FRI0029 EFFECTIVENESS OF A NURSE LED TREAT TO TARGET (T2T) MODEL IN ACHIEVING REMISSION FOR EARLY RHEUMATOID ARTHRITIS PATIENTS IN A REAL-WORLD SETTING

Background:

Rheumatoid Arthritis (RA) is a chronic, inflammatory and systemic autoimmune disease, affecting multiple joints particularly small joints in hands and feet.1For the past two decades, there has been significant change in approach for the diagnosis and treatment of RA. Now early diagnosis and aggressive management of RA is considered key role for preventing permanent damage to joints.2Treat to Target (T2T) strategy has been proven to be very effective in achieving pre-decided outcome either clinical remission (CR) or low disease activity(LDA).3

Objectives:

To assess the outcome of nurse led T2T strategy in Early RA patients within first 2 years of treatment.

Methods:

This was Observational Prospective Study, based on data collected in our ANP led Early Inflammatory Arthritis clinic. All patients diagnosed with inflammatory arthritis were managed following a T2T protocol. Every patient had predefined target set according to co-morbidities, preexisting osteoarthritis and duration of disease. Patients were followed up at varying intervals depending on clinical need until the steroid free target was achieved or for up to 2 years. Clinical Disease Activity Index (CDAI) tool was used to assess disease activity.

Data collected included age, gender, diagnosis, Rheumatoid factor and/or Anti CCP positivity, erosions on x ray at the time of diagnosis and Health Assessment Questionnaire (HAQ-DI). For this analysis, only patients meeting the 2010 ACR/EULAR criteria4for the diagnosis of RA were included.

The primary analysis in this study was the proportion of patients who achieved CR or LDA using different DMARDs used alone or in combination and the clinical determinants of this outcome.

Results:

Out of 417 patients with Early Inflammatory Arthritis, 300 met criteria for RA. 27 were lost to follow up (3 deaths) and 44 remained on the T2T pathway. For the 229 patients completing the pathway, mean age was 43.25 years (SD 9.405), Female gender 146 (63.75%), Anti CCP positive in 160 (69.86%), Rheumatoid Factor (RF) positive in 154 (67.24%), Both RF and Anti CCP positive 141 (61.57%), CDAI at baseline was 22.65 (SD 22.19) and Mean HAQ-DI at presentation 1.19 (SD 0.629). There were 18.34% (42) of patients who had erosive changes on x-ray at presentation.). Outcome of T2T strategy showed that 151 (65.93%) achieved clinical remission and 78(34.06%) achieved low disease activity

Conclusion:

Remission in patients who were less than 40 years of age was 100% as opposed to 49% above the age of 40 years. This difference was found to be statistically significant with a p value of <0.05 (Table 1).

Table 1.

Treat to target outcomes with analysed variables.

Group CharactersRemissionn (%)Low disease activity n (%)TotalP valueFemale92 (63.01)54 (36.99)1460.215Male59 (71.08)24 (28.92)83RF +103 (66.88)51 (33.12)1540.666RF -48 (64)27 (36)75CCP +105 (65.63)55 (34.37)1600.760CCP -44 (67.79)21 (32.31)65< 40 years76 (100)0 (0)760.000>40 years75 (49.02)78 (50.98)153

Further to this, Methotrexate monotherapy was the dominant DMARD used to achieve remission and/or low disease activity in more than 50 % of the RA patients (Figure 1).

References:

[1]Lee DM, Weinblatt ME. Rheumatoid arthritis. Lancet. 2001 Sep 15;358(9285):903-11.

[2]Heidari B. Rheumatoid Arthritis: Early diagnosis and treatment outcomes. Caspian J Intern Med. 2011;2(1):161–170.

[3]Brinkmann GH, Norvang V, Norli ES, Grovle L, Haugen AJ, Lexberg AS, et al. Treat to target strategy in early rheumatoid arthritis versus routine care - A comparative clinical practice study. Semin Arthritis Rheum. 2019;48(5):808-14.

[4]Kay J, Upchurch KS. ACR/EULAR 2010 rheumatoid arthritis classification criteria. Rheumatology (Oxford). 2012;51 Suppl 6:vi5-9.

Disclosure of Interests:

None declared

Detection of CMB-Cluster Lensing using Polarization Data from SPTpol

We report the first detection of gravitational lensing due to galaxy clusters using only the polarization of the cosmic microwave background (CMB). The lensing signal is obtained using a new estimator that extracts the lensing dipole signature from stacked images formed by rotating the cluster-centered Stokes QU map cutouts along the direction of the locally measured background CMB polarization gradient. Using data from the SPTpol 500  deg^{2} survey at the locations of roughly 18 000 clusters with richness λ≥10 from the Dark Energy Survey (DES) Year-3 full galaxy cluster catalog, we detect lensing at 4.8σ. The mean stacked mass of the selected sample is found to be (1.43±0.40)×10^{14}M_{⊙} which is in good agreement with optical weak lensing based estimates using DES data and CMB-lensing based estimates using SPTpol temperature data. This measurement is a key first step for cluster cosmology with future low-noise CMB surveys, like CMB-S4, for which CMB polarization will be the primary channel for cluster lensing measurements.

Detection of B-mode polarization in the cosmic microwave background with data from the South Pole Telescope

Gravitational lensing of the cosmic microwave background generates a curl pattern in the observed polarization. This "B-mode" signal provides a measure of the projected mass distribution over the entire observable Universe and also acts as a contaminant for the measurement of primordial gravity-wave signals. In this Letter we present the first detection of gravitational lensing B modes, using first-season data from the polarization-sensitive receiver on the South Pole Telescope (SPTpol). We construct a template for the lensing B-mode signal by combining E-mode polarization measured by SPTpol with estimates of the lensing potential from a Herschel-SPIRE map of the cosmic infrared background. We compare this template to the B modes measured directly by SPTpol, finding a nonzero correlation at 7.7σ significance. The correlation has an amplitude and scale dependence consistent with theoretical expectations, is robust with respect to analysis choices, and constitutes the first measurement of a powerful cosmological observable.

Effects of creating a non-specific, virus-hostile environment in the nasopharynx on symptoms and duration of common cold

The Common Cold remains the most frequent symptomatic viral infection in man. Current best therapies are all symptomatic. New pharmacological therapies are likely to be prescription-bound, and as most Common Cold infections are successfully treated without the intervention of a Physician, there is a need for effective non-prescription therapy options. Aim of this study is to propose a new type of approach, based on the concept of making a hostile biological environment for virus survival and spreading at the point of infection, the nasopharynx. The hypothesis was advanced that infections could be controlled using a physical biological approach to create an environment at the point of infection, that is inhibitory to the survival, and persistence of infecting virus, and of viruses newly released from infected mucosal epithelial cells. A nasal irrigation spray, designed to deliver a low pH gel to the nasal cavity, was developed and tested in this study. The study was a randomised, parallel, double-blind, placebo-controlled evaluation of three formulations of irrigation nasal spray in 441 subjects. The objective was to test whether the formulations reduced Cold severity and Cold duration compared to a placebo nasal spray. Subjects were recruited, and supplied with the product when healthy, and were instructed to begin treating and recording symptom severity once they experienced the "first signs" of a Common Cold. To qualify, subjects had to volunteer that they had at least one of the symptoms: sore/scratchy throat, runny nose or congested nose. The product was used 4 times daily, with at least 4 hours separating each dose, for a maximum of 7 days. Efficacy was assessed by an Interactive Voice Recall System whereby subjects were required to contact the investigation site, by telephone, twice daily when they were asked to assess the severity of their symptoms using a four point ordinal scale where 0 = "absent", and 3 = "severe". The symptoms assessed were sore throat, runny nose, blocked nose, cough and tired/run-down feeling. Two formulations demonstrated significant effects. A hydroxy methyl propyl cellulose based formulation reduced symptom severity compared with placebo by 17% and a Poloxamer based formulation reduced severity by 21%. Duration of illness was reduced with a hydroxy methyl propyl cellulose based formulation by 1.5 days to 2.4 days (according to the dose) and by a Poloxamer based formulation by 2.5 days. Results of this study suggest that the creation of a non virus-specific, inhibitory environment in the nasopharynx holds promise as an effective method of controlling the severity and duration of the Common Cold.

Dementia and its associations in type 2 diabetes mellitus: the Fremantle Diabetes Study

BACKGROUND

recent studies indicate that diabetes is an important risk factor for dementia in older patients, but the cause remains unknown.

OBJECTIVES

to determine whether vascular or diabetes-related risk factors predict the development of dementia in older subjects with diabetes.

PATIENTS

63 patients with type 2 diabetes of mean age 75.3 years.

METHODS

Subjects were screened for cognitive impairment using the Mini-Mental State Examination (MMSE) and informants who knew the subjects answered the Informant Questionnaire for Cognitive Decline in the Elderly (IQCODE). Probable dementia was diagnosed using highly specific criteria based on the combination of both tests. Potential risk factors for dementia obtained at the time of the cognitive test and annually from a median of 3.2 years previously were examined using univariate methods and simple general linear modelling.

RESULTS

since there was a significant association between MMSE and English speaking ability, ten non-Anglo-Celt patients were excluded from the analysis. Probable dementia was diagnosed in six of the remaining 53 subjects (11%). Dementia was significantly and independently associated with higher diastolic and mean arterial blood pressure measurements over the 3 years before assessment. Blood pressure declined over this time in the patients with probable dementia and was similar to that in non-demented subjects at the time of cognitive assessment.

CONCLUSIONS

these preliminary data suggest that the high rate of dementia found in older people with diabetes may be explained by the high rate of hypertension in this population.

Survey of hospital doctors' attitudes and knowledge of oral conditions in older patients

The study was designed to assess the views and knowledge of hospital doctors in general and geriatric medicine on oral health in older people. Eighty two doctors in general and geriatric medicine at two hospitals were shown 12 colour slides of oral mucosal conditions and asked to give a diagnosis for each slide and complete a questionnaire. Completed questionnaires with the answers to the coloured slides were returned completed by 70 doctors. The majority of doctors (84%) felt it was important to examine older patients' mouths, however only 19% (chi(2) p=0.0001) routinely do so. If asked to prescribe nystatin by the nursing staff, 30% said they would do so without examining the mouth itself. Only 9% of doctors knew that wearing dentures was a specific risk factor for oral candidiasis (chi(2) p=0.001). Altogether 56% of doctors did not feel confident in examining the oral cavity and most (77%) did not think they had had sufficient training in this examination. Only two doctors correctly diagnosed all of the slides. An early squamous carcinoma was misdiagnosed by 80% of the doctors (chi(2) p=0.0001). Hospital doctors do not routinely inspect older patients' mouths. Even if shown slides of typical oral mucosal lesions many hospital doctors are unable to diagnose them. Issues on training need to be addressed. From the patients' point of view a public health campaign is required to educate older people on the need for a regular dental review and be aware that doctors may not be able to diagnose serious oral conditions.

Illness-induced context aversion learning in rats with lesions of the dorsal hippocampus

In 2 experiments, rats with electrolytic lesions of the dorsal hippocampus and sham-operated control subjects were given injections of lithium chloride after exposure to a distinctive context. This procedure establishes a context-illness association in intact subjects. In Experiment 1, the strength of the context aversion was assessed by measuring the subjects' willingness to consume a novel flavor in the context. It was found that lesioned subjects showed less suppression of consumption than controls. Experiment 2 tested the ability of the context to block subsequent flavor-aversion learning and revealed less effective blocking in lesioned rats. These results are consistent with the view that hippocampal lesions retard context conditioning; unlike previous work that has made use of conditioned freezing as the measure of context conditioning, the present results are not explicable in terms of lesion-induced changes in general activity.

Bordetella holmesii-like organisms isolated from Massachusetts patients with pertussis-like symptoms

We isolated Bordetella holmesii, generally associated with septicemia in patients with underlying conditions, from nasopharyngeal specimens of otherwise healthy young persons with a cough. The proportion of B. holmesii-positive specimens submitted to the Massachusetts State Laboratory Institute increased from 1995 to 1998.

Illness-induced context aversion learning in rats with lesions of the dorsal hippocampus

In 2 experiments, rats with electrolytic lesions of the dorsal hippocampus and sham-operated control subjects were given injections of lithium chloride after exposure to a distinctive context. This procedure establishes a context-illness association in intact subjects. In Experiment 1, the strength of the context aversion was assessed by measuring the subjects' willingness to consume a novel flavor in the context. It was found that lesioned subjects showed less suppression of consumption than controls. Experiment 2 tested the ability of the context to block subsequent flavor-aversion learning and revealed less effective blocking in lesioned rats. These results are consistent with the view that hippocampal lesions retard context conditioning; unlike previous work that has made use of conditioned freezing as the measure of context conditioning, the present results are not explicable in terms of lesion-induced changes in general activity.

Recommended distributions for exposure factors frequently used in health risk assessment

Although there has been nearly complete agreement in the scientific community that Monte Carlo techniques represent a significant improvement in the exposure assessment process, virtually all state and federal risk assessments still rely on the traditional point estimate approach. One of the rate-determining steps to a timely implementation of Monte Carlo techniques to regulatory decision making is the development of "standard" data distributions that are considered applicable to any setting. For many exposure variables, there is no need to wait any longer to adopt Monte Carlo techniques into regulatory policy since there is a wealth of data from which a robust distribution can be developed and ample evidence to indicate that the variable is not significantly influenced by site-specific conditions. In this paper, we propose several distributions that can be considered standard and customary for most settings. Age-specific distributions for soil ingestion rates, inhalation rates, body weights, skin surface area, tapwater and fish consumption, residential occupancy and occupational tenure, and soil-on-skin adherence were developed. For each distribution offered in this paper, we discuss the adequacy of the database, derivation of the distribution, and applicability of the distribution to various settings and conditions.

Use of a cutoff range in identifying mycobacteria by the Gen-Probe Rapid Diagnostic System

Commercial DNA probes (Gen-Probe Corp., San Diego, Calif.) for Mycobacterium tuberculosis complex Mycobacterium avium, and Mycobacterium intracellulare were compared with conventional methods for accuracy, applicability, and speed for the identification of putative isolates of the M. tuberculosis and M. avium complexes. Results are expressed as percent hybridization. Values of greater than 15% were considered positive, and values of less than 5% were negative. Cultures having hybridization values within an indeterminate range of 5 to 15% were repeated. Mycobacterial isolates resembling M. tuberculosis and M. avium complex from cultures of 589 specimens, representing 432 patients, were entered into this study; 294 cultures were tested with the M. tuberculosis complex probe, and 326 cultures were tested with the M. avium probe. In all cases, probe results agreed with our biochemical identification of the isolates. The M. intracellulare probe was used with 117 isolates morphologically resembling M. avium complex, and one false-negative result was observed. Seventy-two cultures gave initial hybridization results that fell within the indeterminate range and were repeated. If the manufacturer's recommended 10% cutoff value had been used, the original hybridization values would have resulted in 27 misidentified cultures, 16 false-negatives and 11 false-positives.

Socialisation scheme with a high staff-patient ratio

Six months after a comprehensive socialisation scheme began, a prospective controlled study was carried out. The patients were tested in three practical sections - Cooking; Maintenance of Home and Clothing; Other Skills (eg. form-filling); and with a Questionnaire. Forty-eight members of an experimental group received socialisation training after initial testing. They and the 20 controls who did not undergo training were re-evaluated three months later. There was no significant difference between the groups in their initial scores. On retesting, the experimental group showed a significant improvement in Cooking (p less than 0.001), Home Maintenance (p less than 0.001) and the Questionnaire (p less than 0.05). Analysis of the inter-group differences showed significant superiority of the experimental group in Cooking (p less than 0.05) and Home Maintenance (p less than 0.05). It is suggested that such a socialisation scheme be considered for inclusion alongside other rehabilitation services in psychiatric hospitals. The emphasis on a high staff-to-patient ratio and the breakdown of each task into smaller steps emerged as essential elements in the training programme.

The craving factor in the treatment of smoking

A review of previous studies suggests that many of the consistent results obtained may reflect individual differences in smoking behaviour. It was felt that Tomkins' (1966) distinction between craving and non-craving smokers would be particularly relevant to this. The present study investigates the effects of such individual differences in smoking behaviour within a self-control treatment programme. Thirty-four smokers were assigned to three groups: two self-control treatment groups and an attention-monitoring control group. The treatment groups differed in that group II concentrated on the positive aspects of not smoking, whereas group III used a wide range of techniques. Treatment effects were not significant but a critical factor in abstinence, drop-out and percentage reduction during the study was craving/non-craving status. The results indicate that two separate populations of smokers exist who seem to have different responses to treatment. This, it is argued, has blurred analysis of results in previous studies. The two types of smoker may require separate treatment considerations, both in therapy and in long-term management.