POS0379 SMARTPHONE-ASSISTED PATIENT-INITIATED CARE VERSUS USUAL CARE IN PATIENTS WITH RHEUMATOID ARTHRITIS AND LOW DISEASE ACTIVITY: A RANDOMIZED CONTROLLED TRIAL

Background

Most patients with rheumatoid arthritis (RA) visit their rheumatologist every 3-6 months to evaluate their disease activity. This may be inefficient, as research shows that many patients have minimal disease activity.1 When patients monitor their disease and initiate care at the right moment, they may be able to reduce the number of clinic visits, with a lower health care burden and costs. We developed a smartphone app that allows patients to self-monitor their disease activity through a weekly assessment of patient index data (RAPID-3).

Objectives

To assess safety (non-inferiority in disease activity, DAS28) and efficacy (reduction in number of visits) of patient-initiated care assisted by a smartphone app compared to usual care.

Methods

A twelve month, randomized, non-inferiority clinical trial was conducted in RA patients with low disease activity, on stable treatment for at least 6 months prior to entry. Patients were randomized (1:1) to either app supported patient-initiated care with a scheduled follow-up consultation after a year (app-group), or usual care, see Figure 1. The primary outcomes were non-inferiority in terms of change in disease activity (ΔDAS28) after 12 months and the number of consultations with a rheumatologist. The non-inferiority limit was set at 0.5 difference in ΔDAS28 between the groups.

Figure 1.

Typical routine care versus app-supported self-initiated care.

Results

102 of 103 randomized patients completed the study. The mean age was 58, 60 were female and the mean disease duration was 12 years. At baseline mean (SD) DAS28 was 1.67 (0.68) in the app group, and 1.54 (0.72) in the usual care group. After a year, ΔDAS28 was 0.27 in the app group vs 0.35 in the usual care group: the difference in ΔDAS28 was –0.04 in favor of the app group (95%CI –0.39; 0.30) documenting non-inferiority. The number of rheumatologist consultations was significantly lower in the app group: mean (SD) 1.7 (1.8) vs 2.8 (1.4) visits/year; visit rate ratio: 0.62 (95% CI 0.47;0.81, p<0.001).

Conclusion

Patient-initiated care supported with self-monitoring via a smartphone app was non-inferior to usual care in terms of ΔDAS28 and led to a 38% reduction in rheumatologist consultations rate.

References

[1]Haugeberg G et al. Ten years of change in clinical disease status and treatment in rheumatoid arthritis: results based on standardized monitoring of patients in an ordinary outpatient clinic in southern Norway. Arthritis Res Ther 2015

Disclosure of Interests

Bart Seppen: None declared, Jim Wiegel: None declared, Marieke ter Wee: None declared, Dirkjan van Schaardenburg: None declared, Leo Roorda: None declared, Maarten Boers: None declared, Michael Nurmohamed: None declared, W.H. Bos Grant/research support from: AbbVie sponsored this trial

Re-emergence of enterovirus D68 in Europe after easing the COVID-19 lockdown, September 2021

We report a rapid increase in enterovirus D68 (EV-D68) infections, with 139 cases reported from eight European countries between 31 July and 14 October 2021. This upsurge is in line with the seasonality of EV-D68 and was presumably stimulated by the widespread reopening after COVID-19 lockdown. Most cases were identified in September, but more are to be expected in the coming months. Reinforcement of clinical awareness, diagnostic capacities and surveillance of EV-D68 is urgently needed in Europe.

Molecular Epidemiology and Evolutionary Trajectory of Emerging Echovirus 30, Europe

In 2018, an upsurge in echovirus 30 (E30) infections was reported in Europe. We conducted a large-scale epidemiologic and evolutionary study of 1,329 E30 strains collected in 22 countries in Europe during 2016-2018. Most E30 cases affected persons 0-4 years of age (29%) and 25-34 years of age (27%). Sequences were divided into 6 genetic clades (G1-G6). Most (53%) sequences belonged to G1, followed by G6 (23%), G2 (17%), G4 (4%), G3 (0.3%), and G5 (0.2%). Each clade encompassed unique individual recombinant forms; G1 and G4 displayed >2 unique recombinant forms. Rapid turnover of new clades and recombinant forms occurred over time. Clades G1 and G6 dominated in 2018, suggesting the E30 upsurge was caused by emergence of 2 distinct clades circulating in Europe. Investigation into the mechanisms behind the rapid turnover of E30 is crucial for clarifying the epidemiology and evolution of these enterovirus infections.

Multi-centre evaluation of real-time multiplex PCR for detection of carbapenemase genes OXA-48, VIM, IMP, NDM and KPC

BACKGROUND

Resistance to carbapenem antibiotics is emerging worldwide among Enterobacteriaceae. To prevent hospital transmission due to unnoticed carriage of carbapenemase producing micro-organisms in newly admitted patients, or follow-up of patients in an outbreak setting, a molecular screening method was developed for detection of the most prevalent carbapenemase genes; blaOXA-48, blaVIM, blaIMP, blaNDM and blaKPC.

METHODS

A real-time multiplex PCR assay was evaluated using a collection of 86 Gram negative isolates, including 62 carbapenemase producers. Seven different laboratories carried out this method and used the assay for detection of the carbapenemase genes on a selection of 20 isolates.

RESULTS

Both sensitivity and specificity of the multiplex PCR assay was 100%, as established by results on the strain collection and the inter-laboratory comparisons.

CONCLUSIONS

In this study, we present a multiplex real-time PCR that is a robust, reliable and rapid method for the detection of the most prevalent carbapenemases blaOXA-48, blaVIM, blaIMP, blaNDM and blaKPC, and is suitable for screening of broth cultured rectal swabs and for identification of carbapenemase genes in cultures.

Review of a major epidemic of methicillin-resistant Staphylococcus aureus: the costs of screening and consequences of outbreak management

BACKGROUND

A major outbreak of methicillin-resistant Staphylococcus aureus (MRSA) occurred in locations C and Z of our hospital and lasted for several years. It affected 1,230 patients and 153 personnel.

METHODS

Outbreak management was installed according to the Dutch "search and destroy" policy. A rapid, high-throughput method for molecular screening of potential MRSA carriers was implemented. Outbreak isolates were retrospectively genotyped by pulsed field gel electrophoresis. Costs of molecular screening were compared with screening by culture.

RESULTS

Genotyping results revealed 4 distinct epidemic MRSA clones. Three were present in hospital C. Because of a merger of hospitals, these clones spread to hospital Z. Another clone of MRSA affected other health care-related institutions in the region. Because of the implementation of strict containment measures of the "search and destroy" policy, the annual number of tests decreased from 100,000 to 18,000. The disposables and reagents used in polymerase chain reaction technology are more expensive than those of conventional methods. However, the clinical and economic benefits of fast results in regard to expenses of the hospital clearly outweigh the higher costs of screening.

CONCLUSION

The implementation of a rapid, high-throughput molecular screening system greatly contributed to the effectiveness of strict containment measures of the "search and destroy" policy. The major epidemic clones of MRSA in the outbreak were eradicated by this strategy.

Detection of novel chromosome-SCCmec variants in Methicillin Resistant Staphylococcus aureus and their inclusion in PCR based screening

Findings

To facilitate automation, a novel DNA extraction method for MRSA was adopted. The MRSA specific chromosome-SCCmec PCR was adapted, additional primers were added, and the performance was validated. From various laboratories in The Netherlands we received a total of 86 MRSA clinical isolates, that were negative in commercially available tests. We identified 14 MRSA strains with new variant chromosome-SCCmec junctions by sequence analysis. These MRSA strains appeared to carry SCCmec sequences with a high degree of homology to SCC regions of S. epidermidis and S. haemolyticus. All were included for detection in chromosome-SCCmec based PCR.

Background

Efficient management of Methicillin Resistant Staphylococcus aureus (MRSA) in the hospital is needed to prevent dissemination. It is important that MRSA can be rapidly identified, and effective infection control measures can be initiated. Equally important is a rapid MRSA negative report, especially for patients in isolation. For negative screening we implemented fully automated high through-put molecular screening for MRSA.

Conclusions

Fourteen variant chromosome-SCCmec junctions in MRSA, that are not detected in commercially available MRSA detection kits were added to our PCR to detect all currently known variant SCC-mec types of MRSA.

A real-time PCR assay with improved specificity for detection and discrimination of all clinically relevant Bordetella species by the presence and distribution of three Insertion Sequence elements

Background

In Dutch laboratories molecular detection of B. pertussis and B. parapertussis is commonly based on insertion sequences IS481 and IS1001, respectively. Both IS elements are more widely spread among Bordetella species. Both Bordetella holmesii, and B. bronchiseptica can harbour IS481. Also, IS1001 is found among B. bronchiseptica. IS481, and IS1001 based PCR thus lacks specificity when used for detection of specific Bordetella spp.

Findings

We designed a PCR based on IS1002, another IS element that is present among Bordetella species, and exploited it as a template in combination with PCR for IS481, and IS1001. In combining the PCRs for IS481, IS1001, and IS1002, and including an inhibition control, we were able to detect and discriminate all clinically relevant Bordetella species.

Conclusions

We developed an improved PCR method for specific detection of B. pertussis, B. parapertussis, B. holmesii, and B. bronchiseptica.

Assertive community treatment in the Netherlands: a randomized controlled trial

OBJECTIVE

Assertive community treatment is rapidly implemented by many European mental health services, but recently the evidence base has been questioned. Positive results of randomized trials in the USA were not replicated in the UK. The question is whether the UK findings are representative for other European countries with modern mental health services.

METHOD

Open randomized controlled trial of long-term severely mentally ill patients [Health of the Nation Outcome Scales (HoNOS) total score >or=15], assigned to assertive community treatment (n = 59) or to standard community mental health care (n = 59).

PRIMARY OUTCOME

sustained contact; housing stability and admission days. This trial is registered as an International Standard Randomized Clinical Trial, number ISRCTN 11281756.

RESULTS

Assertive community treatment was significantly better in sustaining contact with patients, but not in reducing admission days. No differences in housing stability, psychopathology, social functioning or quality of life were found.

CONCLUSION

The results are in agreement with UK studies. However, the sustained contact potential of assertive community treatment is important, as too many patients are lost in standard care.