Scintillation light detection in the 6-m drift-length ProtoDUNE Dual Phase liquid argon TPC

DUNE is a dual-site experiment for long-baseline neutrino oscillation studies, neutrino astrophysics and nucleon decay searches. ProtoDUNE Dual Phase (DP) is a 6  ×  6  ×  6 m 3 liquid argon time-projection-chamber (LArTPC) that recorded cosmic-muon data at the CERN Neutrino Platform in 2019-2020 as a prototype of the DUNE Far Detector. Charged particles propagating through the LArTPC produce ionization and scintillation light. The scintillation light signal in these detectors can provide the trigger for non-beam events. In addition, it adds precise timing capabilities and improves the calorimetry measurements. In ProtoDUNE-DP, scintillation and electroluminescence light produced by cosmic muons in the LArTPC is collected by photomultiplier tubes placed up to 7 m away from the ionizing track. In this paper, the ProtoDUNE-DP photon detection system performance is evaluated with a particular focus on the different wavelength shifters, such as PEN and TPB, and the use of Xe-doped LAr, considering its future use in giant LArTPCs. The scintillation light production and propagation processes are analyzed and a comparison of simulation to data is performed, improving understanding of the liquid argon properties.

POS0543 MACHINE LEARNING PREDICTS RESPONSE TO METHOTREXATE IN RHEUMATOID ARTHRITIS: RESULTS ON THE ESPOIR, t-REACH AND LEIDEN COHORTS

Background

Methotrexate (MTX) is the first line of treatment for rheumatoid arthritis (RA) patients. Unfortunately, 30% to 40% of RA patients do not respond to MTX, resulting in uncontrolled joint pain and potential joints destruction. At the same time, many efficient second-line treatments exist and can be given to the inadequate responder patients. Predicting patient response to MTX before prescribing the treatment is therefore a major goal and could enable physicians to directly prescribe second-line treatments if inadequate response to MTX is predicted.

Objectives

We aimed to build machine learning models based on simple clinical and biological data to predict patient response to MTX.

Methods

We used data from the ESPOIR early arthritis (1) and Leiden cohorts (2) to train the models, and the tREACH cohort to validate the results. We included patients that fulfilled the EULAR/ACR 2010 criteria and that were treated with MTX in monotherapy as their first treatment for RA. The models take as inputs patient’s characteristics at treatment initiation and predict the therapeutic response, defined as the EULAR response 3 to 12 months after treatment initiation. We evaluated four missing data imputation methods (median, mean, MICE, KNN); we used the backward feature selection algorithm to select the most relevant variables; and compared the performances of four models (Linear Regression, Random Forest, XGBoost, and Catboost) on the training set by cross-validated them using the Area Under the ROC Curve (AUCROC). The best model was then evaluated on the validation dataset.

Results

We included 435 patients from the ESPOIR cohort, 243 patients from the Leiden cohort and 143 patients from the t-REACH cohort. Results of the model are displayed in Table 1. The variables automatically selected to perform prediction were Sex, DAS28, White blood cells, AST, ALT and lymphocytes. Our model performs well on unseen data, this result comes from the fact that we included two different cohorts in our training set which reduces the overfitting of our model and helps him generalize.

Table 1.

Sensitivity, Specificity, PPV and NPV are computed on the T-REACH validation cohort for each strategy

AUC(ESPOIR, LEIDEN)AUC(T-REACH)STRATEGY 1 (High confidence in responders)STRATEGY 2 (high confidence in non-responDeRS)SensitivitYSpecificityPPVNPVSensitivitySpecificityPPVNPV0.720.7320%98%95%40%91%33%71%68%(0.70-0.73)(0.64-0.81)(12%-28%)(83%-100%)(82%-100%)(32%-49%)(85%-97%)(20%-47%)(63%-79%)(48%-86%)

Our model predicts a probability for a patient to respond to MTX. This probability is compared to a decision threshold to obtain the final binary outcome. Two decision thresholds were tested. The first prioritizes a high confidence when identifying responders (Strategy 1) while the second prioritizes a high confidence when identifying non-responders (Strategy 2). This second strategy would enable physicians to identify highly probable inadequate responders to methotrexate and propose them directly a targeted DMARD such as TNF inhibitors, while still treating more than 70% of patients with MTX as first-line treatment.

Conclusion

The machine learning models developed in this study can predict RA patients’ response to methotrexate with a good accuracy exclusively using data available in clinical routine. It paves the way for personalized therapeutic strategies in rheumatoid arthritis.

References

[1]Combe B, Benessiano J, Berenbaum F, Cantagrel A, Daurès J-P, Dougados M, et al. The ESPOIR cohort: A ten-year follow-up of early arthritis in France. Joint Bone Spine 2007;74:440–445.

[2]van Aken, J., van Bilsen, J. H., Allaart, C. F., Huizinga, T. W., & Breedveld, F. C. The Leiden Early Arthritis Clinic. Clinical and experimental rheumatology, 21(5 Suppl 31), S100–S105.

Disclosure of Interests

None declared.

POS1408 AN ULTRASOUND NEGATIVE FOR SUBCLINICAL SYNOVITIS IN PATIENTS WITH ARTHRALGIA: IS IT HELPFUL IN IDENTIFYING THOSE WHO WILL NOT DEVELOP INFLAMMATORY ARTHRITIS? A LONGITUDINAL STUDY IN FOUR ARTHRALGIA COHORTS

Background

Ultrasound (US) has become an established method in the evaluation of joints and is often used in clinical practice to guide management decisions in arthralgia-patients. To date, studies on the prognostic value of MSUS in arthralgia focused on the positive predictive value of subclinical inflammation. However, also the absence of imaging-detected subclinical synovitis is now increasingly used in daily practice to exclude arthralgia-patients from further follow-up. Though, evidence on the value of a negative US in ruling out future IA development in arthralgia-patients (the negative predictive value) is mostly absent. According to the rules of Bayes, predictive values are highly dependent on the prior-risk of developing the disease. The NPV therefore, is strongly related to the prior-risk of not getting IA, which is quite considerable in arthralgia-patients.

Objectives

To investigate the negative predictive value (NPV) of musculoskeletal ultrasound (MSUS) in arthralgia patients at risk for developing inflammatory arthritis (IA).

Methods

An MSUS examination of hands and feet was performed in arthralgia-patients at risk for IA in four independent cohorts. Patients were followed for one-year on the development of IA. Subclinical synovitis was defined as greyscale≥2 and/or power Doppler≥1. NPVs were determined and compared with the prior risks of not developing IA. Outcomes were pooled using meta-analyses and meta-regression analyses. In sensitivity analyses, MSUS-imaging of tender joints only (rather than the full US-protocol) was analyzed and ACPA-stratification applied, the latter being in line with the use of US in daily care.

Results

After one-year 78%, 82%, 77% and 72% of patients in the four cohorts did not develop IA. The NPV of a negative US was 86%, 85%, 82% and 90%, respectively. The meta-analysis showed a pooled non-IA prevalence of 79%(95%CI: 75%-83%) and a pooled NPV of 86%(95%CI:81-89%) (Figure 1). Imaging tender joints only (as generally done in clinical practice) and ACPA-stratification showed similar results.

Figure 1.

Full US protocol; Prior risks of not developing IA (A) and negative predictive values of MSUS (B) in the four cohorts. For comparison, the pooled prior risk and confidence interval from A are depicted in the red column in B.

Conclusion

A negative US result in arthralgia has a high NPV for not developing IA, which is mainly due to the high a-priori risk of not developing IA. The added value of a negative US (<10% increase) was limited.

References

N.A.

Disclosure of Interests

Cleo Rogier: None declared, Giulia Frazzei: None declared, Marion Kortekaas: None declared, Marloes Verstappen: None declared, Sarah Ohrndorf: None declared, Elise van Mulligen: None declared, Ronald van Vollenhoven Speakers bureau: Speaker, for which institutional and/or personal honoraria were received: AbbVie, Galapagos, GSK, Janssen, Pfizer, UCB, Consultant of: Consultancy, for which institutional and/or personal honoraria were received: AbbVie, AstraZeneca, Biogen, Biotest, BMS, Galapagos, Gilead, Janssen, Pfizer, Sanofi, Servier, UCB, Vielabio, Grant/research support from:

Research Support (institutional grants): BMS, GSK, Lilly, UCB

Support for Educational programs (institutional grants): Pfizer, Roche

, Dirkjan van Schaardenburg: None declared, Pascal de Jong: None declared, Annette van der Helm-van Mil: None declared

POS0669 TAPERING SUBCUTANEOUS METHOTREXATE CAUSES MORE DISEASE FLARES COMPARED TO ORAL ADMINISTRATION IN ESTABLISHED RHEUMATOID ARTHRITIS PATIENTS

Background

Thanks to improved treatment strategies, disease remission in rheumatoid arthritis(RA) patients has become more common. Therefore, current guidelines recommend to consider tapering DMARDs, including methotrexate(MTX), in patients who are in sustained remission. Previous research has shown that subcutaneous methotrexate(MTXsc) has a better bioavailability, efficacy and tolerability in active RA than oral MTX[1]. However, these advantages might be a disadvantage when tapering of MTXsc is considered.

Objectives

To compare the 1-year cumulative flare rates between established RA patients who taper subcutaneous and oral MTX.

Methods

Data from the TApering strategies in Rheumatoid Arthritis(TARA) trial were used[2]. In this trial, established RA patients with a well-controlled disease, defined as Disease Activity Score(DAS)≤2.4 and swollen joint count(SJC)≤1, using ≥1 csDMARD and TNF-inhibitor(TNFi) were included. Participants were randomized into two groups which gradually tapered their csDMARD first followed by the TNFi, or vice versa. The csDMARD was tapered by reducing the dosage by a half at baseline, by a quarter at 3 months and was stopped at 6 months. Patients who tapered MTX were included in this analysis. If a disease flare(DAS>2.4 or SJC>1) occurred, the last effective therapy was restarted and intensified every 3 months, until DAS≤2.4 and SJC≤1.

Following an intention-to-treat principle, flare rates were compared between patients who tapered subcutaneous and oral MTX, using a chi-square test. Two sensitivity analyses were performed were we 1) only included patients with a complete follow-up; and 2) assumed that patients developed a flare at the moment of drop-out.

Results

A total of 71 and 17 patients respectively used oral and subcutaneous MTX. The median disease duration was 5.9 years and 70% was female. The median MTX dosage for both administration routes was 20 milligrams per week.

After 12 months, 53% of patients who tapered MTXsc developed a flare compared to 27% who tapered oral MTX (OR 3.1(1.0-9.1, 95%CI), p=0.037)(Figure 1). Respectively 68% and 67% of the patients who developed a flare and were using oral and subcutaneous MTX had a well-controlled disease 3 months after restarting their treatment(p=0.93). Both sensitivity analyses showed similar results.

Figure 1.

Flare development and resolution over time for different administration routes of methotrexate.

The first part on the X-axis illustrates the cumulative % of patients that develop a disease flare during follow up, the second part illustrates the cumulative % of patients that still has active disease (DAS>2.4 +/ SJC44>1) from point of flare development and after restarting the last effective treatment.

Abbreviations: DAS, Disease Activity Score; MTX, methotrexate; SJC44, swollen joint count measured in 44 joints.

Conclusion

Patients who tapered MTXsc have a higher chance at developing a disease flare compared to those who tapered oral MTX. This could be explained by a higher efficacy of MTXsc when similar dosages are used[1]. Alternatively, the better tolerability of MTXsc, especially regarding gastro-intestinal side effects[1], may lead to a difference in adherence.

When deciding to taper MTX, the administration route should be taken into account. Because of the increased risk of flare after tapering MTXsc, these patients could be monitored more closely than those tapering oral MTX.

References

[1]Li D, Yang Z, Kang P, Xie X. Subcutaneous administration of methotrexate at high doses makes a better performance in the treatment of rheumatoid arthritis compared with oral administration of methotrexate: A systematic review and meta-analysis. Semin Arthritis Rheum. 2016 Jun; 45(6):656-662.

[2]van Mulligen E, de Jong PHP, Kuijper TM, van der Ven M, Appels C, Bijkerk C, et al. Gradual tapering TNF inhibitors versus conventional synthetic DMARDs after achieving controlled disease in patients with rheumatoid arthritis: first-year results of the randomised controlled TARA study. Ann Rheum Dis. 2019 Jun; 78(6):746-753.

Disclosure of Interests

None declared

POS0501 SEQUENTIAL ULTRASOUND IN ARTHRALGIA PATIENTS AT RISK FOR INFLAMMATORY ARTHRITIS; IS IT HELPFUL FOR RISK STRATIFICATION IN DAILY PRACTICE?

Background

Musculoskeletal Ultrasound (MSUS) is often used to assess the presence of subclinical joint inflammation in patients presenting with arthralgia suspicious for progression to inflammatory arthritis (IA). Even though evidence-based guidelines for these patients are still absent, presence or absence of subclinical joint inflammation often influences management decisions in daily clinical practice. Studies so far focused on MSUS results at presentation with arthralgia. However, it is unknown if and how MSUS results change over time, and whether repeating MSUS is helpful in demonstrating or ruling out impending RA with greater certainty.

Objectives

To investigate whether sequential imaging at 4-months, in addition to baseline evaluation, is helpful in the risk stratification of arthralgia-patients.

Methods

Arthralgia-patients suspicious for progression to IA were included in the Rotterdam clinically suspect arthralgia cohort. At baseline and at 4-months a bilateral MSUS-examination was performed of the joints and tendons in both hands and feet. Subclinical inflammation was defined as GS>1 and/or PD>0, this was scored according to the latest OMERACT- guidelines.(1, 2) Based on a large US study carried out in a symptom-free population, the cut-off value in MTP 2-3 was considered present if GS ≥3 and/or PD ≥1.(3) Patients were followed for one-year on development of IA, identified with joint examination by experienced rheumatologists. The value of MSUS was studied separately for patients with and without subclinical joint inflammation at baseline. In a sensitivity analysis, ACPA-stratification was applied.

Results

A total of 52 consecutive patients were studied; 29% developed IA after one year. At baseline, 25 patients had subclinical inflammation and 27 patients did not have subclinical inflammation. In these groups respectively 28% and 7% developed IA before the 4-month-visit and therefore did not have repeated MSUS (Figure 1 A/B). In the patients with a positive MSUS at baseline, 28% had a negative MSUS at four months, all these patients did not progress to IA, irrespective of tender joints count(Figure 1A). In the group of patients with a negative MSUS at baseline, 26% achieved a positive MSUS at 4-months. All patients with a negative MSUS at baseline and no tender joints at 4-months did not progress to IA, regardless of the MSUS results. Patients with a negative MSUS at baseline and tender joints at 4-months developed IA infrequently, without relevant differences between those that did or did not develop a positive MSUS at 4-monthts. Overall, only a minority of patients whose MSUS progressed from negative to positive indeed developed IA, whereas this repeated MSUS was falsely positive in most cases(Figure 1B). Despite the small numbers, ACPA-stratification was performed, this showed a similar trend.

Figure 1.

Sequential ultrasound at baseline and after 4-months of follow-up in arthralgia-patients at risk for inflammatory arthritis with subclinical inflammation at baseline (A) and without subclinical inflammation at baseline(B).

Conclusion

Within arthralgia patients with a positive MSUS at baseline, a negative MSUS after 4-months may be an incentive to exclude arthralgia-patients from further follow-up. Within the patients with a negative MSUS at baseline, repeating MSUS may induce more false positive than correct positive results.

References

[1]D’Agostino MA, Terslev L, Aegerter P et al. Scoring ultrasound synovitis in rheumatoid arthritis: a EULAR-OMERACT ultrasound taskforce-Part 1: definition and development of a standardised, consensus-based scoring system. RMD Open. 2017;3(1):e000428.

[2]Naredo E, D’Agostino MA, Wakefield RJ et al. Reliability of a consensus-based ultrasound score for tenosynovitis in rheumatoid arthritis. Ann Rheum Dis. 2013;72(8):1328-34.

[3]Padovano I, Costantino F, Breban M et al. Prevalence of ultrasound synovial inflammatory findings in healthy subjects. Ann Rheum Dis. 2016;75(10):1819-23.

Disclosure of Interests

None declared.

OP0028 EARLY ACHIEVEMENT OF MINIMAL DISEASE ACTIVITY IN PSORIATIC ARTHRITIS IS ASSOCIATED WITH LONG-TERM IMPROVEMENTS IN QUALITY OF LIFE

Background

Minimal disease activity (MDA) is a treatment target in psoriatic arthritis (PsA) that takes both clinical manifestations (joints, skin and enthesis) and the patient perspective into account (1). In a previous study we have shown that achieving MDA in the first year is associated with better quality of life (QoL) regardless whether this was achieved early or late in the first year (2). However, the impact of achieving MDA within the first year on the long-term is lacking.

Objectives

To compare quality of life at 1, 2 and 3 years between PsA patients who achieve MDA in the first year and those who do not.

Methods

Newly diagnosed, DMARD naïve PsA patients with oligo- or polyarthritis and at least 3 years of follow-up, participating in the Dutch southwest Early PsA cohoRt (DEPAR) were included. In short the DEPAR is an observational cohort of newly diagnosed PsA (3). Study visits took place at 3, 6, 9, 12, 18, 24 and 36 months after diagnosis. Patients were categorized in three groups by achievement of MDA in the first year:

Sustained MDA, includes patients who were in MDA at both their 9- and 12-month visit;

Non-sustained MDA, includes patients who achieved MDA in the first year but did not sustain it at both 9- and 12-months;

No MDA, includes patients who did not achieve MDA in the first year.

To measure QoL at 1, 2 and 3 years the Short form-36 (SF-36) questionnaire was used. Descriptive statistics were used to compare QoL.

Results

We included 243 patients (51% male) of whom 113 (47%) were classified as sustained MDA, 64 (26%) as non-sustained MDA and 66 (27%) as no MDA. At baseline, patients had a mean age of 52.7 years and median symptom duration of 9.3 months. Patients in the no MDA group seemed to be older, were more often female and had a longer symptom duration (Table 1). QoL of sustained MDA patients was comparable to the general Dutch population (4) after 1, 2 and 3 years of follow-up. However, patients who did not achieve MDA in the first year had a lower QoL compared to the sustained MDA group and these differences persist in the years thereafter (Figure 1). The physical as well as the mental QoL domains were worse in the no MDA group compared to the other groups.

Table 1.

Baseline characteristics of patients categorized by MDA group

Sustained MDA (n=113)Non-sustained MDA (n=64)No MDA(n=66)Demographics Age (years)51.8 ± 1351.8 ± 1455.3 ± 13 Sex (male)69 (61)33 (52)21 (32) Symptom duration (months)8.5 (4-24)8.1 (3-28)12.9 (5-51)Disease activity Swollen joint count (66)3 (2-5)4 (1-6)4 (2-8) Tender joint count (68)3 (1-6)4 (2-8)8 (4-13) Psoriasis95 (84)58 (91)56 (85)   BSA in case of psoriasis (%)3 (2-4)3.3 (1-6.5)3 (1.5-6) Enthesitis29 (26)28 (44)38 (58)   LEI in case of enthesitis1 (1-2)2 (1-2)2 (1-4)HAQ0.38 (0.13-0.75)0.75 (0.5-1)1 (0.75-1.38)VAS global31 (15-56)46 (23-65)59 (50-77)VAS pain28 (12-52)50 (26-66)69 (53-80)

Results are shown as mean ± standard deviation, n (%) or median (interquartile range). BSA: Body Surface Area; LEI: Leeds Enthesitis Index; HAQ: Health Assessment Questionnaire; VAS: visual analogue scale.

Figure 1.

(A) 1 year, (B) 2 year and (C) 3 year quality of life scores, measured with the SF-36 domains, for MDA groups and compared with the general Dutch population norms (4), (D) percentage of patients who use biologicals over time per MDA group.

Over the years, treatment was intensified in all groups, with biologicals use after three years at 18%, 25% and 31% in the sustained MDA, non-sustained MDA and no MDA group, respectively.

Conclusion

Failure to achieve MDA in the first year after PsA diagnosis is associated with worse quality of life outcomes that persist over the years despite more intensified treatment.

References

[1]Coates LC et al. Ann Rheum Dis. 2010;69(1):48-53.

[2]Wervers et al. Arthritis Res Ther. 2019;21(1):25.

[3]Kasiem et al. Scand J Rheumatol. 2021;50(2):124-31.

[4]Aaronson et al. J Clin Epidemiol. 1998;51(11):1055-68.

Acknowledgements

This study was funded by UCB Pharma. UCB was involved in the development of the research question. UCB was not involved in the evaluation of the results or drafting of the abstract.

Disclosure of Interests

None declared.

Dynamic prediction of mortality in COVID-19 patients in the intensive care unit: A retrospective multi-center cohort study

Background

The COVID-19 pandemic continues to overwhelm intensive care units (ICUs) worldwide, and improved prediction of mortality among COVID-19 patients could assist decision making in the ICU setting. In this work, we report on the development and validation of a dynamic mortality model specifically for critically ill COVID-19 patients and discuss its potential utility in the ICU.

Methods

We collected electronic medical record (EMR) data from 3222 ICU admissions with a COVID-19 infection from 25 different ICUs in the Netherlands. We extracted daily observations of each patient and fitted both a linear (logistic regression) and non-linear (random forest) model to predict mortality within 24 h from the moment of prediction. Isotonic regression was used to re-calibrate the predictions of the fitted models. We evaluated the models in a leave-one-ICU-out (LOIO) cross-validation procedure.

Results

The logistic regression and random forest model yielded an area under the receiver operating characteristic curve of 0.87 [0.85; 0.88] and 0.86 [0.84; 0.88], respectively. The recalibrated model predictions showed a calibration intercept of −0.04 [−0.12; 0.04] and slope of 0.90 [0.85; 0.95] for logistic regression model and a calibration intercept of −0.19 [−0.27; −0.10] and slope of 0.89 [0.84; 0.94] for the random forest model.

Discussion

We presented a model for dynamic mortality prediction, specifically for critically ill COVID-19 patients, which predicts near-term mortality rather than in-ICU mortality. The potential clinical utility of dynamic mortality models such as benchmarking, improving resource allocation and informing family members, as well as the development of models with more causal structure, should be topics for future research.

POS1419 PREDICTIVE FACTORS FOR PULMONARY PROGRESSION IN PATIENTS WITH CONNECTIVE TISSUE DISEASE AND INTERSTITIAL LUNG DISEASE

Background:

Interstitial lung disease (ILD) is associated with decreased quality of life and higher mortality risk in patients with connective tissue disease (CTD). Outcome and treatment response to immunosuppressive therapies is unpredictable, and therefore the management of CTD-ILD can be challenging.

Objectives:

Our study aimed to identify clinical and imaging factors that are predictive for outcome in patients with CTD-ILD.

Methods:

We performed a retrospective cohort study in patients with CTD-ILD who were treated in our centre between 2004 and 2018. Clinical, biochemical data as well as pulmonary function test (PFT) and high-resolution computed tomography (HRCT) results were recorded. Two experienced chest radiologists independently and blindly reviewed the HRCT’s. When the two chest radiologists assessed the ILD pattern differently, a diagnosis was made by consultation of a third expert. The ILD patterns were classified as fibrotic or inflammatory. Overall survival and progressive fibrosing interstitial lung disease (PF-ILD, defined as a significant decline of PFT and HRCT) after two years of treatment were assessed using a Kaplan-Meier plot. Multivariable Cox regression was including for treatment, comorbidity, and age as variables. Factors with a p value < 0.2 in the univariate analysis were included in the multivariate analysis. The correlation between the variation of serum markers and PFT over-time was evaluated with Spearman’s Rho.

Results:

In total, 150 patients with CTD-ILD were included, of which 53 (35.3%) had systemic sclerosis, 19 (12.7%) Sjogren’s syndrome, 29 (19.3%) inflammatory myopathy, 24 (16%) rheumatoid arthritis, 5 (3.3%) systemic lupus erythematosus, 4 (2.7%) mixed connective tissue disease, and 16 (10.7%) undifferentiated connective tissue disease patients. Median disease duration of CTD was 14 months (IQR 2–73) in patients with CTD diagnosis before ILD onset. The median follow-up duration was 40 months (IQR 27.3–60.8). Thirty (20%) deaths occurred, in which the cause of death was a pulmonary infection in 6 (4%) patients and a respiratory failure due to ILD in 10 (6.7%) patients. PF-ILD occurred in 82 (54.7%) patients, which was associated with poor overall survival (HR 3.03, 95%CI 1.15–7.98) (Figure 1). Age, smoking, and steroid usage were associated with increased mortality risk as well (Table 1). There was no dose-related effect of smoking on mortality.

Figure 1.

The Kaplan-Meier plot for progressive fibrosing interstitial lung diseases (PF-ILD). PF-ILF was defined as pulmonary function decline or high-resolution computed tomography progression after two years of treatment.

Inflammatory patterns on baseline HRCT were correlated with a lower risk of FVC decline than fibrotic patterns (OR 0.24, 95%CI 0.09–0.64). The increase in CA15.3 level was associated with the decline in FVC (Rho -0.308, p=0.037). Besides, the elevation in CRP was associated with the reduction in FVC (Rho -0.302, p=0.006) and DLCO (Rho -0.268, p=0.019).

Conclusion:

Our study identified several factors associated with outcomes. Age, smoking, and steroid treatment increased the risk of mortality in patient with CTD-ILD. Inflammatory HRCT pattern at baseline revealed a better pulmonary outcome than a fibrotic pattern. The patients having PF-ILD after two years of treatment showed a higher mortality risk.

Table 1.

Multivariable Cox-regression for the clinical risk of mortality.

Clinical factorCrude HR (95%CI)PAdjusted HR (95%CI)pAge1.11 (1.06–1.15)1.7*10-61.12 (1.07–1.17)3.54*10-6Smoking1.64 (0.79–3.43)0.1872.53 (1.11–5.78)0.028Congestive heart failure1.86 (0.75–4.58)0.1791.17 (0.47–2.91)0.737MMF0.55 (0.23–1.35)0.1950.73 (0.29–1.85)0.512Steroid4.37 (1.67–11.45)0.0034.96 (1.84–13.40)0.002

MMF, mycophenolate mofetil; HR, hazard ratio.

Acknowledgements:

We want to thank Marieke Vianen for the support in data management, Lieke Wintermans and Lisa Hessels for collecting the clinical data.

Disclosure of Interests:

None declared

AB0812 BIOMARKERS FOR CONNECTIVE TISSUE DISEASE-ASSOCIATED INTERSTITIAL LUNG DISEASE: A PILOT STUDY

Background:

Connective tissue disease (CTD)-associated interstitial lung disease (ILD) has high morbidity and increased mortality risk. Biomarkers that can predict prognosis and response to therapy have been studied in recent years, including cytokines, chemokines, adhesion molecules, growth factors, extracellular remodelling molecules and pneumocyte associated proteins. However, there is still a knowledge gap for interpreting biomarkers in the context of imaging and response.

Objectives:

The aim of our study was to identify biomarkers that are associated with inflammatory and fibrotic changes over time on high-resolution computed tomography (HRCT) and response to treatment in CTD-ILD.

Methods:

An exploratory set of 38 biomarkers were measured in serum of patients with CTD-ILD using a multiplex immunoassay, chemiluminescence enzyme immunoassay and enzyme-linked immunosorbent assay. Samples were taken at baseline and one year of follow-up. Clinical data was extracted from electronic medical patients records. Two experienced chest radiologists independently and blindly reviewed the HRCTs. A third expert reviewed the scan in case of discrepancies. They classified ILD patterns according to the classification for idiopathic interstitial pneumonia and categorised into fibrotic or inflammatory. Association between biomarkers at baseline and pulmonary function test (PFT) and HRCT changes in response to treatment were analysed by logistic regression. Responsiveness of biomarkers to treatment was determined using the paired Wilcoxon sign rank test. Correlations between the variation of biomarkers and PFT after one year of treatment were examined using Spearman’s rank correlation coefficient.

Results:

Sixteen patients were included (12 females (75.0%), median age 51 years (IQR 45–62). Underlying CTDs were systemic sclerosis (n=5), Sjogren’s syndrome (n=1), inflammatory myopathies (n=6), rheumatoid arthritis (n=1), systemic lupus erythematosus (n=1), mixed connective tissue disease (n=1), and undifferentiated connective tissue disease (n=1). There were three patients with a fibrotic HRCT pattern and 13 patients with an inflammatory HRCT pattern.

Biomarkers attenuation in CXCL11, CTGF, and KL-6 were associated with inflammatory HRCT patterns as well as less HRCT progression and fewer FVC decline. Furthermore, a decrease in CTGF was observed in patients treated with MMF and corticoids, while a reduction in CXCL11 and SPD were seen in patients treated with hydroxychloroquine. (Table 1) Additionally, an increase in levels of galectin-3 at one-year follow-up was associated with improved predicted FVC (Rho 0.5, p=0.048). (Figure 1)

Table 1.

Biomarker responses to clinical treatment

TreatmentBiomarkersBaseline, Median (IQR)Follow up,Median (IQR)Variation percentagepMMFCTGF (pg/ml)110.69 (63.21–158.06)4.73 (4.73–45.3)-95.730.036(n=7)sVCAM (pg/ml)2061300 (1939200–3042250)1767600 (1707100–1986350)-14.250.031HCQCXCL11 (pg/ml)699.30 (392.50–764.50)333.39 (223.1–487.92)-52.330.031(n=6)SPD (ng/ml)18.70 (13.40–28.73)16.80 (11.70–22.80)-10.160.031SteroidCTGF (pg/ml)81.93 (20.80–158.06)12.76 (4.73–56.74)-84.430.044(n=11)MMP-7 (pg/ml)3146.3 (1779.7–3997.0)4563.3 (2951.9–7625.8)45.040.005

IQR, interquartile range; MMF, mycophenolate mofetil; HCQ, hydroxychloroquine; CTGF, connective tissue growth factor; sVCAM, soluble vascular cell adhesion molecule-1; SPD, surfactant protein D; MMP-7, matrix metalloproteinase 7.

Conclusion:

In this pilot study, CXCL11, CTGF, and KL-6 reduction were associated with inflammatory HRCT patterns and better pulmonary outcome. In contrast to previous research in severe ILD, there was a positive correlation between changes of Galectin-3 and FVC in our study. Further research in a larger group and focusing on combining biomarkers to predict outcome and prognosis are needed.

Figure 1.

Acknowledgements:

We want to thank the Utrecht Immunity and Infection cohort for providing the serum samples, Marieke Vianen for the support in data management and Annemieke Sloeserwij for her help in collecting the samples. We want to thank Henk Ruven from St. Antonius Hospital Utrecht for measuring Krebs von den Lungen 6, and surfactant protein D. We acknowledge Boehringer Ingelheim B.V. the Netherlands for providing financial support for this study.

Disclosure of Interests:

None declared

POS1418 REALIZING EARLY RECOGNITION OF ARTHRITIS IN TIMES OF INCREASED TELEMEDICINE: THE VALUE OF PATIENT-REPORTED SWOLLEN JOINTS

Background:

Early diagnosis and management of patients with inflammatory arthritis(IA) are critical to improve long-term patient-outcomes. Assessment of joint swelling at joint examination is the reference of IA-identification; early access clinics are constructed to promote this early recognition of IA. However, due to the COVID-19 pandemic the face-to-face capacity of such services is severely reduced. The accuracy of patient-reported swelling in comparison to joint examination has been extensively evaluated in established RA (ρ 0.31-0.67), but not in patients suspected for IA.[1]

Objectives:

To promote evidence based care in the era of telemedicine, we determined the accuracy of patient-reported joint swelling for actual presence of IA in persons suspected of IA by general practitioners(GP).

Methods:

Data from two Dutch Early Arthritis Recognition Clinics were studied. These are screening clinics (1.5-lines-setting) where GPs send patients in case of doubt on IA. At this clinic patients were asked to mark the presence of swollen joints on a mannequin with 52 joints. For this study the DIP joints and the metatarsal joints were excluded and, therefore, a total of 42 joints were assessed for self-reported joint swelling. Clinically apparent IA of ≥1 joint determined by the physician was the reference to calculate sensitivity, specificity, positive and negative likelihood ratios (LR+,LR-), and positive and negative predictive values (PPV, NPV) on patient-level. Pearson correlation coefficients(ρ) were determined. Predictive values depend on the prevalence of a disease in a population. Because the prevalence of IA in a 1.5-lines-setting will differ from a primary care setting, post-test probabilities of IA were estimated for two lower prior-test probabilities as example, namely 20% (estimated probability in patients GPs belief IA is likely) and 2% (prior-test probability with less preselection by GPs), using likelihood ratios and nomograms.

Results:

A total of 1637 consecutive patients were studied. Median symptom duration was 13 weeks. 76% of patients marked ≥1swollen joint at the mannequin. 41% of patients had ≥1swollen joint at examination by rheumatologists. ρ was 0.20(patient-level)-0.26(joint-level).

The sensitivity of patients-reported joint swelling was high, 87%, indicating that the majority of patients with IA had marked swelling on the mannequin. However the specificity was 31%, indicating that 69% of persons without IA had also done so. The LR+ was 1.25; the LR- 0.43. The PPV was 46%, the NPV 77%. Thus the PPV increased hardly (from 41% to 46%) and the NPV somewhat (from 59% to 77%). Also in settings with prior-test probabilities of 20% and 2%, estimated PPVs (from respectively 20% and 2% to 24% and 2%) and NPVs (from respectively 80% and 98% to 90% and 99%) hardly increased.

Conclusion:

Patient-reported joint swelling had little value in distinguishing patients with/without IA for different prior-test probabilities, and is less valuable in comparison to self-reported flare detection in established RA.

References:

[1]Barton JL, Criswell LA, Kaiser R, et al. Systematic review and metaanalysis of patient self-report versus trained assessor joint counts in rheumatoid arthritis. J Rheumatol 2009;36:2635-2641.

Disclosure of Interests:

None declared

AB0116 THE EFFECTS OF DISEASE MODIFYING ANTI-RHEUMATIC DRUGS ON PATIENT REPORTED OUTCOMES; PRELIMINARY RESULTS OF A SYSTEMATIC REVIEW AND NETWORK META-ANALYSIS

Background:

The need to involve patient reported outcomes (PROs) in the management of rheumatoid arthritis (RA) increases, since PROs quantify patient relevant outcomes. Although PROs have been incorporated in the core-outcome sets in clinical trials, knowledge about the treatment effects on these PROs is scarce. Therefore, we performed a systematic review on the effects of disease modifying anti-rheumatic drugs (DMARDs), of any type, on relevant PRO domains mentioned in the ICHOM standard set. This might support rheumatologists and RA patients during treatment decisions.

Objectives:

To get insight in the treatment effects of DMARDs of any type on three PRO domains that matter to patients (pain, activity limitations and fatigue).

Methods:

A systematic review was performed in Embase, Medline, Web of Science, Cochrane and Google Scholar. Included were all studies that were published before August 2019 and showed DMARD treatment effects in RA on PROs that are part of the ICHOM standard set. Three Bayesian network meta-analyses were performed for the PRO domains pain, activity limitations and fatigue. Preliminary results of DMARDs (in)directly compared to placebo were visualized by forest plots using R.

Results:

The search strategy yielded n=5974 articles. After selection was performed by 2 independent researchers, n=70 individual articles representing n=53 studies were extracted, over the three PRO domains; pain (n=31), activity limitations (n=41) and fatigue (n=21). In all RCTs, PROs were only reported as secondary or tertiary endpoints. In figure 1, we show the effects on PROs for any type of DMARD investigated compared to placebo. Overall, DMARDs show a greater reduction in pain (standardized mean difference (SMD); -0.97 – -0.22) and most of them in activity limitations (SMD; -0.81 – 0.56). In fatigue, this clear direction is lacking (SMD; -0.86 – 3.5). csDMARDs and anti-TNF seem to perform slightly, but nog significantly, worse than other bDMARDs and tsDMARDs in the first two domains.

Conclusion:

Within in this systematic review we report a reduction for DMARDs of any type on the domains of pain and activity limitations compared to placebo. However, results are still preliminary and should be interpreted with care. A more comprehensive network analysis might give a more definitive answer which DMARD performs best.

Figure 1.

Disclosure of Interests:

None declared

Recommendations for the diagnosis and management of vaccine-induced immune thrombotic thrombocytopenia

There have recently been safety concerns regarding an increased risk of vaccine-induced immune thrombotic thrombocytopenia (VITT) following administration of SARS-CoV-2 adenoviral vector vaccines. The Southern African Society of Thrombosis and Haemostasis reviewed the emerging literature on this idiosyncratic complication. A draft document was produced and revised by consensus agreement by a panel of professionals from various specialties. The recommendations were adjudicated by independent international experts to avoid local bias. We present concise, practical guidelines for the clinical management of VITT.

Prospects for beyond the Standard Model physics searches at the Deep Underground Neutrino Experiment: DUNE Collaboration

The Deep Underground Neutrino Experiment (DUNE) will be a powerful tool for a variety of physics topics. The high-intensity proton beams provide a large neutrino flux, sampled by a near detector system consisting of a combination of capable precision detectors, and by the massive far detector system located deep underground. This configuration sets up DUNE as a machine for discovery, as it enables opportunities not only to perform precision neutrino measurements that may uncover deviations from the present three-flavor mixing paradigm, but also to discover new particles and unveil new interactions and symmetries beyond those predicted in the Standard Model (SM). Of the many potential beyond the Standard Model (BSM) topics DUNE will probe, this paper presents a selection of studies quantifying DUNE's sensitivities to sterile neutrino mixing, heavy neutral leptons, non-standard interactions, CPT symmetry violation, Lorentz invariance violation, neutrino trident production, dark matter from both beam induced and cosmogenic sources, baryon number violation, and other new physics topics that complement those at high-energy colliders and significantly extend the present reach.

FRI0110 TAPERING TOWARDS DMARD-FREE REMISSION IN ESTABLISHED RHEUMATOID ARTHRITIS: 2 YEAR RESULTS OF THE TARA TRIAL

Background:

In rheumatoid arthritis (RA) disease outcomes have improved enormously in the last decades. Due to early initiation of therapy, a treat-to-target approach and a growing arsenal of disease-modifying antirheumatic drugs (DMARDs) and biologics, RA patients are in sustained remission more often. This raises the subsequent questions whether treatment should be continued, tapered or stopped. Although DMARD free remission (DFR) is nowadays achievable for increasing numbers of RA patients, the optimal tapering approach still needs to be defined.

Objectives:

To evaluate the 2-year clinical effectiveness of two gradual tapering strategies, namely tapering the csDMARD first followed by the TNF-inhibitor, or tapering the TNF-inhibitor first followed by the csDMARD.

Methods:

In this multicenter single-blinded randomised controlled trial RA patients with controlled disease for at least 3 consecutive months, defined as a DAS≤2.4 and a swollen joint count (SJC) ≤1, which was achieved with csDMARDs and a TNF-inhibitor were included. Eligible patients were randomised into gradual tapering csDMARDs followed by the TNF-inhibitor, or vice versa. Medication was tapered in three steps over the course of 6 months. After 12 months, the other DMARD was tapered. Gradual tapering was done by cutting the dosage into half, a quarter and thereafter it was stopped. In case of a flare (DAS44>2.4 or SJC>1) the previous effective dose was restarted and tapering was not initiated any further throughout the whole study period. The primary outcome for the clinical effectiveness was the number of patients with a disease flare, defined as DAS44>2.4 and/or SJC>1. Secondary outcomes were DFR, disease activity, quality of life and functional ability. Outcomes were calculated in an intention-to-treat analysis, using all available data.

Results:

A total of 189 patients were randomly assigned to tapering the csDMARD first or tapering the TNF-inhibitor first. The cumulative flare rate, after 24 months, for tapering the csDMARD first was 61% (95% CI, 50% - 69%) and for tapering the TNF-inhibitor first was 62% (95% CI, 50%-70%) (p=0.35)(figure 1). The cumulative flare rate differed the most between both groups between 12 and 18 months of follow-up (figure 1). Figure 2 shows an overview of how gradual tapering took place and which medication patients were using at different time points(figure 2). This was indicated for both tapering arms, and for the first and second year (figure 2). For the second year, tapering status was only indicated for the patients who actually tapered medication, so who stayed flare-free in the first year. Patients that tapered their csDMARD first were more often able to completely taper their csDMARD (n=30), and subsequently they also had a higher chance of reaching DFR(n=15) (table 1). However, mean DAS and mean HAQ over time and after 2 years did not differ between both tapering arms (table 1).

Table 1.

Baseline characteristics and results after 24 months.

Tapering csDMARD first (n=94)Tapering TNF-inhibitor first (n=95)Baseline (T0)Age (years), mean (sd)55.9 (14.1)57.2 (10.6)Gender, female, n(%)66 (71)58 (61)Symptom duration (years), median (IQR)6.0 (4.3-8.5)6.3 (4.1-8.9)ACPA positive, n(%)61 (72)65 (75)RF positive, n(%)49 (57)56 (64)2-year follow-up (T24)Cumulative flare, n(%)57 (61)59 (62)DMARD free remission, n(%)15 (16)8 (8)Tapered, n(%)30 (32)20 (21)DAS, mean (sd)1.39 (0.67)1.30 (0.70)ΔDAS (T24-T0), mean (sd)0.41 (0.55)0.33 (0.77)HAQ-DI, mean (sd)0.62 (0.53)0.52 (0.51)ΔHAQ-DI (T24-T0), mean (sd)0.074 (0.40)0.058 (0.31)

Conclusion:

The order in which tapering and stopping medication was performed was not superior to each other based on flare rates, DAS and HAQ. However, patients who tapered their csDMARD first could more often completely taper off their medication and, therefore, also reached DFR more often.

Disclosure of Interests:

None declared

SAT0126 BIOLOGICAL MANAGEMENT IN RHEUMATOID ARTHRITIS: RESULTS OF A REAL-WORLD COHORT FROM THE NETHERLANDS

Background:

Management of rheumatoid arthritis (RA) has improved dramatically due to early diagnosis, treat-to-target approaches based on disease activity measures, and the introduction of biological disease modifying anti-rheumatic drugs (bDMARDs). Tumor necrosis factor inhibitors (TNFis) are the most frequently prescribed bDMARDs after failure on conventional synthetic (cs)DMARDs. However, data on drug survival and predictors that influence the survival time are sparse. Moreover, drug survival could decrease with the number of bDMARDs that have been used.

Objectives:

To investigate drug survival for first and second line biologicals and factors that influence survival time.

Methods:

We used a retrospective observational cohort in which data were retrieved from the local pharmacy database and patient records of the Erasmus Medical Center in the Netherlands. We included patients who started with a TNF-inhibitor between 2000 and 2020 and were diagnosed with RA. Data on age, gender, disease duration, time to first biological, survival time, co-medication and reasons for discontinuation were collected.

Results:

Data were already derived from 216 RA patients (table 1). Of the included patients 28 (13%) started their first TNFi within 6 months after diagnosis, while 56 (26%) patients started their first TNFi two years after diagnosis. Median (95%) survival time of the first-line biological was 1.6 years (1-2), and for the second-line biological 0.8 years (0.5-0.9). Biological survival was significantly longer for the first-line biological compared to the second (p=0.0008) (Figure 1A). Discontinuation reasons for the first-line biological were ineffectiveness (38%), adverse events (13%), remission (18%), pregnancy (17%), patient preference (4%) or other reasons (10%). Discontinuation reasons for the second-line biological were ineffectiveness (51%), adverse events (17%), remission (7%), pregnancy (13%), patient preference (2%) or other reasons (10%)(table 1). Drug survival for the first-line biological was significantly longer when it was combined with a csDMARD (p=0.05) (Figure 1B). Furthermore, multivariable cox regression analyses showed a significant relation between first-line biological survival time and gender (p=0.005, hazard ratio 0.28 (95% CI 0.12-0.68)) and erosions (p=0.004, hazard ratio 0.37 (95% CI 0.19-0.73)) when discontinuation due to remission was omitted from the analysis. Within aforementioned analyses we corrected for ACPA, age of diagnosis, age at first biological, and BMI. The chance that patients stopped with their biological due to remission was negatively influenced by having erosions (p=0.02, hazard ratio 0.07 (95% CI 0.007-0.66)) and positively influenced by age at first biological (p=0.03, hazard ratio 1.4 (95% CI 1.03-1.94)) in a multivariable cox model in which we corrected for gender, ACPA, erosions, BMI, and age of diagnosis.

Table 1.

Characteristics of patient population

RA patients, n=216Age at diagnosis, mean (sd)37.5 (16)Age at first biologic, mean (sd)42.4 (16)Gender, female, n (%)194 (90)ACPA positive, n (%)157 (73)RF positive, n (%)158 (73)Erosive disease, n (%)85 (40)BMI, mean (sd)26.9 (6.7)Time to first biological, years, mean (sd)4.9 (5.7)Discontinuation reasons 1stbiological, n(%)Ineffective58 (38)Adverse event20 (13)Remission27 (18)Pregnancy26 (17)Patient preference6 (4)Other16 (10)Discontinuation reasons 2ndbiological, n(%)Ineffective42 (51)Adverse event14 (17)Remission6 (7)Pregnancy11 (13)Patient preference2 (2)Other8 (10)

Conclusion:

Median drug survival of the first biological is 1.6 years. Drug survival time is prolonged if patients are using co-medication and shortened in the presence of erosions. Furthermore, drug survival diminishes with the number of bDMARDs that are used.

References:

Disclosure of Interests:

None declared

FRI0598 DMARD-FREE REMISSION IN RHEUMATOID ARTHRITIS: AN ACHIEVABLE AND SUSTAINABLE OUTCOME? A SYSTEMATIC LITERATURE REVIEW

Background:

Current treatment guidelines for rheumatoid arthritis (RA) suggest tapering DMARDs.1Discontinuation of DMARD-treatment is of increasing interest, and DMARD-free remission (DFR) is regarded an important future outcome.2 3However, lack of knowledge on DFR prevalence, its sustainability, and the characteristics of patients achieving DFR currently hampers the use of DFR as primary outcome.

Objectives:

To increase the understanding of DFR in RA, and to support studies aiming to include this as primary outcome, we systematically reviewed the literature to determine prevalence and sustainability of DFR. Potential predictors of DFR were evaluated to increase insight in patient characteristics favourable for achieving this outcome.

Methods:

A systematic literature search was performed in March 2019 in multiple databases. All clinical trials and observational studies reporting on discontinuation of DMARDs in RA-patients in remission were included. Our quality assessment included a general assessment and assessment of the description of DFR. Prevalence of DFR and its sustainability, flares during tapering and after DMARD-stop were summarized. Also, potential predictors of achieving DFR were reviewed.

Results:

From 631 articles, 51 were included, comprising 14 clinical trials and 5 observational studies. DFR-definition differed, especially for the duration of DMARD-free state. Considering only high and moderate-quality studies, DFR was achieved in 5.0%-24.3%, and sustained DFR (duration>12 months) in 11.6%-19.4%. Flares occurred frequently during DMARD-tapering (41.8%-75.0%) and in the first year after achieving DFR (10.4%-11.8%), whilst late flares, >1 year after DMARD-stop, were infrequent (0.3%-3.5%). Many patient characteristics lacked association with DFR. Absence of auto-antibodies and shared epitope alleles increased the risk of achieving DFR.

Conclusion:

DFR is achievable in RA, and is sustainable in ~10%-20% of patients.1DFR can become an important outcome measure for clinical trials, and requires consistency in the definition. Considering the high rate of flares in the first year after DMARD-stop, a DMARD-free follow-up of >12 months is advisable to evaluate sustainability.

References:

[1] Smolen JS, Landewe R, Bijlsma Jea. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2016 update.Ann Rheum Dis2017;76(6):960-77. doi: annrheumdis-2016-210715 [pii];10.1136/annrheumdis-2016-210715 [doi]

[2] Ajeganova S, van Steenbergen HW, van Nies JA, et al. Disease-modifying antirheumatic drug-free sustained remission in rheumatoid arthritis: an increasingly achievable outcome with subsidence of disease symptoms.Ann Rheum Dis2016;75(5):867-73. doi: annrheumdis-2014-207080 [pii];10.1136/annrheumdis-2014-207080 [doi]

[3] Stamm TA, Machold KP, Aletaha D, et al. Induction of sustained remission in early inflammatory arthritis with the combination of infliximab plus methotrexate: the DINORA trial.Arthritis Res Ther2018;20(1):174. doi: 10.1186/s13075-018-1667-z [doi];10.1186/s13075-018-1667-z [pii]

Acknowledgments:

We would like to thank J. Schoones, librarian of Leiden University Medical Center, for constructing and carrying out the literature search.

Disclosure of Interests:

None declared

AB1127 IS SHOULDER INVOLVEMENT IN CLINICALLY SUSPECT ARTHRALGIA AN EARLY FEATURE OF RHEUMATOID ARTHRITIS? -A LONGITUDINAL ULTRASOUND STUDY

Background:

Multiple studies have demonstrated that shoulder complaints are frequent in Rheumatoid arthritis (RA). Recently, it has been shown that shoulder involvement is predictive for RA development in patients with undifferentiated arthritis(UA) and its value is comparable to that of small joint involvement. The phase of clinically suspect arthralgia (CSA) precedes the phase of clinically apparent arthritis; in this phase subclinical tenosynovitis of the hands, is associated with the development of RA. Given the similarities in predictive values between the shoulder and small joints in UA, and the predictive value of tenosynovitis in CSA, we hypothesized that subclinical tenosynovitis of the bicep tendon is also associated with RA development. We examined the biceps tendon, since this is the only tendon of the shoulder that is enclosed by a synovial sheath as it passes through the bicipital groove.

Objectives:

Therefore, the aim of this study is to examine the predictive value of tenosynovitis of the bicep tendon by ultrasound (US) on developing inflammatory arthritis (IA) in CSA-patients.

Methods:

The SONAR (Sonographic evaluation of hands, shoulders and feet in patients presenting with inflammatory arthralgia to identify subclinical arthritis) is a multi-center observational cohort study in which patients were followed for the development of clinically apparent inflammatory arthritis (IA). Visits were done at baseline and 6 monthly thereafter. At baseline a US of both shoulders was made. 1-year follow-up data were used. IA was defined as having an arthritis verified by the treating physician. US abnormalities of (1) the biceps tendon, (2) the glenohumeral joint and (3) the subdeltoid bursa, were assessed for tenosynovitis, arthritis and bursitis.. Reference values for tendon thickness and effusion of the bursa were determined according to Schmidt et al.(1)

Results:

A total of 170 patients were included and underwent bilateral ultrasound (US) of the shoulder joint. Shoulder symptoms were infrequent (Table 1). After one year 37 patients developed IA (22%). ACPA positivity was associated with the development of IA (Table 1). As presented in Table 1, US abnormalities of the shoulder were found but none were associated with IA-development. In particular biceps tenosynovitis was not increased in the patients that developed IA.

Table 1.

Baseline characteristics and ultrasound abnormalities at baseline in patients with CSA.

Baseline characteristicsAll CSA-patientsn=170CSA-patients with IA(n=37)CSA-patients without IA (n=133)P valueGender, female, n (%)140 (82)30 (81)110 (83)0.82Age, years, mean (SD)45 (12)47 (12)44 (12)0.28Symptom duration, weeks median (IQR)30 (19-43)37 (23-43)28 (19-39)0.14TJC44, median (IQR)5 (3-8)5 (3-8)5 (3-8)0.81Shoulder pain, n (%)9 (5)0 (0)9 (6.8)0.10SJC44, median (IQR)0 (0-0)0 (0-0)0 (0-0)-ESR, median (IQR)10 (5-21)9 (5-22)11 (5-21)0.66RF-positive, n (%)46 (28)12 (34)34 (26)0.33ACPA-positive, n (%)26 (16)10 (29)16 (12)0.019US abnormalitiesof the shoulderAny USabnormalities, n (%)(n=170)50 (29)8 (22)42 (32)0.24Biceps tendon Tenosynovitis, n (%)(n=164)19 (12)5 (15)14 (11)0.48Biceps tendon thickness, n (%)(n=164)6 (4)0 (0)6 (5)0.19Subdeltoid bursa effusion, n (%)(n=159)29 (18)3 (9)26 (21)0.094Effusion joint, n (%)(n=157)0 (0)0 (0)0 (0)-

Abbreviations:IA: Inflammatory Arthritis, TJC44: Tender Joint Count in 44 joints, SCJ44: Swollen Joint Count in 44 joints,, ESR: Erythrocyte sedimentation rate, RF: Rheumatoid Factor, ACPA: Anti-citrullinated Protein Antibody

Conclusion:

Subclinical tenosynovitis of the shoulder is not an early feature of RA in patients with CSA.

Reference:

[1]Schmidt WA, Schmidt H, et al.Standard reference values for musculoskeletal ultrasonography.Ann Rheum Dis. 2004 Aug;63(8):988-94.

Acknowledgments:

*van der Helm- van Mil and de Jong contributed equal to this study

Disclosure of Interests:

None declared

OP0281 TWO-YEAR COST-EFFECTIVENESS BETWEEN TWO GRADUAL TAPERING STRATEGIES IN RHEUMATOID ARTHRITIS: COST-UTILITY ANALYSIS OF THE TARA TRIAL

Background:

Current guidelines recommend to consider tapering treatment in rheumatoid arthritis (RA) patients who are in sustained remission, but the optimal approach to de-escalate conventional synthetic and biological DMARDs (respectively csDMARDs and bDMARDs) remains unknown. The benefits of tapering are a decreased risk of long-term adverse events and a reduction of health care costs, especially when bDMARDs are tapered. However, tapering treatment may lead to more transient or persistent disease flares, which have a direct impact on patients’ lives and societal costs.

Objectives:

To evaluate the two year cost-utility ratio between tapering the csDMARD first followed by the TNF-inhibitor, and tapering the TNF-inhibitor first followed by the csDMARD.

Methods:

The TARA trial is a multicenter single-blinded randomized controlled trial. RA patients that used a csDMARD(s) plus a TNF-inhibitor and who had a well-controlled disease for at least 3 months, defined as a DAS≤2.4 and a swollen joint count (SJC)≤1, were included. Patients were randomized into gradual tapering their csDMARD followed by the TNF-inhibitor or vice versa. Medication was tapered in three steps over the course of 6 months. Gradual tapering was done by cutting the dosage into half, a quarter and thereafter it was stopped. Data on QALYs (measured with the Dutch EuroQol [EQ5D]), direct and indirect costs were used to calculate the Incremental Cost Effectiveness Ratio (ICER). The incremental cost-effectiveness ratio (ICER) and the incremental net monetary benefit (iNMB) were used to assess cost-effectiveness between both tapering strategies. Direct costs comprises costs for treatment and medical consumption, while indirect costs comprises costs due to loss of productivity (i.e. sick leave and unemployment).

Results:

Of the 189 included patients, 94 started tapering their TNF-inhibitor first, while the other 95 tapered their csDMARD first. QALYs (sd) were, respectively, 1.64 (0.22) and 1.65 (0.22). Medication costs were significantly lower in the patients who tapered the TNF-inhibitor first, but indirect cost were higher due to more productivity loss. Therefore, total costs per QALY were similar for both tapering strategies (p=0.62). The ICER between tapering csDMARDs and the TNF-inhibitor was -€184534 (-€417314, €48245; 95% CI)(figure 1). The mean iNMB was €2831 at a willingness-to-pay (WTP) level of €80000. At all WTP levels the probability of being cost-effective was higher (62% vs. 28%) for tapering the TNF-inhibitor first (figure 2)

Conclusion:

Medication costs are lower when the TNF-inhibitor is tapered first, but this is counterbalanced by higher indirect costs due to loss of productivity. Therefore, overall cost savings are smilar for both tapering strategies. However, tapering the TNF-inhibitor first has a higher chance of being cost-effective at all WTP thresholds. For this reason we advise to taper the TNF-inhibitor first when tapering medication is considered.

Disclosure of Interests:

None declared

SAT0071 SUBCLINICAL SYNOVITIS IN ARTHRALGIA: HOW OFTEN DOES IT RESULT IN CLINICAL ARTHRITIS? A LONGITUDINAL STUDY TO REFLECT ON STARTING POINTS FOR DMARD TREATMENT

Background:

Clinically apparent arthritis is mandatory for diagnosing and classifying RA. It is often used as endpoint in arthralgia cohorts and as a starting point for DMARD therapy in clinical practice. In recent literature subclinical synovitis, visualized with MRI or ultrasound, is increasingly used as a starting point for DMARD therapy in absence of clinically apparent arthritis. However, not all patients with a subclinical synovitis will develop clinically apparent arthritis, and thus may be overtreated. It has even been suggested to replace the entry-criterion of clinical arthritis by subclinical synovitis within the 2010 classification criteria for RA to diminish overtreatment. However this might lead to an overclassification of the disease. Because of aforementioned reasoning we aimed to evaluate the risk of overtreatment of these approaches and therefore performed a longitudinal study in three observational arthralgia cohorts.

Objectives:

To determine the frequency of non-progression to clinical arthritis in patients with subclinical synovitis, also after considering the 2010-criteria.

Methods:

Three individual cohorts of arthralgia patients without clinically apparent arthritis (n=166, 473 and 168) were followed for 1-year on the development of inflammatory arthritis (IA). At baseline subclinical synovitis in hands or feet was visualized with ultrasound (US) (defined as greyscale≥2 and/or power-doppler≥1) in cohort 1 and 3 and MRI (synovitis score ≥1 by two readers) in cohort 2. For all patients with subclinical synovitis the proportion of progressors (‘true positives’) and non-progressors (‘false positives’) were determined. The same analysis was done in the subgroup of patients that fulfilled the 2010 criteria for RA, if subclinical synovitis was used as entry criterion. Analyses were stratified for ACPA.

Results:

At baseline 36%, 41% and 31% of patients had subclinical synovitis. Of the ACPA-positive arthralgia patients with subclinical synovitis 46%, 56% and 29% respectively developed IA, whereas 54%, 44% and 71% did not progress. Within ACPA-negative arthralgia patients with subclinical synovitis 34%, 15% and 10% developed IA; whereas 66%, 85% and 90% did not progress (Figure 1A). Similar results were seen in the subgroup of patients that fulfilled the 2010 criteria with subclinical synovitis as entry criterion (Figure 1B).

Figure 1.

Percentage of arthralgia patients with subclinical synovitis that did and did not develop IA, in three independent cohorts:(A) Percentage of patients with subclinical synovitis that did and did not progress to IA after one-year follow-up, stratified for ACPA status. (B) Percentage of patients with subclinical synovitis and ≥6 points at baseline that did and did not progress to IA after one-year follow-up stratified for ACPA status.

Conclusion:

Replacing clinical arthritis by subclinical synovitis in arthralgia introduces a high false-positive rate: 44-71% (ACPA-pos) and 66-90% (ACPA-neg) of patients with subclinical synovitis did not develop clinically apparent arthritis within one year. Applying the 2010-criteria in this setting did not diminish the false positive rate. Starting DMARDs in patients without clinical synovitis may therefore introduce considerable overtreatment.

Acknowledgments *:

C Rogier and F Wouters contributed equal to this study

Disclosure of Interests:

None declared

OP0283 COMPARING COST-UTILITY OF DMARDS IN SERONEGATIVE RHEUMATOID ARTHRITIS PATIENTS; A TREACH SUBANALYSIS

Background:

The diversity of the clinical phenotype of rheumatoid arthritis (RA) is increasing due to the emphasis on early diagnosis and treatment. This resulted in an increased number of RA patients without autoantibodies, also known as seronegative RA. We recently showed that newly diagnosed seronegative RA patients initially treated with hydroxychloroquine (iHCQ) had a similar clinical efficacy to initial methotrexate (iMTX). To our knowledge, however, there are no data on the cost-effectiveness of different initial treatment strategies in seronegative RA patients.

Objectives:

To evaluate the 1-year cost-effectiveness between three different initial treatment strategies in seronegative rheumatoid arthritis (RA) patients, according to 2010 criteria.

Methods:

For this analysis we selected all seronegative RA patients (n=131) within the intermediate probability stratum of the tREACH trial (table 1). Selected patients either received initial methotrexate 25mg/week (iMTX), hydroxychloroquine 400mg/day (iHCQ) or oral glucocorticoids, starting dose 15mg, in a 10-week tapering scheme without csDMARDs (iGCs). Quality adjusted life year (QALY) were derived from the EQ-5D. Costs were calculated with data from patient records and questionnaires. Direct costs are health care costs, whereas indirect costs are costs due to productivity loss. The incremental cost-effectiveness ratio (ICER) was used to assess the cost-effectiveness between treatment strategies.

Table 1.

Baseline characteristics and response after 1 year.

A.iMTX (n=50)B.iHCQ (n=40)C.iGCs (n=41)Baseline (t=0)Age (years), mean (SD)57 (14)54 (14)53 (15)Sex, female, n (%)38 (76)24 (60)27 (66)Symptom duration (days), mean (SD)143 (86-209)146 (102-226)126 (94-192)Das, mean (SD)3.43 (0.92)2.93 (0.84)3.50 (0.93)HAQ, mean (SD)1.20 (0.56)0.90 (0.61)1.03 (0.69)Response after 1 year (t=12)Das, mean (SD)1.71 (0.81)1.78 (0.97)1.72 (1.00)HAQ, mean (SD)0.78 (0.55)0.77 (0.60)0.71 (0.68)

Results:

Average QALYs (sd), for iMTX, iHCQ and iGCs were respectively 0.71 (0.14), 0.73 (0.13) and 0.70 (0.15). The average total costs (sd) per QALY for iMTX, iHCQ and iGCs were respectively €11.004 (17.611), €13.231 (19.886) and €18.415 (35.660). Direct and indirect costs were higher in the iGCs group compared to iMTX and iHCQ (table 2). The ICERs did not differ between the initial treatment strategies (figure 1A-C). For WTP levels <€33.900 iMTX has the highest probability of being cost-effective, while for WTP levels >€33.900 iHCQ has the highest probability (figure 1D).

Table 2.

Total costs per QALY after 1 year of follow-up.

A.iMTX (n=50)B.iHCQ (n=40)C.iGCs (n=41)QALYs (AUC)0.71 (0.14)0.73 (0.13)0.70 (0.15)Cost per QALY (EQ5D) Total direct costs, €€3873 (4706)€3262 (4434)€5008 (6869)•Medication, €€2224 (4025)€1134 (2493)€3135 (5343)*•Medical consumption, €€1394 (1067)€1915 (3274)€1874 (2367)•Hospitalization, €€256 (1353)€213 (785)- Total indirect costs, €€7131 (15164)€9969 (17340)€13406 (31255)Total costs, €€11004 (17611)€13231 (19886)€18415 (35660)

Results shown are mean (SD) unless stated otherwise. *p<.05 for HCQ vs. GCs (student t test)

Conclusion:

iMTX and iHCQ are more cost-effective than iGCs. However, depending on the WTP threshold either iMTX or iHCQ has the highest probability of being cost-effective.

Figure:

Disclosure of Interests:

None declared

P1244Survival after septal myectomy in male and female patients with hypertrophic obstructive cardiomyopathy

In recent years, studies have debated the impact of gender on the presentation and clinical course of HCM, with research showing that at time of myectomy, women are older, have worse diastolic function and more advanced cardiac remodeling. The clinical impact of these differences is unknown.

We included 221 HCM patients (57% men) who underwent septal myectomy and are followed in our center. Time to treatment was calculated in relation to symptom onset. Pre- and post-operative clinical and echocardiographic data were collected. Gender differences were assessed at baseline and in survival analyses for the composite endpoint of all-cause mortality, cardiac transplantation, re-intervention and aborted sudden cardiac death.

Women were older at time of myectomy, but time until treatment was similar (table). Pre-operative echocardiographic indices were comparable among groups, but were significantly higher in women when correcting for body surface area. At three months, no differences were found in clinical and echocardiographic results. After 6.1 [2.9–10.1] years, 24% of women and 23% of men had reached the composite endpoint (p=0.30, figure).

Gender comparison pre- and post-myectomy Men (n=125) Women (n=96) p value Age 49±14 54±17 0.02 Maximal wall thickness, mm 19.9±4.7 19.8±5.8 0.97 Indexed maximal wall thickness, mm/m2 9.8±2.5 11.5±4.5 0.001 Left atrial diameter, mm 48.1±7.3 45.9±7.3 0.06 Indexed left atrial diameter, mm/m2 23.5±3.5 26.5±7.5 0.002 LV end-diastolic diameter, mm 45.4±7.6 42.8±5.6 0.04 Indexed LV end-diastolic diameter, mm/m2 22.1±3.7 23.6±3.0 0.02 Gradient reduction, %* 75.1±25.0 72.9±28.6 0.63 Improvement in symptoms*† 97 (95%) 64 (89%) 0.34 MWT = maximal wall thickness; LV = left ventricle. *At three months follow-up; †Defined as a reduction of ≥1 NYHA class, measured in 102 men and 72 women.

Survival after myectomy

Although women present later in life and seem to have more advanced disease at time of myectomy, time to treatment is similar and survival after myectomy is excellent for both men and women.

(18)F-FDG PET scanning of abdominal aortic aneurysms and correlation with molecular characteristics: a systematic review

Purpose

The purpose of this study is to give an overview of studies investigating the role of fludeoxyglucose F18 (¹⁸F-FDG) positron emission tomography (PET) scanning in patients with aortic aneurysms with a focus on molecular characteristics of the aneurysm wall.

Methods

MEDLINE, EMBASE, and the Cochrane database were searched for relevant articles. After inclusion and exclusion, we selected 18 relevant articles reporting on ¹⁸F-FDG PET scanning of aortic aneurysms.

Results

The sample size of studies is limited, and there are no standardized imaging protocols and quantification methods. ¹⁸F-FDG PET scanning was shown to display molecular characteristics of the aortic wall. Different studies showed contradictory findings of aortic ¹⁸F-FDG uptake in aneurysm patients compared to controls.

Conclusions

Non-invasively determining molecular characteristics of aortic wall weakening might lead to better rupture and growth prediction. This might influence the decision of the surgeon between conservative and surgical treatment of aneurysms. To date, there is conflicted evidence regarding the use of ¹⁸F-FDG PET scanning to predict aneurysm rupture and growth. The role of ¹⁸F-FDG PET scanning in rupture risk prediction needs to be further investigated, and standardized imaging protocols and quantification methods need to be implemented.

Electronic supplementary material

The online version of this article (doi:10.1186/s13550-015-0153-8) contains supplementary material, which is available to authorized users.

International standardisation work on the measurement of radon in air and water

Radon is considered to be the main source of human exposure to natural radiation. As stated by the World Health Organization, the exposure due to the inhalation of indoor radon is much greater than the one via the ingestion of water as radon degasses from water during handling. In response to these concerns about the universal presence of radon, environmental assessment studies are regularly commissioned to assess the radon exposure of public and workers. The credibility of such studies relies on the quality and reliability of radon analysis as well as on the sample representativeness of the radiological situation. The standard-setting approach, based on consensus, seemed to lend itself to a settlement of technical aspects of potential comparison. At present, two Working Groups of the International Standardization Organization are focussing on drafting standards on radon and its decay products measurement in air and water. These standards, which aim for a set of rigorous metrology practices, will be useful for persons in charge of the initial characterisation of a site with respect to natural radioactivity as well as to those performing the routine surveillance of specific sites.

Short Communication: Quantification of the Transmission of Microorganisms to Milk via Dirt Attached to the Exterior of Teats

Pathogens and spoilage microorganisms can be transmitted to milk via dirt (e.g., feces, bedding material, soil, or a combination of these) attached to the exterior of the cows' teats. To determine the relevance of this pathway and to perform quantitative microbial risk analysis of the microbial contamination of farm tank milk (FTM), it is important to know the amount of dirt transmitted to milk via the exterior of teats. In this study at 11 randomly selected Dutch farms the amount of dirt transmitted to milk via the exterior of teats is determined using spores of mesophilic aerobic bacteria as a marker for transmitted dirt. The amount of transmitted dirt to milk varied among farms from approximately 3 to 300 mg/L, with an average of 59 mg/L. The usefulness of the data for microbial risk analyses is briefly illustrated using the contamination of FTM with spores of butyric acid bacteria as a case study. In a similar way the data can be used to identify measures to control the contamination of FTM with other microorganisms or chemical residues.

Minimizing the Level of Butyric Acid Bacteria Spores in Farm Tank Milk

A year-long survey of 24 dairy farms was conducted to determine the effects of farm management on the concentrations of butyric acid bacteria (BAB) spores in farm tank milk (FTM). The results were used to validate a control strategy derived from model simulations. The BAB spore concentrations were measured in samples of FTM, feces, bedding material, mixed corn and grass silage fed to cows in the barn, and soil. In addition, a questionnaire was used to gather farm management information such as bedding material used and teat cleaning method applied. The average BAB spore concentration in FTM was 2.7 log10 spores/L, and 33% of the FTM samples exceeded a concentration of 3 log10 spores/L. Control of the average spore concentration in mixed silage fed was the only aspect of farm management that was significantly related to the concentration of BAB spores in FTM. Farms that fed mixed silage with the lowest average BAB spore concentrations (3.4 log10 spores/g) produced FTM with the lowest average concentration (2.1 log10 spores/L). The efficiency of farm management in controlling the BAB spore concentration in FTM depended to a large extent on the ability of farmers to prevent incidents with elevated BAB spore concentrations in mixed silage (>5 log10 spores/g) and not on the average BAB spore concentration in mixed silage across the year. The survey showed that farmers should aim for a concentration in mixed silage of less than 3 log10 spores/g and should prevent the concentration from exceeding 5 log10 spores/g to ensure a concentration in FTM of less than 3 log10 spores/L. These results correspond with the previously reported model simulations.

Minimizing the Level of Bacillus cereus Spores in Farm Tank Milk

In a year-long survey on 24 Dutch farms, Bacillus cereus spore concentrations were measured in farm tank milk (FTM), feces, bedding material, mixed grass and corn silage, and soil from the pasture. The aim of this study was to determine, in practice, factors affecting the concentration of B. cereus spores in FTM throughout the year. In addition, the results of the survey were used in combination with a previously published modeling study to determine requirements for a strategy to control B. cereus spore concentrations in FTM below the MSL of 3 log10 spores/L. The B. cereus spore concentration in FTM was 1.2 +/- 0.05 log10 spores/L and in none of samples was the concentration above the MSL. The spore concentration in soil (4.9 +/- 0.04 log10 spores/g) was more than 100-fold higher than the concentration in feces (2.2 +/- 0.05 log10 spores/g), bedding material (2.8 +/- 0.07 log10 spores/g), and mixed silage (2.4 +/- 0.07 log10 spores/g). The spore concentration in FTM increased between July and September compared with the rest of the year (0.5 +/- 0.02 log10 spores/L difference). In this period, comparable increases of the concentrations in feces (0.4 +/- 0.03 log10 spores/g), bedding material (0.5 +/- 0.05 log10 spores/g), and mixed silage (0.4 +/- 0.05 log10 spores/g) were found. The increased B. cereus spore concentration in FTM was not related to the grazing of cows. Significant correlations were found between the spore concentrations in FTM and feces (r = 0.51) and in feces and mixed silage (r = 0.43) when the cows grazed. The increased concentrations during summer could be explained by an increased growth of B. cereus due to the higher temperatures. We concluded that year-round B. cereus spores were predominantly transmitted from feeds, via feces, to FTM. Farmers should take measures that minimize the transmission of spores via this route by ensuring low initial contamination levels in the feeds (<3 log10 spores/g) and by preventing growth of B. cereus in the farm environment. In addition, because of the extremely high B. cereus spore concentrations in soil, the contamination of teats with soil needs to be prevented.

Concentrations of Butyric Acid Bacteria Spores in Silage and Relationships with Aerobic Deterioration

Germination and growth of spores of butyric acid bacteria (BAB) may cause severe defects in semihard cheeses. Silage is the main source of BAB spores in cheese milk. The objectives of the study were to determine the significance of grass silages and corn silages as sources of BAB spores and to investigate the relationships between high concentrations of BAB spores in corn silage and aerobic deterioration. In the first survey, samples were taken from various locations in silos containing grass and corn silages and from mixed silages in the ration offered to the cows on 21 farms. We demonstrated that the quantity of BAB spores consumed by cows was determined by a small fraction of silage with a high concentration of spores (above 5 log10 BAB/g). High concentrations were most often found in corn silage within areas with visible molds (69% of the samples). Areas with visible molds in grass silage and surface layers of corn silage contained, respectively, 21 and 19% of the cases of concentrations above 5 log10 BAB spores/g. Based on these results, we concluded that currently in the Netherlands, corn silage is a more important source of BAB than is grass silage. In a second survey, 8 corn silages were divided into 16 sections and each section was studied in detail. High concentrations of BAB spores were found in only the top 50 cm of these 8 silages. Elevated concentrations of BAB spores were associated with different signs of aerobic deterioration. In 13% of the sections in corn silage with more than 5 log10 yeasts and molds/g, more than 5 log10 BAB spores/g were found. Sections with a temperature of more than 5 degrees C above ambient temperature contained, in 21% of the cases, more than 5 log10 BAB spores/g. Concentrations above 5 log10 BAB spores/g were measured in 50% of the sections with a pH above 4.4. All sections with a pH above 4.4 also showed a temperature that was more than 5 degrees C above ambient temperature and a concentration of yeasts and molds above 5 log10 cfu/g. Based on these results, we postulated that high concentrations of BAB spores in corn silage are the result of oxygen penetration into the silage, resulting in aerobic deterioration and the formation of anaerobic niches with an increased pH just below the surface. Growth of BAB in these anaerobic niches with an increased pH caused the locally high concentrations of BAB in corn silage.

Predictive Modeling of Bacillus cereus Spores in Farm Tank Milk During Grazing and Housing Periods

The shelf life of pasteurized dairy products depends partly on the concentration of Bacillus cereus spores in raw milk. Based on a translation of contamination pathways into chains of unit-operations, 2 simulation models were developed to quantitatively identify factors that have the greatest effect on the spore concentration in milk. In addition, the models can be used to determine the reduction in concentration that could be achieved via measures at the farm level. One model predicts the concentration when soil is the source of spores, most relevant during grazing of cows. The other model predicts the concentration when feed is the main source of spores, most relevant during housing of cows. It was estimated that when teats are contaminated with soil, 33% of the farm tank milk (FTM) contains more than 3 log(10) spores/L of milk. When feed is the main source, this is only 2%. Based on the predicted spore concentrations in FTM, we calculated that the average spore concentration in raw milk stored at the dairy processor during the grazing period is 3.5 log(10) spores/L of milk and during the housing period is 2.1 log(10) spores/L. It was estimated that during the grazing period a 99% reduction could be achieved if all farms minimize the soil contamination of teats and teat cleaning is optimized. During housing, reduction of the concentration by 60% should be feasible by ensuring spore concentrations in feed below 3 log(10) spores/g and a pH of the ration offered to the cows below 5. Implementation of these measures at the farm level ensures that the concentration of B. cereus spores in raw milk never exceeds 3 log(10) spores/L.

Improving Farm Management by Modeling the Contamination of Farm Tank Milk with Butyric Acid Bacteria

Control of contamination of farm tank milk (FTM) with the spore-forming butyric acid bacteria (BAB) is important to prevent the late-blowing defect in semi-hard cheeses. The risk of late blowing can be decreased via control of the contamination level of FTM with BAB. A modeling approach was applied to identify an effective control strategy at the farm level. The simulation model developed was based on a translation of the contamination pathway into a chain of unit operations. Using various simulations, the effects of factors related to feed quality, feed management, cattlehouse hygiene, and milking practices on the contamination level of FTM were evaluated. Contamination level of silage was found to be the most important factor. When silage contains on average less than 3 log10 BAB/g, a basic pretreatment of udder teats before milking (approximately 75% removal of attached spores) is sufficient to assure an FTM contamination level below 1 BAB/mL. When silage contains more than 5 log10 BAB/g, it should not be fed, because it then becomes almost impossible to assure an FTM contamination level below 1 BAB/mL. Measures aimed at improving cattlehouse hygiene, the contamination via soil, and the contamination level of other feeds contribute only marginally to the control of the contamination of FTM with BAB. Application of the modeling methodology could be beneficial for the control of the contamination of FTM with other microorganisms such as Bacillus cereus.

Co-constructing cooperation with mandated clients

Dominant practice models for social work were originally developed and intended for work with voluntary clients. The professional literature indicates that use of these models with involuntary clients often alienates rather than engages. This article describes the use of solution-focused interviewing as a way to engage involuntary and mandated clients. A conversation with a court-ordered client is presented and analyzed to demonstrate how practitioners can begin the co-construction of cooperation with mandated clients through adopting a not-knowing posture, focusing on and amplifying what clients want and client strengths and successes, and asking relationship questions to generate possibilities for change specific to the mandated context. The ethical implications of this noncoercive, nonconfrontational approach are addressed, along with its implications for a view of how clients change.

Masked fear words produce increased SCRs: an anomaly for Ohman's theory of pre-attentive processing in anxiety

A. Ohman and J.J.F. Soares (1994) demonstrated that masked presentation of phobic pictures produces increased skin conductance responses (SCRs) in phobic subjects. A. Ohman (1993) explained this phenomenon in terms of a hypothetical "feature detector" that identifies physical characteristics of stimuli and activates the arousal system without involving significance evaluation or consciousness. By exposing spider phobics to spider words, general threat words, and neutral words instead of pictures, this explanation was tested. Words were presented both masked and unmasked while electrodermal activity was measured. Under unmasked conditions, SCRs were largest for spider words followed by general threat words, then neutral words. When masked, the difference between spider words and general threat words disappeared but SCRs remained significantly smaller for neutral words. It is concluded that activation of the arousal system by masked threat cues does not necessarily depend on their perceptual characteristics.

PERSONALITY DISORDERS AND SOCIAL FUNCTIONING IN DEPRESSED PATIENTS

There is a high level of comorbidity of personality disorders with major depression. Patients who suffer from both depression and an axis II disorder are, in general, more severely ill and ill for longer periods. The presence of personality disorders also has a negative influence on the social functioning of depressed patients, and it has emerged that certain demographic characteristics are present to a significant extent. This article presents the results of a study of 244 out-patients suffering from major depression. The issues addressed were: Firstly, which axis II disorders are found in this group and are there correlations with the demographic characteristics? Secondly, is there a relationship between individual axis II disorders and the severity of the depression and social functioning? It emerges that 60% of the patients with a Hamilton score of at least 14 have one or more axis II disorders according to the VKP self-report, and that 30% have three or more, with more than 50% in cluster C. It was found also that the schizoid and borderline personality disorders in particular are significantly linked to several demographic characteristics. The patients here are more often single and those with a lower level of education. Using the Hamilton Depression Rating Scale, little significant correlation was found between the presence of an axis II disorder and the severity of the depression. A significant difference was found using the Symptom Check List -90. In social functioning, the citizen role, the social role and the family role turn out to be correlated most significantly, as are the total number of impairments. In addition, the highest correlation is found particularly in cluster C, and the number of axis II disorders is almost always significantly related to the individual roles. The discussion turns to the influence of the measuring instruments used and to the composition of the population, as well as the clinical relevance of the diagnosis of axis II disorders and social functioning in patients with a major depression.

Glutamine synthetase expression in perinatal spiny mouse liver

The pronounced increase in the protein/mRNA ratio of ammonia-metabolising enzymes in rat liver in the last prenatal week represents a clear example of a post-transcriptional level of control of gene expression. Both the underlying mechanism, namely an increase in translational efficiency of the mRNA and/or enhanced stability of the protein, and its importance for perinatal adaptation are unknown. We investigated this process in spiny mouse liver, because the comparison of rat and spiny mouse can discriminate adaptively from developmentally regulated processes in the perinatal period. We focused on glutamine synthetase (GS) because of the conveniently small size of its mRNA. Prenatally, GS enzyme activity slowly accumulated to approximately 1.3 U x g-1 liver at birth and postnatally more rapidly to 5.5 U x g-1 at 2 weeks. Both phases of enzyme accumulation obeyed exponential functions. Western-blot analysis showed that changes in GS activity reflected changes in GS protein content. GS mRNA content of the liver was 45 fmol x g-1 at 2 weeks before birth and slowly declined to approximately 25 fmol x g-1 at 2 weeks after birth. The GS protein/mRNA ratio increased 2.5-fold prenatally and sixfold postnatally. Analysis of prenatal and postnatal polysome profiles revealed no evidence of GS mRNA-containing ribonucleoprotein particles. Instead, GS mRNAs were (fully) occupied by 12 ribosomes, indicating regulation at the level of elongation. The kinetics of GS protein accumulation, in conjunction with GS mRNA content, are consistent with an approximately sixfold increase in its rate of synthesis at birth as the result of a corresponding stimulation of the rate of elongation.

Genomic structure of SAS, a member of the transmembrane 4 superfamily amplified in human sarcomas

SAS is a recently identified member of the transmembrane 4 superfamily (TM4SF) that is frequently amplified in human sarcomas. To further its characterization and to confirm its classification, the genomic structure of the SAS gene was determined. The SAS gene covers approximately 3.2 kb of DNA. It contains six exons within its translated region, three of which are highly conserved in the TM4SF. 5' to the translation start site are two putative transcription start sites, two CCAAT consensus sequences, and potential binding sites for both Sp1 and ATF transcription factors. Comparison of SAS organization to human ME491, CD9, and CD53 and murine CD53 and TAPA-1 confirms that SAS is a member of this family of genes and is consistent with the theory that these genes arose through duplication and divergent evolution.

Cloning and characterization of the Ewing's sarcoma and peripheral neuroepithelioma t(11;22) translocation breakpoints

Ewing's sarcoma (ES) and peripheral neuroepithelioma (PN) are related tumors, possibly of neural crest origin, which are cytogenetically characterized by the specific translocation t(11;22)(q24;q12). The cos5 locus, previously identified in the vicinity of the chromosome 22 breakpoint of this translocation, was shown by in situ hybridization on interphase nuclei to lie between VIIIF2 and LIF, two loci located on either side of the breakpoint and at a distance of less than 2,000 kb. The progressive expansion of this locus by chromosome walking led to the construction of a 300 kb contig, which finally crossed the breakpoint. The subsequent cloning of the two translocation junction fragments of a PN, followed by the molecular characterization of the translocation breakpoints of 20 ES and PN, showed that most chromosome 22 breakpoints are clustered within a small, 2 kb region. In contrast, the chromosome 11 breakpoints are scattered over a region of at least 40 kb. The translocation leads to the synthesis of chimeric transcript that links sequences from chromosomes 22 and 11. Finally, no evidence was found of any specific difference in the position of ES and PN translocation breakpoints.

Rapid isolation of cosmids from defined subregions by differential Alu-PCR hybridization on chromosome 22-specific library

A method based on the differential screening of a chromosome-specific cosmid library with amplified inter-Alu sequences obtained from a set of somatic cell hybrids has been developed to target the isolation of probes from predefined subchromosomal regions. As a model system, we have used a chromosome 22-specific cosmid library and four cell hybrids containing different parts of this chromosome. The procedure has identified cosmids that demonstrate differential hybridization signals with Alu-PCR products from these cell hybrids. We show, by in situ hybridization or individual mapping, that their hybridization pattern is indicative of their sublocalization on chromosome 22, thus resulting in a large enrichment factor for the isolation of probes from specific small chromosome subregions. Depending on the local Alu-sequence density, from 3 to 10 independent loci per megabase of genome can thus be identified.