A retrospective cohort study evaluating pregnancy outcomes in women with MIDD

AIMS

The most common pathogenic mitochondrial mutation associated with mitochondrial disease is m.3243A>G. Increased obstetric complications, such as spontaneous abortion, gestational diabetes (GDM), preterm delivery, and preeclampsia, have been reported in women carrying this mutation. We aimed to determine the fetal and maternal outcomes in pregnant women with mitochondrial disease.

METHODS

We retrospectively studied the obstetric and perinatal outcomes in 88 pregnancies of 26 women with genetically confirmed mitochondrial disease (m.3243A>G in the MTTL1 gene (n = 25); m.12258C>A in the MT-TS2 gene (n = 1)). Outcomes included pregnancy related complications, mode of delivery, gestational age at delivery and birthweight.

RESULTS

Mean heteroplasmy rate was 18%. The miscarriage rate was higher than background at 25%. 21 pregnancies (24%) were complicated by GDM; 9 pregnancies (13.6%) had a preterm delivery and 2 of them (3%) an extreme premature delivery < 32 weeks. One woman had preeclampsia and one had a postpartum hemorrhage. The caesarean section (CS) rate was 20%. For every unit increase in maternal heteroplasmy levels there was a 26% increased risk of undergoing an assisted operative vaginal delivery (OR 1.26, 95% CI 1.04-1.53, P = 0.002, Bonferroni corrected P = 0.005) and an 18% increased risk of undergoing a CS (OR 1.18, 95% CI 1.01-1.39, P = 0.01, Bonferroni corrected P = 0.03) compared to a spontaneous vaginal delivery. There was a statistical significant correlation between maternal and offspring heteroplasmy levels. Spearman correlation rho = 0.96, 95% CI 0.78-0.99, P = 0.0002.

CONCLUSION

Women with mitochondrial disease appear to have more frequent obstetric complications including miscarriage and GDM. Pre-pregnancy diagnosis of m.3243A>G will enable the counseling of women and increase awareness of possible obstetric complications.

tRNA-derived fragments are altered in diabetes

AIMS

Maternally inherited diabetes and deafness (MIDD) is a rare form of adult-onset diabetes that can be difficult to diagnose due to its variable clinical phenotype. Transfer RNA-derived small fragments are a novel, emerging class of small non-coding RNAs (sncRNAs) that have significant potential as serum biomarkers due to their stress-induced generation, abundance, stability and ease of detection.

METHODS

We investigated the levels of tiRNA 5'ValCAC (alone and in combination with miR-23b-3p) identified from small RNA sequencing studies in serum samples from healthy controls, type 1 diabetes, type 2 diabetes and MIDD subjects.

RESULTS

Serum levels of 5'ValCAC were reduced in MIDD and type 2 diabetes subjects compared to controls. Type 2 diabetes subjects had higher serum levels of miR-23b-3p compared to all other subjects. Receiver Operating Characteristic analysis showed the potential of 5'ValCAC and miR-23b-3p as MIDD biomarkers, with the combination showing excellent separation from type 2 diabetes subjects.

CONCLUSIONS

This is the first report showing altered serum levels of tiRNAs in diabetes subjects. The combined use of 5'ValCAC and miR-23b-3p as serum biomarkers could potentially differentiate between MIDD subjects and type 2 diabetes subjects.

An intersectional analysis of sociodemographic disparities in Covid-19 vaccination: A nationwide register-based study in Sweden

BACKGROUND

Studies on sociodemographic disparities in Covid-19 vaccination uptake in the general population are still limited and mostly focused on older adults. This study examined sociodemographic differences in Covid-19 vaccination uptake in the total Swedish population aged 18-64 years.

METHODS

National Swedish register data within the SCIFI-PEARL project were used to cross-sectionally investigate sociodemographic differences in Covid-19 vaccination among Swedish adults aged 18-64 years (n = 5,987,189) by 12 October 2021. Using logistic regression models, analyses were adjusted for sociodemographic factors, region of residence, history of Covid-19, and comorbidities. An intersectional analysis approach including several cross-classified subgroups was used to further address the complexity of sociodemographic disparities in vaccination uptake.

FINDINGS

By 12 October 2021, 76·0% of the Swedish population 18-64 years old had received at least two doses of Covid-19 vaccine, an additional 5·5% had received only one dose, and 18·5% were non-vaccinated. Non-vaccinated individuals were, compared to vaccinated, more often younger, male, had a lower income, were not gainfully employed, and/or were born outside Sweden. The social patterning for vaccine dose two was similar, but weaker, than for dose one. After multivariable adjustments, findings remained but were attenuated indicating the need to consider different sociodemographic factors simultaneously. The intersectional analysis showed a large variation in vaccine uptake ranging from 32% to 96% in cross-classified subgroups, reflecting considerable sociodemographic heterogeneity in vaccination coverage.

INTERPRETATION

Our study, addressing the entire Swedish population aged 18-64 years, showed broad sociodemographic disparities in Covid-19 vaccine uptake but also wide heterogeneities in coverage. The intersectional analysis approach indicates that focusing on specific sociodemographic factors in isolation and group average risks without considering the heterogeneity within such groups will risk missing the full variability of vaccine coverage.

FUNDING

SciLifeLab / Knut & Alice Wallenberg Foundation, Swedish Research Council, Swedish government ALF agreement, FORMAS.

Anatomic and functional discordance among patients with non-obstructive coronary disease

Background

Non-obstructive coronary artery disease (CAD) is associated with increased adverse cardiovascular (CV) events. However, it is unclear if functional stenosis, as assessed by FFRCT &lt;0.80, further stratifies risk among patients with non-obstructive CAD and which factors contribute to this anatomic-functional discordance (stenosis &lt;50% and FFRCT &lt;0.80).

Purpose

We hypothesized that patients with anatomically non-obstructive CAD by CTA and an abnormal FFRCT value of ≤0.80 have a phenomenon termed anatomic-functional discordance, and this discordance would be associated with increased adverse outcomes.

Methods

Patients in the ADVANCE (Assessing Diagnostic Value of Non-invasive FFRCT in Coronary Care) Registry who had exclusively non-obstructive CAD (anatomic stenosis &lt;50%) were stratified by FFRCT &gt;0.80 in all coronary vessels (concordant) vs. FFRCT &lt;0.80 in at least one vessel (discordant). Baseline patient demographics, coronary computed tomography angiography findings, downstream testing and clinical outcomes were compared between groups. The primary composite endpoint included revascularization, CV hospitalization, heart failure, arrhythmia, non-fatal myocardial infarction, unplanned hospitalization for an acute coronary syndrome leading to urgent revascularization, and all-cause death.

Results

Among 1,261 patients with non-obstructive CAD, 543 (43.1%) had functional stenosis with FFRCT &lt;0.80. Patients in the discordant group were older, more likely to have hypertension, hyperlipidemia, and had significantly higher indexed left ventricular (LV) mass and significantly lower coronary volume-to-mass ratios when compared with patients in the concordant group. Downstream non-invasive testing was more common among patients with discordance (35.9% vs 20.2%, p&lt;0.0001) and more frequently resulted in a positive downstream test (10.3% vs. 3.3%, p&lt;0.0001). Invasive angiography was also more common among patients with discordance (25.2% vs. 11.6%, p&lt;0.0001). Anatomic-functional discordance was associated with higher rates of CV hospitalization and percutaneous coronary intervention (both p&lt;0.0001), but no significant difference in all-cause death. After adjustment, anatomic-functional discordance was associated with a significantly higher risk of the composite endpoint (adjusted HR 2.79, 95% CI 1.67–4.65), Figure 1. As shown in Figure 2, the more vessels with anatomic-functional discordance, the higher the rate of adverse cardiac events.

Conclusion

Anatomic-functional discordance was present in nearly half of patients with exclusively non-obstructive CAD. The lower coronary volume: LV mass ratio may reflect abnormal coronary physiology at lower thresholds of anatomical stenosis among those with discordance. Compared to patients with concordance, patients with discordance had worse clinical outcomes suggesting that anatomic-functional discordance may stratify risk for adverse CV events among patients with non-obstructive CAD.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): The analysis was an investigator-initiated analysis sponsored by Heart Flow.

553 Does Patella Implant Design Affect Outcomes? Patella Resurfacing in Total Knee Arthroplasty: A Systematic Review and Meta-Analysis

Aim

To investigate whether implant design affect (1)incidence of anterior knee pain, (2)patient reported outcomes and (3)reintervention rates in a resurfaced vs non-resurfaced Total Knee Arthroplasty (TKA).

Method

MEDline, pubmed and google scholar studies were evaluated using SIGN assessment tool and data analysis was conducted using Review Manager 5.2 on only randomised controlled trials. Search terms: arthroplasty, replacement, knee (Mesh), TKA, prosthesis, patella, patellar resurfacing, patellar retaining.

Results

33 randomised controlled studies were identified. A total of 11 used the modern “patella-friendly” implants and 22 used the older “patella non-friendly” implants.

There was no significant difference in anterior knee pain rates for either surgical option. When using patella-friendly implant, patella resurfacing results in a statistically higher clinical (P 0.007, MD -0.77) and functional (P &lt; 0.0001, MD -1.87) KSS than the non-resurfaced counterparts, but scores were not clinically significant. When the patella was not resurfaced, there was a significant increased risk of reoperation with “non-patella friendly” implant (p=0.04, OR 1.42, CI 1.01, 2.00), whilst there was no significant difference between reoperation rates for the “patella friendly” implants (OR 1.17, CI 0.59,2.30).

Conclusions

Patella implant design has been shown to significantly improve KSS scores but with no clinical significance. Risk of further procedures was significantly higher in non-resurfaced patella TKAs with “non-friendly” implants, likely due to increased rates of anterior knee pain in these older generation implants leading to secondary resurfacing. However, when utilising “patella-friendly” implants, resurfacing does not lower reintervention rates. This meta-analysis finds no clinical indication to resurface the patellar whilst performing a TKA.

AB0571 DERIVATION AND INDEPENDENT VALIDATION OF THE LUPUS ARTHRITIS AND MUSCULOSKELETAL DISEASE ACTIVITY SCORE (LAMDA): A MORE SENSITIVE, SPECIFIC AND RESPONSIVE TOOL FOR LUPUS ARTHRITIS

Background

The MSK components of the BILAG and SLEDAI have limited sensitivity, specificity and responsiveness.

Objectives

To develop a better disease activity tool for MSK lupus.

Methods

“LAMDA” was derived using data from the multicentre USEFUL study (PMID:33792659); 133 patients with inflammatory MSK pain received intramuscular depomedrone then were assessed for 66/68 SJC/TJC, BILAG-2004, SLEDAI-2K, physician MSK-VAS, inflammatory markers, patient pain and disease-activity-VAS and MSK-ultrasound. Baseline variables were modelled against US using penalized (Lasso) regression. For validation we evaluated: (i) responsiveness at week 6 in USEFUL and (ii) association with quality of life and treatment decision in an independent study (n=100).

Results

LAMDA was a composite of SJC, patient-MSK-pain-VAS, physician-MSK-disease-activity-VAS and ESR ranging from 0 to 26.5. Response effect size was greater for the LAMDA (0.37) than the BILAG-MSK (0.31), SLEDAI-MSK (0.27) and total US score (0.33). With active US at baseline, LAMDA’s effect size was 0.42.

In the validation study LAMDA score correlated with better physical function (R = -0.49, p<0.001), pain (R = -0.44, p=0.002) and Burden to Others (R = -0.38, p=0.009). LAMDA was higher when therapy was increased (mean (95% CI) difference 12.9 (5.8, 19.9), p<0.001).

Conclusion

LAMDA is a continuous disease activity instrument for MSK lupus that is sensitive to imaging-synovitis without swelling, more responsive than other instruments and correlates with quality of life and treatment decision. LAMDA may improve the ability of clinicians to monitor and treat MSK lupus, and determine the efficacy of therapies in clinical trials.

Acknowledgements

Funding: Lupus UK and NIHR

Disclosure of Interests

Khaled Mahmoud: None declared, Ahmed Zayat: None declared, Md Yuzaiful Md Yusof: None declared, Lee-Suan Teh: None declared, Shah Khan: None declared, Chee-Seng Yee: None declared, David D’Cruz: None declared, Nora Ng: None declared, David Isenberg: None declared, Coziana Ciurtin: None declared, Philip G Conaghan: None declared, Paul Emery: None declared, Christopher John Edwards: None declared, Elizabeth Hensor: None declared, Edward Vital Speakers bureau: GSK, AstraZeneca, Consultant of: GSK, AstraZeneca, Roche, Aurinia, Lilly, ILTOO, Novartis, Grant/research support from: AstraZeneca, Sandoz

Hand-arm vibration and outcomes of surgery for Dupuytren's contracture

BACKGROUND

Dupuytren's contracture was recently designated a prescribed occupational disease when it occurs in patients with previous hand-arm vibration (HAV) exposure.

AIMS

The aims of this study were to describe the impact of self-reported HAV exposure on upper limb function and satisfaction following surgery for Dupuytren's contracture.

METHODS

Paired pre- and postoperative Quick version of Disabilities of the Arm, Shoulder and Hand (QuickDASH) and patient satisfaction questionnaires were prospectively collected from all patients undergoing surgery for Dupuytren's contracture over a 6-year period. Patients self-reported HAV exposure duration.

RESULTS

Results were available for 425 hands (65%) at mean 13 months postoperatively. There were 111 patients (26%) that reported HAV exposure. The prevalence of HAV exposure was significantly greater in male compared with female patients (32% versus 4%; P < 0.001). A statistically significant difference in preoperative (difference 7.47; 95% confidence interval 4.78-10.17; P < 0.001) and postoperative QuickDASH score (difference 6.78; 95% confidence interval 2.69-10.88; P < 0.001) was observed between the two groups, but difference in QuickDASH improvement was not significantly different (difference 1.76; 95% confidence interval -1.58 to 5.10; P > 0.05). No significant difference in satisfaction rate or return to work was observed between the two groups.

CONCLUSIONS

Previous HAV exposure influenced the pre and postoperative function in patients undergoing surgery for Dupuytren's contracture, but had no effect on satisfaction or return to work. Further prospective research will be required to determine whether the introduction of a compensatory framework will have a more profound effect on the functional outcomes of surgery.

POS0746 THE ARTHRITIS COMPONENT OF THE SLEDAI SHOULD ONLY BE SCORED IF THERE IS JOINT SWELLING

Background:

SLE disease activity tools do not optimally define disease activity and response. The SLEDAI arthritis item is common, and sufficient to define SRI response. Lupus patients with arthralgia often have no swelling. Glossary definitions of arthritis in different versions of the SLEDAI have included: swelling, swelling between visits, effusion, tenderness, warmth and erythema. MSK ultrasound in SLE can identify synovitis without swelling, ultrasound synovitis is associated with worse symptoms and serology, predicts response to therapy, and is more responsive to therapy than clinical variables.

Objectives:

To validate different glossary definitions for SLEDAI arthritis using musculoskeletal ultrasound.

Methods:

We analysed baseline data from a multicentre longitudinal study. Physicians scored SLEDAI-2K in 133 patients with joint pain that was considered inflammatory, but not necessarily swelling. Stable immunosuppressants and prednisolone <=5mg were permitted. If the arthritis criterion was scored, we asked physicians to report which glossary features drove their decision. Musculoskeletal ultrasound of hands and wrists was performed on the same day, blinded to clinical findings. We defined abnormal grey-scale in joints as 1 joint with GS>=2, and in tendons as >=1 tendon with GS >=1, and abnormal power Doppler as >=1 joint or tendon with PD >=1.

Results:

78/133 patients had arthritis scored on SLEDAI-2K. In 21/78, swelling was not a reason for that decision. These 21 patients had either tenderness (16/21), swelling reported between visits (4/21) or both of these (1/21). No patient was scored for warmth, erythema or effusion alone. Comparison of SLEDAI definitions and ultrasound is shown in Table 1. Of 57 patients with SLEDAI arthritis scored due to swelling, 90% had an abnormal ultrasound. The positive predictive value was 89% (95% CI 79 – 94). Of 21 patients with SLEDAI arthritis scored without swelling, 48% had an abnormal ultrasound. The positive predictive value was 48% (95% CI 31 – 67). There was no substantive difference in clinical and serological variables comparing patients with SLEDAI arthritis without swelling and patients without SLEDAI arthritis. In contrast, patients with SLEDAI arthritis with swelling had worse ESR (p=0.0003), Physician MSK disease activity VAS (p<0.001) and patient EMS VAS (p=0.0019) and IgG (p=0.0625) compared to the other two groups.

Conclusion:

Although ultrasound proven synovitis in the absence of swelling is not uncommon, it is not reliably identified using other signs or symptoms. The arthritis item of the SLEDAI was likely to be associated with ultrasound synovitis if scored because of swelling, but not if scored because of tenderness or swelling between visits. Our results support raising the threshold criteria for arthritis so that it should only be scored when there is joint swelling. Previous clinical trial datasets could be re-analysed excluding SLEDAI arthritis scores not confirmed by a swollen joint count greater than one.

SLEDAI-2K at baselineUltrasound Abnormalities at BaselineTest statistics for any ultrasound abnormalityGS jointsn/N (%)PD jointsn/N (%)GS tendonsn/N (%)PD tendonsn/N (%)Any abnormalityn/N (%)Sensitivity% (95% CI)Specificity% (95% CI)PPV% (95% CI)NPV% (95% CI)All patients (n=133)77/133 (58)33/133 (25)36/133 (27)27/106 (20)83/133 (62)----MSK SLEDAI = No (n=55)20/55 (36)2/55 (4)9/55 (16)3/55 (6)22/55 (40)----MSK SLEDAI = Yes (n=78)57/78 (73)31/78 (40)27/78 (35)24/78 (31)61/78 (78)73 (62, 82)b66 (51, 78) b78 (70, 84) b60 (49, 69) b-Due to swelling (n=57)48/57 (84)28/57 (49)21/57 (37)19/57 (33)51/57 (90)61 (50, 71)c88 (75, 95) c89 (79, 94) c57 (50, 64) c-Without swelling (n=21)a9/21 (43)3/21 (14)6/21 (29)5/21 (24)10/21 (48)31 (16, 50) d75 (60, 87) d48 (31, 67) d60 (45, 68) d

Disclosure of Interests:

Khaled Mahmoud: None declared, Ahmed Zayat: None declared, Md Yuzaiful Md Yusof: None declared, Katherine Dutton: None declared, Lee-Suan Teh: None declared, Chee-Seng Yee: None declared, David d’cruz: None declared, Nora Ng: None declared, David Isenberg: None declared, Coziana Ciurtin: None declared, Philip G Conaghan: None declared, Paul Emery: None declared, Christopher John Edwards Shareholder of: Research grant support from; Abbvie, Biogen, Pfizer, Consultant of: Personal fee from; Abbvie, BMS, Biogen, Celgene, Celltrion, Fresenius, Gilead, GSK, Janssen, Lilly, Mundipharma, Pfizer, MSD, Novartis, Roche, Samsung, Sanofi, UCB, Grant/research support from: Research grant support from; Abbvie, Biogen, Pfizer, Elizabeth Hensor: None declared, Edward Vital Speakers bureau: AstraZeneca, Genentech, Aurinia, Lilly, Modus, Consultant of: AstraZeneca, Genentech, Aurinia, Lilly, Modus, Grant/research support from: Sandoz, AstraZeneca,

Pictorial information about subclinical atherosclerosis reduces the CVD risk: Results from the VIPVIZA RCT

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): Region Västerbotten and the Swedish Research Council

Background

The VIPVIZA trial has previously shown beneficial effects on cardiovascular disease (CVD) risk scores 1 year after sending pictorial information of carotid ultrasound imaging (Picture 1) to individuals and their physicians

Purpose

To investigate whether the beneficial effects on CVD-risk observed at 1-year were sustained over three years 

Methods

VIPVIZA is a pragmatic prospective open-label randomized controlled trial with blinded evaluators performed within a CVD prevention programme integrated in the regular primary health care in Västerbotten County, Sweden. Individuals aged 40, 50 or 60 years old with one CVD risk factor were enrolled and randomised 1:1 to intervention (n = 1749, pictorial information about subclinical atherosclerosis provided to participants and physicians, Picture 1) or control group(n = 1783, no information to participants or physicians). Intervention participants also recieved a follow-up phone call and the corresponding physicians written guideline-based information about the clinical significance of carotid ultrasound results. Participants were examined at baseline (2013-2016), after one and at three years

Results

A significant beneficial effect on cardiovascular risk was observed at the 3-year follow-up; Framingham Risk Score (FRS) was 13.38 for the intervention group and 14.08 for the control group(p = 0.047) and SCORE was 1.69 vs. 1.82(p = 0.022) respectively. The 3-year results adjusted for sex and educational level showed significant differences between the intervention and control group in FRS, SCORE, P-Total-Cholesterol, P-LDL-Cholesterol and waist circumference in favour of the intervention group. Analysis by sex showed difference in differences(DID) in FRS for men -1.19(95% CI -2.01 to -0.37) and -0.50(95% CI -0.93 to -0.07) for women and in SCORE for men -0.20(95% CI -0.33 to -0.06) and -0.08 (95% CI -0.13 to -0.04) for women, between the two groups over 3 years. Similarly, there were significant differences in DID in all educational groups. Further stratification by baseline FRS and SCORE risk category, showed a beneficial pattern of the intervention in all risk groups, however the DID at the 3-year follow-up was statistically significant only in the intermediate risk group for both FRS -1.34(95% CI -2.13 to -0.56) and SCORE -0.19(95% CI -0.32 to -0.05)

Conclusions

This study provides evidence of sustained effects over three years of pictorial information of subclinical carotid atherosclerosis on the reduction of cardiovascular risk regardless of sex and educational level. Importantly, a statistically significant intervention effect was seen in the intermediate risk group, where the majority of CVD events occur. Visualization of subclinical atherosclerosis may be one way to approach individuals at intermediate risk of CVD, a group where sufficient prevention is often overlooked. However, further studies are needed to investigate the intervention effect on hard end points as CVD-events and death.

Abstract Figure. Picture 1

Changes in the provision of instrumental support by older adults in nine European countries during 2004-2015: a panel data analysis

BACKGROUND

Providing support to others has been shown to be beneficial to older adults. As people age, their health and social relationships change. These changes may also relate to changes in social support provision. We examined the trajectory of instrumental support provision by older people in three European regions throughout 11 years of follow-up. We then examined the extent to which age at baseline, sex, and region (representing welfare state regime) influenced the variations in the trajectory.

METHODS

Data collected from 8354 respondents who had completed at least waves 1 and 6 of the Survey of Health, Ageing and Retirement in Europe (SHARE) was analysed. Instrumental support provision was determined from asking a single question regarding whether the respondent provided help personally for people outside their household. Region, sex, and age at baseline were the main predictors tested. We used growth modelling to address the aims of this study.

RESULTS

The northern European region (Sweden and Denmark) had the highest odds ratio of instrumental support provision. The likelihood of being involved in providing instrumental support decreased by 8% annually (OR: 0.916, 95%CI: 0.893,0.940) over the 11 years of follow-up. Older respondents were less likely to provide instrumental support and their trajectories declined faster than those of the younger respondents. Sex difference in instrumental support provision was more apparent among younger-older people in the southern European region.

CONCLUSIONS

Older European adults are an important source of instrumental support, especially for their families. The probability of instrumental support provision by European older adults declines over time. Age, sex, and welfare state regime predict this trajectory.

One-year Oxford knee scores should be used in preference to 6-month scores when assessing the outcome of total knee arthroplasty

Purpose

The primary aim of this study was to assess whether there was a clinically significant difference in the mean Oxford knee score (OKS) between 6 and 12 months after total knee arthroplasty (TKA). The secondary aim was to identify variables associated with a clinically significant change in the OKS between 6 and 12 months.

Methods

A retrospective cohort study was undertaken using an established arthroplasty database of 1574 primary TKA procedures. Patient demographics, body mass index (BMI), comorbidities, OKS and EuroQoL 5-domain (EQ-5D) score were collected preoperatively and at 6 and 12 months postoperatively. A clinically significant change in the OKS was defined as 5 points or more.

Results

There was a 1.1-point increase in the OKS between 6 and 12 months postoperatively, which was statistically significant (95% confidence (CI) 0.8–1.3, p < 0.0001). There were 381 (24.2%) patients who had a clinically significant improvement in their OKS from 6 to 12 months. After adjusting for confounding, patients with a lower BMI (p = 0.028), without diabetes mellitus (p < 0.001), a better preoperative OKS (p < 0.001) or a worse 6-month OKS (p < 0.001) were more likely to have a clinically significant improvement. A 6-month OKS < 36 points was a reliable predictor of a clinically significant improvement in the 6-month to 12-month OKS (area under the curve 0.73, 95% CI 0.70–0.75, p < 0.001).

Conclusion

Overall, there was no clinically significant change in the OKS from 6 to 12 months; however, a clinically significant improvement was observed in approximately a quarter of patients and was more likely in those scoring less than 36 points at 6 months. Level of evidence: retrospective diagnostic study, level III.

OP0179 USEFUL STUDY I: A MULTICENTRE LONGITUDINAL STUDY TO TEST WHETHER ULTRASOUND CAN IDENTIFY PATIENTS WITH MUSCULOSKELETAL SYMPTOMS OF LUPUS WITH BETTER RESPONSE TO THERAPY

Background:

In SLE, musculoskeletal manifestations impact on quality of life and trial outcomes. We previously showed that assessments based on joint swelling lack sensitivity, specificity and responsiveness compared to ultrasound (US).

Objectives:

To determine clinical features predicting US synovitis and whether patients with US synovitis respond better to therapy

Methods:

SLE patients were recruited if the referring physician deemed they had inflammatory pain warranting treatment. Swollen joints were not required. At baseline, physicians recorded features of inflammation, concurrent fibromyalgia and osteoarthritis. Stable doses of prednisolone (≤5mg/day), antimalarials or immunosuppressants were allowed. Participants received depomedrone 120mg IM then were assessed at 0, 2 and 6 weeks for 66/68 swollen and tender joint counts, BILAG-2004, SLEDAI-2K, physician global and MSK-VAS, inflammatory markers, patient pain and disease activity-VAS, HAQ-DI, LupusQoL, US of hands and wrists (blinded to patient and clinical assessor). An internal pilot determined the primary endpoint:(Early Morning stiffness-VAS (EMS-VAS) at 2 weeks (adjusted for baseline) between patients with US-synovitis (GS≥2 or PD≥1 in ≥1 joint) vs. normal US at baseline. 20% difference was considered clinically meaningful. Sensitivity analyses adjusted for prednisolone and immunosuppressants.

Results:

122/133 patients completed all visits. There was significant disagreement between clinical examination and US. 78/133 had US synovitis; 68% of these had ≥1 swollen joint. Of 66/133 patients with ≥ 1 swollen joint, 20% had normal US. US-synovitis was more likely with joint swelling, a symmetrical small joint distribution and active serology. Physician-determined EMS, other lupus features or prior response to therapy were not associated. Fibromyalgia or osteoarthritis did not reduce the probability of US synovitis.

In the full analysis set (n=133) there was no difference in EMS VAS at 2 weeks according to US synovial status at baseline (difference -8mm, 95% CI -19, 4mm, p=0.178). 32 patients had fibromyalgia. After excluding them, we found a statistically and clinically significantly better clinical response to depomedrone in patients with US-synovitis at baseline (baseline-adjusted EMS VAS at 2 weeks -12mm, 95% CI -24, 0mm, p=0.049). This difference was greater in the treatment-adjusted sensitivity analysis (-12.8 (95% CI -22, -3mm), p=0.007) and the per-protocol-adjusted sensitivity analysis (-14.8mm (95% CI -20.8, -8.8mm), p<0.001). Patient with US synovitis had higher rates of improvement in the MSK BILAG-2004 (56% vs. 26%, p=0.09) and SLEDAI-2K (37% vs. 15%, p=0.03).

Conclusion:

In lupus arthritis, distribution and serology, but not other features, help identify US-synovitis. US-synovitis was independent of features of fibromyalgia, but fibromyalgia confounded assessment of clinical response. US should be used to select SLE arthritis patients for therapy and clinical trials, especially when there are inflammatory symptoms without swollen joints.

Acknowledgments:

The Project was funded by Lupus-UK

Disclosure of Interests:

Khaled Mahmoud: None declared, Ahmed Zayat: None declared, Md Yuzaiful Md Yusof: None declared, Katherine Dutton: None declared, Lee-Suan Teh: None declared, Chee-Seng Yee: None declared, David d’cruz Grant/research support from: GlaxoSmithKline, Nora Ng: None declared, David Isenberg Consultant of: Study Investigator and Consultant to Genentech, Coziana Ciurtin Grant/research support from: Pfizer, Consultant of: Roche, Modern Biosciences, Philip G Conaghan Consultant of: AbbVie, BMS, Eli Lilly, EMD Serono, Flexion Therapeutics, Galapagos, GSK, Novartis, Pfizer, Speakers bureau: AbbVie, Eli Lilly, Novartis, Pfizer, Paul Emery Grant/research support from: AbbVie, Bristol-Myers Squibb, Merck Sharp & Dohme, Pfizer, Roche (all paid to employer), Consultant of: AbbVie (consultant, clinical trials, advisor), Bristol-Myers Squibb (consultant, clinical trials, advisor), Lilly (clinical trials, advisor), Merck Sharp & Dohme (consultant, clinical trials, advisor), Novartis (consultant, clinical trials, advisor), Pfizer (consultant, clinical trials, advisor), Roche (consultant, clinical trials, advisor), Samsung (clinical trials, advisor), Sandoz (clinical trials, advisor), UCB (consultant, clinical trials, advisor), Christopher Edwards Grant/research support from: Abbvie, Biogen, Roche, Consultant of: Abbvie, Samsung, Speakers bureau: Abbvie, BMS, Biogen, Celgene, Fresenius, Gilead, Janssen, Lilly, Mundipharma, Pfizer, MSD, Novartis, Roche, Samsung, Sanofi, UCB, Elizabeth Hensor: None declared, Edward Vital Grant/research support from: AstraZeneca, Roche/Genentech, and Sandoz, Consultant of: AstraZeneca, GSK, Roche/Genentech, and Sandoz, Speakers bureau: Becton Dickinson and GSK

FRI0599 USEFUL II: DERIVATION OF THE LUPUS ARTHRITIS AND MUSCULOSKELETAL DISEASE ACTIVITY SCORE (LAMDA) USING DATA FROM A MULTICENTRE LONGITUDINAL STUDY

Background:

Musculoskeletal (MSK) disease is the commonest manifestation of SLE. We showed that the MSK components of the BILAG index and SLEDAI have limited sensitivity, specificity and responsiveness compared to ultrasound (US) synovitis. The USEFUL study evaluated response to glucocorticoids in SLE patients with inflammatory pain.

Objectives:

To develop a disease activity tool for lupus MSK manifestations that is continuous, responsive, sensitive, and correlates with US-synovitis

Methods:

133 patients who received depomedrone 120mg IM were assessed at 0, 2 and 6 weeks for 66/68 swollen and tender joint counts, BILAG2004 index, SLEDAI-2K, physician global and MSK-VAS, inflammatory markers, patient pain and disease activity-VAS. Total US score (OMERACT-EULAR) in the hands and wrists was calculated blinded to patient and clinical assessor. Patients reported overall response using a Likert scale.

The LAMDA was developed by modelling a core set of clinical variables against total US score using penalized (Lasso) regression. Responsiveness was compared between LAMDA and other variables at week 6 using effect sizes. Minimum clinically important difference (MCID) was explored using the SEM and minimal disease activity threshold using ROC.

Results:

The variables selected for the LAMDA score were swollen joint count, patient MSK pain VAS, physician MSK disease activity VAS and ESR. A continuous score was derived. This had a theoretical range from 0 to 26.5 based on maximum ESR of 100. The highest value observed in USEFUL was 15. LAMDA was significantly higher in patients with active US (mean (SD) 5.71 (2.67), n=78) compared to patients with normal US (3.27 (1.77), n=55; difference (95% CI) -2.45 (-3.26, -1.63), t=-5.93, p<0.001). This difference remained significant in patients with no swollen joints (difference (95% CI) -0.71 (-1.40, -0.02), t=-2.06, p=0.044).

Effect size was greater for the LAMDA (0.37) than the BILAG-MSK (0.31), SLEDAI-MSK (0.27) and total US score (0.33). In patients with active US at baseline, LAMDA’s effect size was 0.42.

The MCID was 0.71 and correlated with patient-reported change in pain. A threshold for minimal disease activity of 3.23 optimized sensitivity (0.77 (0.65, 0.89)) and specificity (0.80 (0.68, 0.92)) against US score >0.

Conclusion:

The LAMDA score is a novel continuous disease activity instrument for MSK manifestations of SLE derived from variables familiar to rheumatologists. The LAMDA score is sensitive to imaging detected synovitis without swelling and more responsive than other instruments. . LAMDA may improve the ability of clinicians to accurately determine therapeutic efficacy in clinical trials and practice. Future work will validate the LAMDA score in independent cohorts and randomized trials.

Acknowledgements:

This project was funded by Lupus UK

Disclosure of Interests:

Khaled Mahmoud: None declared, Ahmed Zayat: None declared, Md Yuzaiful Md Yusof: None declared, Coziana Ciurtin Grant/research support from: Pfizer, Consultant of: Roche, Modern Biosciences, Chee-Seng Yee: None declared, David Isenberg Consultant of: Study Investigator and Consultant to Genentech, Lee-Suan Teh: None declared, Katherine Dutton: None declared, David d’cruz Grant/research support from: GlaxoSmithKline, Nora Ng: None declared, Philip G Conaghan Consultant of: AbbVie, BMS, Eli Lilly, EMD Serono, Flexion Therapeutics, Galapagos, GSK, Novartis, Pfizer, Speakers bureau: AbbVie, Eli Lilly, Novartis, Pfizer, Paul Emery Grant/research support from: AbbVie, Bristol-Myers Squibb, Merck Sharp & Dohme, Pfizer, Roche (all paid to employer), Consultant of: AbbVie (consultant, clinical trials, advisor), Bristol-Myers Squibb (consultant, clinical trials, advisor), Lilly (clinical trials, advisor), Merck Sharp & Dohme (consultant, clinical trials, advisor), Novartis (consultant, clinical trials, advisor), Pfizer (consultant, clinical trials, advisor), Roche (consultant, clinical trials, advisor), Samsung (clinical trials, advisor), Sandoz (clinical trials, advisor), UCB (consultant, clinical trials, advisor), Christopher Edwards Grant/research support from: Abbvie, Biogen, Roche, Consultant of: Abbvie, Samsung, Speakers bureau: Abbvie, BMS, Biogen, Celgene, Fresenius, Gilead, Janssen, Lilly, Mundipharma, Pfizer, MSD, Novartis, Roche, Samsung, Sanofi, UCB, Elizabeth Hensor: None declared, Edward Vital Grant/research support from: AstraZeneca, Roche/Genentech, and Sandoz, Consultant of: AstraZeneca, GSK, Roche/Genentech, and Sandoz, Speakers bureau: Becton Dickinson and GSK

Phenotype, genotype and glycaemic variability in people with activating mutations in the ABCC8 gene: response to appropriate therapy

AIMS

To examine the phenotypic features of people identified with ABCC8-maturity-onset diabetes of the young (MODY) who were included in the adult 'Mater MODY' cohort and to establish their response to sulfonylurea therapy.

METHODS

Ten participants with activating ABCC8 mutations were phenotyped in detail. A 2-hour oral glucose tolerance test was performed to establish glycaemic tolerance, with glucose, insulin and C-peptide measurements taken at baseline and 30-min intervals. Insulin was discontinued and sulfonylurea therapy initiated after genetic diagnosis of ABCC8-MODY. A blinded continuous glucose monitoring sensor was used to establish glycaemic control on insulin vs a sulfonylurea.

RESULTS

The mean age at diagnosis of diabetes was 33.8 ± 11.1 years, with fasting glucose of 18.9 ± 11.5 mmol/l and a mean (range) HbA_1c of 86 (51,126) mmol/mol [10.0 (6.8,13.7)%]. Following a genetic diagnosis of ABCC8-MODY three out of four participants discontinued insulin (mean duration 10.6 ± 1.69 years) and started sulfonylurea treatment. The mean (range) HbA_1c prior to genetic diagnosis was 52 (43,74) mmol/mol (6.9%) and the post-treatment change was 44 (30,57) mmol/mol (6.2%; P=0.16). Retinopathy was the most common microvascular complication in this cohort, occurring in five out of 10 participants.

CONCLUSIONS

Low-dose sulfonylurea therapy resulted in stable glycaemic control and the elimination of hypoglycaemic episodes attributable to insulin therapy. The use of appropriate therapy at the early stages of diabetes may decrease the incidence of complications and reduce the risks of hypoglycaemia associated with insulin therapy.

Sagittal alignment of the cemented femoral component in revision total knee arthroplasty influences the anterior and posterior condylar offset: Stem length does not affect these variables

BACKGROUND

The position of the femoral component can influence knee kinematics by altering the posterior (PCO) and anterior condylar offset (ACO). The primary aim of this study was to assess whether the length of the cemented stem influences the sagittal position of the femoral component after revision total knee arthroplasty (rTKA). The secondary aim was to determine the influence of the sagittal position on PCO and ACO.

METHODS

There were 172 consecutive patients over a seven-year period that underwent rTKA with a cemented semi-constrained prosthesis. The 172 patients were separated into two groups: 115 with short stems (50 mm) and 57 with longer stems (100 or 150 mm). Using rotationally acceptable lateral radiographs, the degree of flexion(+)/extension(-) of the femoral components, PCO, and ACO were measured.

RESULTS

There was no significant difference (p > 0.25) between the two groups for sagittal position, PCO, or ACO. The average flexion of the femoral component with short stems was 2.2 ± 4.1° and 2.2 ± 3.4° for long stems (difference = 0.0, 95% confidence intervals (CI) -1.3 to 1.2). The average PCO ratio was 1.02 ± 0.15 for short stems and 0.99 ± 0.17 for long stems (difference = 0.03, 95% CI -0.02 to 0.08). The average ACO ratio was at 0.07 ± 0.08 for short stems and 0.08 ± 0.08 for long stems (difference = 0.01, 95% CI -0.01 to 0.04). There was a significant correlation between sagittal alignment of the femoral component and PCO (flexion increased PCO, r = 0.39, p < 0.0001) and ACO (flexion decreased ACO, r = -0.34, p < 0.0001).

CONCLUSIONS

Cemented stem length does not influence the position of femoral component in the sagittal axis, PCO, or ACO. Surgical technique and sizing of the femoral component may be more predictive.

What determines gender inequalities in social capital in Ukraine?

Background

Social capital is a social determinant of health that has an impact on equity and well-being. It may be unequally distributed among any population. The aims of this study are to investigate the distribution of different forms of social capital between men and women in Ukraine and analyse how potential gender inequalities in social capital might be explained and understood in the Ukrainian context.

Method

The national representative cross-sectional data from the European Social Survey (wave 6) was used with a sample of 1377 women and 797 men. Seven outcomes that represent cognitive and structural social capital were constructed i.e. institutional trust, generalised trust, reciprocity, safety, as well as bonding, bridging and linking forms. Multivariate logistic regression and post-regression Fairlies decompositions were used for the analyses.

Results

There are several findings that resulted from the analyses i), access to institutional trust, linking and bridging social capital is very limited; ii), the odds for almost all forms of social capital (besides safety) are lower for men; iii), feeling about income and age explain most of the gender differences and act positively, as well as offsetting the differences.

Conclusion

Social capital is unequally distributed between different population groups. Some forms of social capital have a stronger buffering effect on women than on men in Ukraine. Reducing gender and income inequalities would probably influence the distribution of social capital within the society.

•

There is a limited access to institutional trust, linking and bridging social capital.

•

The odds for almost all forms of social capital are lower for men (besides safety).

•

Feeling about income and age explain most of the gender differences.

•

Feeling about income and age offset most of the gender differences.

Differentiating mouse embryonic stem cells express markers of human endometrium

BACKGROUND

Modeling early endometrial differentiation is a crucial step towards understanding the divergent pathways between normal and ectopic endometrial development as seen in endometriosis.

METHODS

To investigate these pathways, mouse embryonic stem cells (mESCs) and embryoid bodies (EBs) were differentiated in standard EB medium (EBM). Immunofluorescence (IF) staining and reverse-transcription polymerase chain reaction (RT-PCR) were used to detect expression of human endometrial cell markers on differentiating cells, which were sorted into distinct populations using fluorescence-activated cell sorting (FACS).

RESULTS

A subpopulation (50%) of early differentiating mESCs expressed both glandular (CD9) and stromal (CD13) markers of human endometrium, suggestive of a novel endometrial precursor cell population. We further isolated a small population of endometrial mesenchymal stem cells, CD45-/CD146+/PDGFR-β+, from differentiating EBs, representing 0.7% of total cells. Finally, quantitative PCR demonstrated significantly amplified expression of transcription factors Hoxa10 and Foxa2 in CD13+ EBs isolated by FACS (p = 0.03).

CONCLUSIONS

These findings demonstrate that mESCs have the capacity to express human endometrial cell markers and demonstrate potential differentiation pathways of endometrial precursor and mesenchymal stem cells, providing an in vitro system to model early endometrial tissue development. This model represents a key step in elucidating the mechanisms of ectopic endometrial tissue growth. Such a system could enable the development of strategies to prevent endometriosis and identify approaches for non-invasive monitoring of disease progression.

Prevalence of older people with intellectual disability in Sweden: a spatial epidemiological analysis

BACKGROUND

The expected increase in longevity of individuals with intellectual disabilities (ID) in many countries of the world is a direct result of medical and social advances, which have also extended the longevity of the general population. It is important to assess the need for social services for people with ID across different administrative levels to ensure sufficient resources are allocated to where they are most needed. This study estimates the annual prevalence of older people with ID from 2004 to 2012 and in different counties and municipalities in Sweden, by sex and age group; identifies proxy indicators related to the care of older people with ID in different counties in 2012 in Sweden and analyses the spatial distribution and clustering of municipalities with a high prevalence of older people with ID.

METHODS

Individuals with ID were identified through the national register based on the Swedish Act concerning Support and Service for Persons with Certain Functional Impairments (the LSS act) and the national death register. This study focuses on older individuals aged 55+ during the period of 2004-2012. The estimated prevalence was calculated at the county and municipality level and plotted on a municipality-level map. Moran's I statistics was used to identify any spatial clustering of municipalities with a large number of individuals with ID.

RESULTS

The prevalence of ID among older individuals aged 55+ in Sweden increased from 2004 to 2012. The prevalence was consistently higher among men, and the gender gap increased slightly in recent years. Age-specific prevalence estimates showed ID to be higher in younger age groups, and the gender gap decreased in older age groups. The prevalence was higher in northern counties in Sweden (over 500 individuals per 100 000 population aged 55+). Higher prevalence areas were clustered in northern municipalities, whereas municipalities with high prevalence of older individuals with ID in the middle and southern regions of Sweden demonstrated a more widespread distribution.

CONCLUSIONS

The existence of clusters of counties with a high prevalence of older individuals with ID necessitates further assessment of how resources have been allocated to different counties and municipalities in Sweden. Investigations of the quality of social services provided to individuals with ID across different counties in Sweden are warranted. It is important to ensure that high quality supports are being provided to older individuals with ID in order to grant them the same right to healthy ageing as their counterparts living without ID throughout their life course.

An experimental implementation of oblivious transfer in the noisy storage model

Cryptography's importance in our everyday lives continues to grow in our increasingly digital world. Oblivious transfer has long been a fundamental and important cryptographic primitive, as it is known that general two-party cryptographic tasks can be built from this basic building block. Here we show the experimental implementation of a 1-2 random oblivious transfer protocol by performing measurements on polarization-entangled photon pairs in a modified entangled quantum key distribution system, followed by all of the necessary classical postprocessing including one-way error correction. We successfully exchange a 1,366 bit random oblivious transfer string in ~3 min and include a full security analysis under the noisy storage model, accounting for all experimental error rates and finite size effects. This demonstrates the feasibility of using today's quantum technologies to implement secure two-party protocols.

Ultrasound-guided synovial biopsy: a safe, well-tolerated and reliable technique for obtaining high-quality synovial tissue from both large and small joints in early arthritis patients

OBJECTIVE

To determine the tolerability, safety and yield of synovial tissue in an early arthritis cohort using a minimally invasive, ultrasound (US)-guided, synovial biopsy technique in small, medium and large joints.

METHODS

93 sequential biopsy procedures were assessed from a total of 57 patients (baseline and 36 repeat biopsies at 6 months) recruited as part of the 'Pathobiology of Early Arthritis Cohort' study. Patients completed a tolerability questionnaire prior to and following the synovial biopsy procedure. The synovial biopsy was performed under US guidance with US images of the joint recorded prior to each procedure. Synovial tissue was harvested for immunohistochemistry and RNA extraction.

RESULTS

Five different joint sites were biopsied (knee, elbow, wrist, metacarpal phalangeal and proximal interphalangeal). No significant complications were reported following the procedure. No difference in pain, swelling and stiffness of the biopsied joint from before and after the procedure was demonstrated. A median of 14 biopsy samples was retrieved from each procedure with 93% of biopsy procedures yielding good quality tissue. RNA yield was good in all joints and in repeat biopsies. Multivariant analysis demonstrated a significantly greater yield of RNA and graded tissue in relation to a high prebiopsy, grey-scale synovitis score (0-3, semiquantitative).

CONCLUSIONS

A minimally invasive approach to synovial tissue harvesting, using US guidance, is both safe and well-tolerated by patients. Tissue quality/RNA yield is preserved in subsequent biopsies following therapeutic intervention. A high US grey-scale synovitis score is a predictor of good quality/quantity of tissue and RNA.

Manipulating ferroelectric domains in nanostructures under electron beams

Freestanding BaTiO3 nanodots exhibit domain structures characterized by distinct quadrants of ferroelastic 90° domains in transmission electron microscopy (TEM) observations. These differ significantly from flux-closure domain patterns in the same systems imaged by piezoresponse force microscopy. Based upon a series of phase field simulations of BaTiO3 nanodots, we suggest that the TEM patterns result from a radial electric field arising from electron beam charging of the nanodot. For sufficiently large charging, this converts flux-closure domain patterns to quadrant patterns with radial net polarizations. Not only does this explain the puzzling patterns that have been observed in TEM studies of ferroelectric nanodots, but also suggests how to manipulate ferroelectric domain patterns via electron beams.

Non-specific sex-differential effect of DTP vaccination may partially explain the excess girl child mortality in Ballabgarh, India

OBJECTIVE

To test the hypothesis that a gender differential exists in the effect on child mortality of BCG, DTP, measles vaccine as administered under programme conditions in Ballabgarh HDSS area.

METHODS

All live births in 28 villages of Ballabgarh block in North India from 2006 to 2011 were followed until 31 December 2011 or 36 months of age whichever was earlier. The period of analysis was divided into four time periods based on eligibility for vaccines under the national immunisation schedule (BCG for tuberculosis, primary and booster doses of diphtheria-tetanus-pertussis and measles). Cox proportional hazards regression was used to assess the association between sex and risk of mortality by vaccination status using age as the timescale in survival analysis and adjusting for wealth index, access to health care, the presence of a health facility in the village, parental education, type of family, birth order of the child and year of birth.

RESULTS

702 deaths (332 boys and 370 girls) occurred among 12,142 children in the cohort in the 3 years of follow-up giving a cumulative mortality rate of 57.5 per 1000 live births with 35% excess girl child mortality. Age at vaccination for the four vaccines did not differ by sex. There was significant excess mortality among girls after immunisation with DTP, for both primary (HR 1.65; 95% CI:1.17-2.32) and DTPb (2.21; 1.24-3.93) vaccinations. No significant excess morality among girls was noted after exposure to BCG 1.06 (0.67-1.67) or measles 1.34 (0.85-2.12) vaccine.

CONCLUSION

This study supports the contention that DTP vaccination is partially responsible for higher mortality among girls in this study population.