-effectiveness and sustainability is required.

Past and projected temporal trends in arthroscopic hip surgery in England between 2002 and 2013

Introduction

Hip arthroscopy is increasingly adopted for the treatment of intra-articular and extra-articular pathologies. Studies from USA demonstrate a 365% increase in the number of procedures performed between 2004 and 2009 and 250% increase between 2007 and 2011. There is limited evidence of long-term efficacy for this procedure and hip arthroscopy is not universally funded across England. The aim of this study is to describe temporal trends in the adoption of hip arthroscopy in England between 2002 and 2013 and to forecast trends for the next 10 years.

Methods

A search of the Hospital Episodes Database was performed for all codes describing arthroscopic hip procedures with patient age, sex and area of residence.

Results

11 329 hip arthroscopies were performed in National Health Service hospitals in England between 2002 and 2013. The number of hip arthroscopies performed increased by 727% (p<0.0001) during this period and is forecast to increase by 1388% in 2023. Females represent 60% of all patients undergoing hip arthroscopy (p<0.001). Median age category is 40–44 for females and 35–39 for males and average age decreased during the study period (p<0.0001). There is significant regional variation in procedure incidence. In the final year of this study the highest incidence was in the Southwest (8.63/100 000 population) and lowest in East Midlands (1.29/100 000 population).

Conclusions

The increase in number of hip arthroscopies performed in England reflects trends in USA and continued increases are forecast. Evidence from robust clinical trials is required to justify the increasing number of procedures performed and regional variation suggests potential inequality in the provision of this intervention.

Identification of stable reference genes for quantitative PCR in cells derived from chicken lymphoid organs

Quantitative polymerase chain reaction (qPCR) is a powerful technique for quantification of gene expression, especially genes involved in immune responses. Although qPCR is a very efficient and sensitive tool, variations in the enzymatic efficiency, quality of RNA and the presence of inhibitors can lead to errors. Therefore, qPCR needs to be normalised to obtain reliable results and allow comparison. The most common approach is to use reference genes as internal controls in qPCR analyses. In this study, expression of seven genes, including β-actin (ACTB), β-2-microglobulin (B2M), glyceraldehyde-3-phosphate dehydrogenase (GAPDH), β-glucuronidase (GUSB), TATA box binding protein (TBP), α-tubulin (TUBAT) and 28S ribosomal RNA (r28S), was determined in cells isolated from chicken lymphoid tissues and stimulated with three different mitogens. The stability of the genes was measured using geNorm, NormFinder and BestKeeper software. The results from both geNorm and NormFinder were that the three most stably expressed genes in this panel were TBP, GAPDH and r28S. BestKeeper did not generate clear answers because of the highly heterogeneous sample set. Based on these data we will include TBP in future qPCR normalisation. The study shows the importance of appropriate reference gene normalisation in other tissues before qPCR analysis.

The essential role of medical ethics education in achieving professionalism: the Romanell Report

This article-the Romanell Report-offers an analysis of the current state of medical ethics education in the United States, focusing in particular on its essential role in cultivating professionalism among medical learners. Education in ethics has become an integral part of medical education and training over the past three decades and has received particular attention in recent years because of the increasing emphasis placed on professional formation by accrediting bodies such as the Liaison Committee on Medical Education and the Accreditation Council for Graduate Medical Education. Yet, despite the development of standards, milestones, and competencies related to professionalism, there is no consensus about the specific goals of medical ethics education, the essential knowledge and skills expected of learners, the best pedagogical methods and processes for implementation, and optimal strategies for assessment. Moreover, the quality, extent, and focus of medical ethics instruction vary, particularly at the graduate medical education level. Although variation in methods of instruction and assessment may be appropriate, ultimately medical ethics education must address the overarching articulated expectations of the major accrediting organizations. With the aim of aiding medical ethics educators in meeting these expectations, the Romanell Report describes current practices in ethics education and offers guidance in several areas: educational goals and objectives, teaching methods, assessment strategies, and other challenges and opportunities (including course structure and faculty development). The report concludes by proposing an agenda for future research.

Serum biomarkers of clinical and cytologic response in dogs with idiopathic immune-mediated polyarthropathy

Background

Immune‐mediated polyarthopathy (IMPA) is common in dogs, and is monitored by serial arthrocenteses.

Hypothesis/Objectives

Plasma C‐reactive protein (CRP), interleukin‐6 (IL‐6), and CXCL8 (interleukin‐8) would serve as noninvasive markers of joint inflammation in IMPA.

Animals

Nine client‐owned dogs with idiopathic IMPA; 6 healthy controls.

Methods

Prospective study. Plasma CRP, IL‐6, and CXCL8 were measured by ELISA at baseline, 2, and 4 weeks during treatment with prednisone at 50 mg/m²/day. Arthrocenteses, the canine brief pain inventory (CBPI), and accelerometry collars were used to assess joint inflammation, lameness, and mobility at all 3 time points.

Results

C‐reactive protein concentrations were higher in IMPA dogs (median 91.1 μg/mL, range 76.7–195.0) compared with controls (median <6.3 μg/mL, <6.3–13.7; P = .0035), and were significantly lower at week 2 (10.6 μg/mL, <6.3–48.8) and week 4 (<6.3 μg/mL, <6.3–24.4; P < .001).

C‐reactive protein was correlated with median CBPI scores (r = 0.68; P = .0004), joint cellularity (r = 0.49, P = .011), and mobility by accelerometry (r = −0.42, P = .048). Plasma IL‐6 concentrations were also higher in IMPA dogs (median 45.9 pg/mL), compared with controls (median <15.7 pg/mL; P = .0008). IL‐6 was lower in IMPA dogs by week 4 (<15.7 pg/mL; P = .0099), and was modestly correlated with CBPI scores (r = 0.47, P = .023). CXCL8 did not differ significantly between IMPA and healthy dogs.

Conclusions

Plasma CRP and IL‐6 might be useful surrogate markers of synovial inflammation and disease activity in dogs with IMPA.