Response-guided neoadjuvant sacituzumab govitecan for localized triple-negative breast cancer: results from the NeoSTAR trial

BACKGROUND

Sacituzumab govitecan (SG), a novel antibody-drug conjugate (ADC) targeting TROP2, is approved for pre-treated metastatic triple-negative breast cancer (mTNBC). We conducted an investigator-initiated clinical trial evaluating neoadjuvant (NA) SG (NCT04230109), and report primary results.

PATIENTS AND METHODS

Participants with early-stage TNBC received NA SG for four cycles. The primary objective was to assess pathological complete response (pCR) rate in breast and lymph nodes (ypT0/isN0) to SG. Secondary objectives included overall response rate (ORR), safety, event-free survival (EFS), and predictive biomarkers. A response-guided approach was utilized, and subsequent systemic therapy decisions were at the discretion of the treating physician.

RESULTS

From July 2020 to August 2021, 50 participants were enrolled (median age = 48.5 years; 13 clinical stage I disease, 26 stage II, 11 stage III). Forty-nine (98%) completed four cycles of SG. Overall, the pCR rate with SG alone was 30% [n = 15, 95% confidence interval (CI) 18% to 45%]. The ORR per RECIST V1.1 after SG alone was 64% (n = 32/50, 95% CI 77% to 98%). Higher Ki-67 and tumor-infiltrating lymphocytes (TILs) were predictive of pCR to SG (P = 0.007 for Ki-67 and 0.002 for TILs), while baseline TROP2 expression was not (P = 0.440). Common adverse events were nausea (82%), fatigue (76%), alopecia (76%), neutropenia (44%), and rash (48%). With a median follow-up time of 18.9 months (95% CI 16.3-21.9 months), the 2-year EFS for all participants was 95%. Among participants with a pCR with SG (n = 15), the 2-year EFS was 100%.

CONCLUSIONS

In the first NA trial with an ADC in localized TNBC, SG demonstrated single-agent efficacy and feasibility of response-guided escalation/de-escalation. Further research on optimal duration of SG as well as NA combination strategies, including immunotherapy, are needed.

On-site testing and treatment of sexually transmitted infections among female sex workers using molecular point-of-care testing integrated into harm reduction services in Madrid, Spain

INTRODUCTION

This study aimed to evaluate the feasibility of molecular point-of-care testing for STIs, the prevalence of STIs and associated factors, and testing and treatment uptake among street-based female sex workers (FSWs) attending a mobile harm reduction unit in Madrid, Spain.

METHODS

This was a prospective, longitudinal study. From August 15th to December 6th, 2022, participants were screened for Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis using molecular testing (Xpert) on self-collected urine samples at a mobile harm reduction unit. Additionally, rapid tests were used to screen participants for HIV, hepatitis C virus (HCV), and syphilis. On-site same-day results and treatment for those infected were offered.

RESULTS

Among 77 FSWs included the median age was 40 (range, 33-48), 64 % were homeless, and 84 % reported drug use in the past six months. Four participants self-reported having HIV, of whom all were on antiretroviral therapy, and 14 (18 %) had HCV antibodies, including three with current infection. The prevalence of at least one STI was 66 %. When categorized by type of STI, the prevalences were as follows: 15 % for CT, 15 % for NG, 51 % for TV, and 21 % for syphilis. Notably, the prevalence of STIs was higher among FSW with recent drug use, with no cases of CT or NG detected among FSWs who did not recently use drugs. In adjusted analysis, drug use was associated an increased odds of having an STI (adjusted odds ratio, 10.47; 95 % CI: 1.67-65.42). All participants consented to screening, and all but one received on-site result-based linkage to treatment.

CONCLUSIONS

This study demonstrates the feasibility, high STI prevalence, and high linkage to testing and treatment following point-of-care molecular testing among street-based FSWs who have recently used drugs in Madrid, Spain.

Cochlear nerve dysplasia in unilateral severe to profound congenital sensorineural hearing loss - Prevalence in Australian children and the impact of socioeconomic disadvantage on its management

INTRODUCTION

Congenital unilateral sensorineural hearing loss (cuSNHL) carries potentially significant social, educational, and developmental consequences. Early diagnosis enables investigation, and consideration of options for management and early intervention, helping to mitigate the effects of hearing loss. Cochlear nerve dysplasia (CND) is a prominent cause of cuSNHL and may affect candidacy for cochlear implantation. Socioeconomic disadvantage may impact on a patient's family's capacity to participate in necessary intervention and follow-up.

METHODS

Infants with severe-profound cuSNHL referred to a large Australian quaternary pediatric center between October 2004 and December 2020 were retrospectively included. Audiometric and clinical data, and the presence of hearing loss risk factors were obtained from a prospectively collated database. In Australia MRI scans are provided free-of-charge to citizens and residents. MRI scans were reviewed to determine the status of the nerves within the internal acoustic meatus (IAM grade) along with attendance rates. Travel distance to the hospital was also calculated. Reasons for non-attendance at MRI were obtained from patient medical records and correspondence. Socioeconomic, educational, and occupational indices, and travel distances were obtained using patient residential postcodes with reference to Australian Bureau of Statistics data.

RESULTS

A total of 98 patients were reviewed, 64.3% (n = 63) of whom underwent MRI. The median age at diagnosis was 40 days (IQR 27). The prevalence of CND was 75% (n = 47). Importantly, there was no significant difference in the degree of hearing loss between IAM grades (F(4,57) = 1.029, p = 0.405). Socioeconomic indices were significantly lower in patients not attending MRI investigations compared with patients who did attend. Travel distance was not significantly different between the two groups.

CONCLUSION

CND is a prominent cause of cuSNHL in Australian infants. MRI at a young age allows parent education regarding management options and timely intervention where indicated. Socioeconomic disadvantage significantly impacts on participation in further routine assessment of cuSNHL, potentially limiting management options for these children long term.

Evaluating a novel approach to stimulate open science collaborations: a case series of "study-a-thon" events within the OHDSI and European IMI communities

OBJECTIVE

We introduce and review the concept of a study-a-thon as a catalyst for open science in medicine, utilizing harmonized real world, observation health data, tools, skills, and methods to conduct network studies, generating insights for those wishing to use study-a-thons for future research.

MATERIALS AND METHODS

A series of historical study-a-thons since 2017 to present were reviewed for thematic insights as to the opportunity to accelerate the research method to conduct studies across therapeutic areas. Review of publications and experience of the authors generated insights to illustrate the conduct of study-a-thons, key learning, and direction for those wishing to conduct future such study-a-thons.

RESULTS

A review of six study-a-thons have provided insights into their scientific impact, and 13 areas of insights for those wishing to conduct future study-a-thons. Defining aspects of the study-a-thon method for rapid, collaborative research through network studies reinforce the need to clear scientific rationale, tools, skills, and methods being collaboratively to conduct a focused study. Well-characterized preparatory, execution and postevent phases, coalescing skills, experience, data, clinical input (ensuring representative clinical context to the research query), and well-defined, logical steps in conducting research via the study-a-thon method are critical.

CONCLUSIONS

A study-a-thon is a focused multiday research event generating reliable evidence on a specific medical topic across different countries and health systems. In a study-a-thon, a multidisciplinary team collaborate to create an accelerated contribution to scientific evidence and clinical practice. It critically accelerates the research process, without inhibiting the quality of the research output and evidence generation, through a reproducible process.

233 BISPHOSPHONATES: ANOTHER COMPLEX DRUG TO PRESCRIBE

Background

Bisphosphonates provide effective treatment for osteoporosis. They accumulate a bone reservoir lasting for 3 years and beyond. The 2021 NICE guidelines recommend a medication review and a ‘drug holiday’ after 5 years of oral bisphosphonate therapy for low-fracture risk patients. Continuing treatment for high risk individuals is advised: age=/>75, previous hip or vertebral fracture, one or more fractures during treatment, recent DEXA scan with T score =/<−2.5, and/or current treatment with oral glucocorticoids. This retrospective audit aimed to assess compliance with NICE guidelines in a primary care setting.

Methods

Data were collected using the Health One online medical record system in an urban general practice. Inclusion criteria: all patients =/> 65 years old, prescribed oral bisphosphonate therapy for osteoporosis for >5 years. Exclusion criteria: deceased, did not attend clinic >1 year, patients on bisphosphonate treatment for conditions other than osteoporosis.

Results

137 patients with a history of bisphosphonate therapy were identified. 76 patients were on bisphosphonate treatment for greater than 5 years. Of the 76 patients, 33 were classified as low-fracture risk and appropriately commenced a drug holiday, while 22 correctly remained on bisphosphonates due to a high fracture risk. The remaining 21 patients inappropriately continued therapy without receiving a medication review, repeat DEXA or fracture-risk assessment.

Conclusion

One third of patients on bisphosphonates beyond 5 years were not assessed for a drug holiday. The aim of a bisphosphonate ‘drug holiday’ is to reduce poly-pharmacy and prevent rare but serious long-term adverse events (such as atypical fractures, osteonecrosis of the jaw, gastric cancer and atrial fibrillation). Factors which had an impact on inappropriate prescribing should be assessed. Incorporating computer-based prescribing alerts could support safe prescribing practices.

Assessment of Layperson Knowledge of AED use in Sports Clubs

Aims To investigate knowledge and attitudes among sports club members toward AEDs, and to examine the potential benefits of an educational programme as an intervention for increasing awareness and willingness to use an AED. Methods A number of selected sports clubs were visited, and participants aged ≥16 were asked to complete a questionnaire relating to current awareness and attitudes toward AEDs, and their willingness to use the device. Each participant then attended a 2-hour small-group teaching session where they were educated on the role and use of an AED, with opportunity to practice AED use in a controlled environment. After receiving teaching, each individual again completed the questionnaire. Results 142 people participated in the study. Before teaching, the average level of knowledge regarding AED use was relatively low. The most common reason identified for unwillingness to operate an AED was lack of knowledge on how to correctly use the device. Paired data analysis showed that attendance at a 2-hour educational programme led to a significant improvement in layperson awareness and understanding of AED use. After teaching, 77.5%(n=110) of participants reported that they would definitely be willing to use an AED, compared with 20.4%(n=30) before teaching. Conclusion A structured educational programme can increase layperson awareness, confidence and willingness to operate an AED.

Throwing cardiac rehabilitation into the 21st Century: a focus group study exploring the impact of COVID-19 on cardiac rehabilitation delivery in Victoria, Australia

Funding Acknowledgements

Type of funding sources: None.

Background

Cardiac rehabilitation (CR) education and exercise are predominantly delivered in group face-to-face settings. This delivery model was challenged during the COVID-19 pandemic due to government enforced lockdowns which restricted the delivery of these models of care. The Australian state of Victoria experienced the longest and most severe local restrictions and was in lockdown for approximately 26 weeks of 2020. 

Purpose

We aimed to explore the experience, barriers and enablers of delivering CR during a pandemic, and identify strategies for future COVID-safe programs among cardiac rehabilitation clinicians.

Methods

Victorian members of the Australian Cardiovascular Health and Rehabilitation Association (ACRA) were invited to attend an exploratory qualitative online focus group in November 2020. An inductive thematic analysis was undertaken before deductively applying the Non-adoption, Abandonment, Scale-up, Spread and Sustainability (NASSS) framework to identify barriers and enablers for technology adoption in CR.

Results

30 members participated in a 106 minute focus group. 17 members who provided demographics represented multiple disciplines (nursing n = 13, exercise physiology n = 3, physiotherapy n = 1) and geographical settings (metropolitan n = 10, regional n = 4, rural n = 3). Four main themes were identified: Consequences of sudden service delivery change; Technology use – challenges and benefits; Capacity (program and staff); and The way forward. The deductive NASSS analysis demonstrated the main challenges of continuing remotely delivered CR lie with all adopters (staff, patients, carers) and with organisations. Future CR strategies included the importance of resuming face-to-face programs but important barriers including finding capacity, particularly staffing, to run concurrent telehealth programs remain to be addressed. 

Conclusion

The COVID-19 pandemic forced and expedited significant changes to CR delivery models. While clinicians agreed that delivery of CR via telehealth will continue, it is now timely to review remote models of care and plan how they will integrate alongside traditional face-to-face programs.

Patients' preferences for treatment with the new direct acting antiviral therapies for chronic hepatitis C virus infection

Objectives:

The efficacy of new direct-acting antivirals (DAAs) in treating hepatitis C infection can depend on treatment adherence, which may be influenced by the patient’s current lack of awareness of the disease. This study set out to understand the treatment naïve chronic hepatitis C patients’ preferences for new DAAs (attributes) and to compile information about the diagnosis process.

Material and method:

Spanish quantitative market research study conducted between November 2018 and January 2019 to assess the posology preferences of treatment-naïve patients with chronic hepatitis C before starting treatment (seen by hepatologists and infectious diseases specialists). A telephone interview was carried out to collect demographic, diagnostic and treatment preference data, consisting of two dosing OPTIONS: 1) three tablets/day (single dose), at the same time, with food (8 weeks). 2) single tablet/day, at any time with/without food (12 weeks). A descriptive analysis of pooled results was performed.

Results:

104 patients (mean age: 49 years) with hepatitis C diagnosed 7.3±9.7 years ago (average), mainly in primary care (PC) (42%). The most common reasons for not having started treatment were health problems/comorbidities (31%). Fifty-eight percent of patients were not informed about the available treatments. Seventy-two percent of patients preferred a simple tablet/day, at any time, with/without food (12 weeks), and considered compatibility with other treatments, side effects, ease of administration, treatment duration and the number of tablets to be very important.

Discussion:

Patient preferences are mainly driven by dosing flexibility and simplicity, including freedom to take the medication with/without food. The role of PC in the diagnosis should be taken into account. There are still patients who are untreated after diagnosis.

OP0216 DEVELOPMENT AND VALIDATION OF PATIENT-LEVEL PREDICTION MODELS FOR ADVERSE HEALTH OUTCOMES AMONGST ADULT RA PATIENTS INITIATING FIRST-LINE TREATMENT OF METHOTREXATE MONOTHERAPY: A MULTINATIONAL REAL-WORLD COHORT ANALYSIS INCLUDING 164,735 SUBJECTS

Background:

EULAR guidelines recommend the early initiation of methotrexate (MTX) monotherapy as soon as possible after the diagnosis of rheumatoid arthritis (RA). Evaluating patient-level risks for adverse outcomes after MTX initiation would allow clinicians to provide more personalised care.

Objectives:

To develop and validate patient-level prediction models for adverse health outcomes including leukopenia, pancytopenia, infection (serious, opportunistic, all), cardiovascular disease (CVD) (myocardial infarction (MI), stroke), and cancer (breast, colorectal, uterus) in adult RA patients initiating first-line treatment of MTX monotherapy

Methods:

Health data from claims and electronic health records were used including patients from 7 European countries (Spain, Estonia, Netherlands, Belgium, Germany, France, and the UK), the United States of America, Australia, and Japan. All RA patients initiating first-line treatment of MTX monotherapy with at least one year of prior observation were included. Prediction models for the outcomes were developed for a time at risk of 3 months (infections, leukopenia, pancytopenia), 2 years (MI and stroke), and 5 years (cancers) on the Optum© De-Identified Clinformatics® Data Mart Database. Models were developed using LASSO logistic regression and were evaluated using the area under the receiver operator characteristic curve (AUROC) for discrimination and graphically assessed for calibration. The models were externally validated on all other databases.

Results:

A total of 21,307 subjects were used for training and validated against 143,427 patients from 14 sites. MI (AUROC internal 0.77, AUROC external ranging from 0.49 to 0.78), stroke (AUROC internal 0.78, AUROC external ranging from 0.68 to 0.79) and serious infection (AUROC internal 0.75, AUROC external ranging from 0.63 to 0.79) had good predictive validity [Table 1]. Discrimination for all other outcomes was lower, with all AUC<0.7 in internal validation. For detailed results see:https://data.ohdsi.org/ehdenRaPrediction/

Table 1.

Internal (Optum) and external validation results: AUC ROC for discrimination

DatabaseAcute MI within 2yStroke within 2ySerious Infection within 3mOptum (internal)0.770.780.75PanTher0.760.780.74IQVIA_AMBEMR0.760.72CCAE0.730.730.66IQVIA_GERMANY0.640.70IQVIA_THIN0.620.65MDCR0.680.680.67IQVIA_HOSPITAL0.670.630.61MDCD0.720.790.63JMDC0.490.750.71IQVIA_LPDFRANCE0.69Estonia0.670.770.82IQVIA_AUS0.58IPCI0.68SIDIAP0.650.75

Conclusion:

Clinical tools were developed that successfully identify subjects at risk of MI, stroke and serious infection at the initiation of first-line MTX therapy. The developed algorithms had good transportability and generally, the models with high AUROC had adequate internal calibration although some external validations show they could benefit from recalibration. For short-term opportunistic and all infections, as well as 5-year cancer models, we were unable to achieve a high enough AUROC to warrant validating externally.

Disclosure of Interests:

Cynthia Yang: None declared, Ross Williams: None declared, Joel Swerdel Shareholder of: J&J shares, Grant/research support from: Full-time employment salary from Janssen, Consultant of: Janssen employee, Employee of: Janssen, Paid instructor for: Janssen employee, have instructed at conferences, Speakers bureau: Janssen employee, have spoken at conferences, Meghna Jani Speakers bureau: Grifols, Talita Duarte-Salles: None declared, Katerina Chatzidionysiou Consultant of: AbbVie, Pfizer, Lilly., Daniel Prieto-Alhambra Grant/research support from: Professor Prieto-Alhambra has received research Grants from AMGEN, UCB Biopharma and Les Laboratoires Servier, Consultant of: DPA’s department has received fees for consultancy services from UCB Biopharma, Speakers bureau: DPA’s department has received fees for speaker and advisory board membership services from Amgen, Patrick Ryan: None declared, Peter Rijnbeek: None declared

SAT0134 COMPARATIVE RISK OF CANCER ASSOCIATED WITH FIRST-LINE DMARDS USE IN RHEUMATOID ARTHRITIS: REAL WORLD EVIDENCE FROM THE OHDSI NETWORK

Background:

Conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) are recommended as first line treatment for rheumatoid arthritis (RA) patients, but limited information exists on the comparative risk of cancer associated with their use.

Objectives:

To compare the risk of incident overall (excluding non-melanoma skin) and site-specific cancers (colorectal, lung, lymphoma, leukaemia) associated with first-line use of csDMARDs in patients with RA.

Methods:

We conducted a multinational cohort study informed by data from 7 healthcare databases including claims and electronic medical records from 4 countries (SIDIAP-Spain, MDCR-US Optum-US, CCAE-US, IQVIA AMBEMR-US, IQVIA-Germany, THIN-UK) part of the Observational Health Data Sciences and Informatics (OHDSI) network. All patients aged ≥18 years who initiated methotrexate (MTX), hydroxychloroquine (HCQ), sulphasalazine (SSZ), or leflunomide (LEF) as first-line monotherapy after a diagnosis of RA between 2005 to 2018 were eligible. Individuals with a prior diagnosis of another inflammatory arthropathy or cancer, or <1 year of follow-up were excluded. Patients were followed from 1-year after treatment initiation to the earliest of incident cancer, loss to follow-up, or 5-years. Cox proportional-hazard models for MTX against each other csDMARD were performed after propensity score stratification. A large set of negative control outcomes were analysed to calibrate hazard ratios (cHRs). Estimates were pooled where homogeneity across sources was adequate (I2<0.4).

Results:

Across the databases, 127,547 RA patients initiating csDMARD therapy were included in the analyses (MTX: 73,996, HCL: 36,381 SSZ: 9,383 LEF: 7,787). The pooled incidence rate of overall cancer for MTX was 22.8 per 1,000 person years. The pooled summary and source-specific estimated cHRs for overall cancer are shown below in Figure 1. While little difference was seen for HCQ and SSZ compared to MTX, LEF was consistently associated with a reduced cancer risk: pooled cHR (95% CI) 0.67 (0.59 to 0.76) and cHRs ranged from 0.53 (0.36 to 0.80) in CCAE-US to 0.84 (0.58 to 1.22) in SIDIAP-Spain. There were insufficient cases to look site-specific cancers within data sources, although pooled results suggest little risk difference in leukemia, lymphoma, colorectal, or lung cancers.

Figure 1.

Calibrated hazard ratios (cHRs) of overall cancer risk with their respective confidence intervals (95%CI) by study database. Database estimates not reported where adequate covariate balance not attained. Meta-analysis results not reported where I2>0.4.

Conclusion:

Compared to MTX users, patients treated with LEF had a lower risk of overall cancer. Risk of four specific cancers did not differ by first line csDMARD exposure.

Disclosure of Interests: :

Talita Duarte-Salles: None declared, Martina Recalde: None declared, James Weaver Shareholder of: J&J Shares, Grant/research support from: Full-time employment salary from Janssen, Consultant of: Janssen employee, Employee of: Janssen, Paid instructor for: Janssen employee, have instructed at conferences, Speakers bureau: Janssen employee, have spoken at conferences, Edward Burn: None declared, Karine Marinier Employee of: Servier, Yesika Díaz: None declared, Ben Illingens: None declared, David Vizcaya Employee of: Bayer, Katerina Chatzidionysiou Consultant of: AbbVie, Pfizer, Lilly., Patrick Ryan: None declared, Daniel Prieto-Alhambra Grant/research support from: Professor Prieto-Alhambra has received research Grants from AMGEN, UCB Biopharma and Les Laboratoires Servier, Consultant of: DPA’s department has received fees for consultancy services from UCB Biopharma, Speakers bureau: DPA’s department has received fees for speaker and advisory board membership services from Amgen

THU0212 FIRST LINE TREATMENT WITH CONVENTIONAL SYNTHETIC DISEASE MODIFYING ANTIRHEUMATIC DRUGS IN RHEUMATOID ARTHRITIS: A MULTINATIONAL POPULATION-BASED COHORT FROM 14 REAL WORLD HEALTHCARE DATABASES AND 9 COUNTRIES - REALITY VERSUS GUIDELINES

Background:

Treatment guidelines recommend early initiation of csDMARDs following diagnosis of rheumatoid arthritis (RA), with methotrexate (MTX) as first-line therapy. Scarce evidence exists on adherence to this guidance

Objectives:

To characterize first-line csDMARD treatment during the first year following an RA diagnosis.

Methods:

14 real world databases (3 Primary care, 6 primary/secondary care records, 5 claims) from 9 countries were included, all mapped to the OMOP common data model.

Patients were included on the earliest event of: 1st diagnosis of RA or 1st DMARD prescription with an RA diagnosis within 30 days. Patients were >18 years-old, required 1+ year pre-index data, and at least 1-year follow-up. Study period covered 2000-2018. Previous users of DMARDs or non-RA inflammatory arthritis history were excluded. Only MTX, Hydroxychloroquine (HCQ), Sulfasalazine (SSZ) and Leflunomide (LEF) were available in all databases.

Results:

We identified 323,547 eligible participants. Large variation was observed internationally (Figure 1). MTX as first-line monotherapy ranged from 33.3% to 74.5%, and in combination with HCQ from 2.1% to 6.7%. Three additional csDMARDs were used as first-line: HCQ in 10.1% to 30.2%, SSZ in 0.9% to 28.7%, and LEF in 1.8% to 15.2%.

Figure 1.

First line csDMARD treatment during 1yr from first observed RA diagnosis

Conclusion:

We report wide heterogeneity of first-line csDMARDs regimens internationally. Despite recommendations for MTX to be first line therapy, data suggest that a large proportion of patients receive alternative csDMARD.

Disclosure of Interests: :

Anthony G Sena Shareholder of: J&J shares, Grant/research support from: Full-time employment salary from Janssen, Consultant of: Full-time employment salary from Janssen, Employee of: Janssen employee, Paid instructor for: Janssen employee, Speakers bureau: Janssen employee, Denis Granados: None declared, Nigel Hughes Shareholder of: J&J shares, Grant/research support from: Full-time employment salary from Janssen, Consultant of: Janssen employee, Employee of: Janssen employee, Paid instructor for: Janssen employee, Speakers bureau: Janssen employee, WALID FAKHOURI Shareholder of: E Lilly Shares, Employee of: Eli Lilly and Company, Antje Hottgenroth Shareholder of: Eli Lilly shares, Employee of: Lilly Deutschland GmbH, Raivo Kolde: None declared, Sulev Reisberg: None declared, Carmen Olga Torre: None declared, Talita Duarte-Salles: None declared, Yesika Díaz: None declared, Jose Felipe Golib-Dzib Grant/research support from: Full-time employment salary from Janssen, Employee of: Yes, Janssen employee, Paid instructor for: Janssen Employee, Speakers bureau: Janssen Employee, Emily S. Brouwer Shareholder of: J&J shares, Takeda shares, Grant/research support from: Full-time employment salary from Janssen, Consultant of: Janssen employee, Employee of: Janssen employee, Paid instructor for: Janssen Employee, Speakers bureau: Janssen Employee, Edward Burn: None declared, Jennifer Lane: None declared, David Vizcaya Employee of: Bayer, Sara Bruce Wirta Employee of: Janssen-Cilag Sweden AB, Marcel de Wilde: None declared, Katia Verhamme: None declared, Peter Rijnbeek: None declared, Elke Theander Employee of: Janssen-Cilag Sweden AB, Katerina Chatzidionysiou Consultant of: AbbVie, Pfizer, Lilly., Daniel Prieto-Alhambra Grant/research support from: Professor Prieto-Alhambra has received research Grants from AMGEN, UCB Biopharma and Les Laboratoires Servier, Consultant of: DPA’s department has received fees for consultancy services from UCB Biopharma, Speakers bureau: DPA’s department has received fees for speaker and advisory board membership services from Amgen, Patrick Ryan: None declared

SAT0131 CARDIO- AND CEREBROVASCULAR RISK WITH CONVENTIONAL SYNTHETIC DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (CSDMARDS) IN RHEUMATOID ARTHRITIS (RA): A REAL-WORLD COMPARATIVE ASSESSMENT

Background:

RA is associated with an increased cardiovascular (CV) risk. csDMARDs are first-line treatments for RA and can mitigate this risk, but limited data exist on their CV effects. Previous trials have reported protective effects for methotrexate (MTX) and hydroxychloroquine (HCQ), but no similar data exist on sulfasalazine (SSZ) or leflunomide (LEF).

Objectives:

To assess the comparative effect of csDMARDs on the risk of myocardial infarction (MI) and stroke in RA patients

Methods:

Data from 6 claims/electronic health records databases across Germany, US, and UK, all mapped to the Observational Medical Outcomes Partnership (OMOP) common data model. A cohort study was conducted including patients ≥18 years old, with first RA diagnosis in 2005-2019, initiating csDMARD monotherapy with MTX, HCQ, SSZ, or LEF. Those with a prior diagnosis of other inflammatory arthritis or <1 year prior follow-up were excluded. Patients were followed until first outcome, death, loss of or 5 years follow-up. Propensity score stratification was used, and hazard ratios (HR) estimated for HCQ, SSZ and LEF compared to MTX in each dataset using Cox regression. HR were calibrated (cHR) for residual confounding using negative control outcomes. Estimates were pooled where I2for heterogeneity <0.4. Intention to treat and an on treatment analyses are reported.

Results:

145,248 patients were included (MTX: 73,996, HCQ: 49,752, SSZ: 12,256, LEF: 9,244). Pooled rates of MI and stroke for MTX were 7.64 and 10.26 per 1,000 person years respectively. Detailed estimate cHRs are shown in Figure 1 for the intention to treat analysis. MI risk with SSZ and LEF was comparable to MTX. Risk of stroke was similar between LEF and MTX, but reduced for HCQ and SSZ compared to MTX, with pooled cHR (95% CI) 0.86 (0.78 to 0.95) and 0.71 (0.52 to 0.98) for HCQ and SSZ respectively. Similar results were found for “on treatment” analyses.

Figure 1.

Calibrated hazard ratios (cHRs) for MI and stroke

Conclusion:

Overall, all four csDMARDs had similar effects on MI risk. HCQ and SSZ use were associated with a decreased risk of stroke compared to MTX. The observed differences may be attributable to differential effects on the atherosclerotic process, differential disease control, or both.

Database estimates not reported where adequate covariate balance not attained. Meta-analysis results not reported where I2>0.4. MEDICARE did not pass diagnostics for SSZ and LEF analyses. cHR: calibrated Hazard Ratio; CI: Confidence Interval; MTX: Methotrexate; HCQ: Hydroxychloroquine; SSZ: sulphasalazine; LEF: Leflunomide; THIN: The Health Improvement Network (UK); Optum: Optum de-identified Clinformatics Datamart (US); MDCR: Medicare (US); GERMANY: IQVIA Disease Analyzer EMR (Germany); CCAE: IBM MarketScan Commercial Claims and Encounters (US); AMBEMR: IQVIA Ambulatory EMR (US)

Database estimates not reported where adequate covariate balance not attained. Meta-analysis results not reported where I2>0.4. MEDICARE did not pass diagnostics for SSZ and LEF analyses. cHR: calibrated Hazard Ratio; CI: Confidence Interval; MTX: Methotrexate; HCQ: Hydroxychloroquine; SSZ: sulphasalazine; LEF: Leflunomide; THIN: The Health Improvement Network (UK); Optum: Optum de-identified Clinformatics Datamart (US); MDCR: Medicare (US); GERMANY: IQVIA Disease Analyzer EMR (Germany); CCAE: IBM MarketScan Commercial Claims and Encounters (US); AMBEMR: IQVIA Ambulatory EMR (US)

Disclosure of Interests: :

Albert Prats-Uribe: None declared, Ben Illingens: None declared, David Vizcaya Employee of: Bayer, James Weaver Shareholder of: J&J Shares, Grant/research support from: Full-time employment salary from Janssen, Consultant of: Janssen employee, Employee of: Janssen, Paid instructor for: Janssen employee, have instructed at conferences, Speakers bureau: Janssen employee, have spoken at conferences, Edward Burn: None declared, Ruta Sawant Shareholder of: AbbVie, Employee of: AbbVie, Karine Marinier Employee of: Servier, Patrick Ryan: None declared, Daniel Prieto-Alhambra Grant/research support from: Professor Prieto-Alhambra has received research Grants from AMGEN, UCB Biopharma and Les Laboratoires Servier, Consultant of: DPA’s department has received fees for consultancy services from UCB Biopharma, Speakers bureau: DPA’s department has received fees for speaker and advisory board membership services from Amgen

SAT0138 DRUG-RELATED PANCYTOPENIA AND LEUKOPENIA IN RHEUMATOID ARTHRITIS: ARE ALL CSDMARDS EQUAL?

Background:

Cytopenia is a known side-effect of conventional synthetic disease modifying anti-rheumatic drugs (csDMARDs) in rheumatoid arthritis (RA). There is a lack of data on the comparative risk of cytopenia with different csDMARDs.

Objectives:

To assess the comparative risk of leukopenia and pancytopenia for the most frequently used first-line csDMARDs: methotrexate (MTX), hydroxychloroquine (HCQ), sulphasalazine (SSZ), and leflunomide (LEF).

Methods:

The study used data from 7 databases from 4 countries: CCAE, MDCR, Optum, IQVIA Ambulatory EMR (US); IQVIA THIN IMRD EMR (UK); IQVIA Disease Analyzer EMR (Germany); and SIDIAP (Spain). Cohorts included adult patients with a diagnosis of RA from 2005 to 2019 with at least one-year prior follow-up, no prior inflammatory arthritis, initiaton of first-line csDMARD, and no cytopenia in the preceding 30 days. Participants were followed from one day after treatment initiation to the earliest of event occurrence, treatment discontinuation/switching plus 14 days in the on-treatment analysis, five years in the intent-to-treat (ITT) analysis, or loss to follow-up. MTX was used as reference group. Cox models were fitted with propensity score stratification for observed confounding and negative control outcomes calibration for residual error. Estimates across database were pooled where I2<40% was seen.

Results:

Overall 166,347 patients were included. Pooled rates of leukopenia and pancytopenia for MTX were 10.9 and 3.2 per 1,000 person years, respectively. Figure 1 and 2 show the results for the different databases and pooled estimates where applicable. Database estimates are not reported where adequate covariate balance not attained, and meta-analysis not shown where I2>0.4. MTX showed slightly higher hazards of leukopenia and of pancytopenia compared to LEF but no consistently differential risks compared to HCQ or SSZ.

Figure 1.

Calibrated hazard ratios (95% CI) vs MTX, on-treatment analysis

Conclusion:

Cytopaenia is rare, and apparently more frequent with MTX and less with LEF. Since prior full blood counts were inconsistently obtained in fewer than 50% of csDMARD new users (e.g. more frequent in MTX [42%] than HCQ [32%] in CCAE and Optum; roughly equal in MDCR), these results should inform future monitoring recommendations.

Figure 2.

Calibrated hazard ratios (95% CI) vs MTX, ITT analysis

Disclosure of Interests:

Loreto Carmona Grant/research support from: Novartis Farmaceutica, SA, Pfizer, S.L.U., Merck Sharp & Dohme España, S.A., Roche Farma, S.A, Sanofi Aventis, AbbVie Spain, S.L.U., and Laboratorios Gebro Pharma, SA (All trhough institution), James Weaver Shareholder of: J&J Shares, Grant/research support from: Full-time employment salary from Janssen, Consultant of: Janssen employee, Employee of: Janssen, Paid instructor for: Janssen employee, have instructed at conferences, Speakers bureau: Janssen employee, have spoken at conferences, Edward Burn: None declared, Ben Illingens: None declared, David Vizcaya Employee of: Bayer, Ruta Sawant Shareholder of: AbbVie, Employee of: AbbVie, Talita Duarte-Salles: None declared, Patrick Ryan: None declared, Daniel Prieto-Alhambra Grant/research support from: Professor Prieto-Alhambra has received research Grants from AMGEN, UCB Biopharma and Les Laboratoires Servier, Consultant of: DPA’s department has received fees for consultancy services from UCB Biopharma, Speakers bureau: DPA’s department has received fees for speaker and advisory board membership services from Amgen

The Impact of the Storm Emma on Irish Emergency Department Attendances

Aim The impact of severe weather events on Irish EDs has not yet been characterised. The aim of this study was to examine the impact of Storm Emma on the attendance patterns to an Irish ED. Methods Data was collected for 64hrs prior to the red alert (Pre-Red), 38hrs of the red alert (Red) and for the 256 hrs (10 days) post the red alert (Post-Red) during Storm Emma. A Comparison was made with the same time periods in 2017. Results There was a statistically significant decrease in attendance during the Red period in 2018, compared with 2017 (119 vs. 234, p<0.001), with a rebound surge in attendances in the Post-Red period (1,861 vs 1,578, p<0.001). Mean patient experience times were significantly longer in the Post-Red period in 2018 (9.5+/-9.5hrs vs 7.9+/-8.2hrs, p<0.001). Conclusion This study has detailed the impact of a severe weather event on an Irish ED and will help inform preparedness for the future.

Peritoneal Equilibration Test

Peritoneal transfer rates of urea, creatinine, glucose, protein potassium, and sodium as well as drain and residual volumes were measured during 103 equilibration tests performed in 18 diabetic and 68 nondiabetic patients. Equilibration test was performed over a 4-hour dwell exchange with 2 L of 2.5% Dianeal solution. Excellent reproducibility was seen after tests were standardized for length of preceding exchange, times of inflow and drainage, patient position, methods of obtaining and processing samples and laboratory assays. Diabetics did not have lower peritoneal solute transfers than nondiabetics. Wide variations were found in the study population.

Measurements of creatinine, glucose and sodium transfer were particularly useful in predicting the patient's response to the standard CAPO. The patients with highaverage peritoneal solute transport did well on standard CAPO even after losing residual renal function. Patients with high peritoneal solute transfer rates were likely to have inadequate ultrafiltration on standard CAPO. These patients did much better on dialysis modalities with short dwell exchanges, i.e. nightly peritoneal dialysis (NPO) or daytime ambulatory peritoneal dialysis (OAPO). Patients with low average, and particularly low peritoneal transport rates were likely to develop symptoms and signs of inadequate dialysis as their residual renal function became negligible, particularly in individuals with high body surface area.

Repeated tests were helpful in evaluating causes of insufficient ultrafiltration and/or inadequate dialysis.

Catheter Break-in for Continuous Ambulatory Peritoneal Dialysisuniversity of Missouri Experience

Retrospective analysis of the results of several break-in techniques in our institution revealed that a 10 day delay in CAPD initiation after a midline Tenckhoff catheter insertion is sufficient to prevent leakage in patients maintained on intermittent peritoneal dialysis. A leak or obstruction related to an insufficient surgical technique can be promptly diagnosed and corrected. An irrigation technique seems to be useful in non-uremic patients, but frequently fails to disclose a one-way obstruction with a consequent delay in a surgical correction. Recently we have introduced a modification of this technique in which the patency of the catheter is checked with one in and out exchange using a small volume of dialysate during outpatient clinic visits every 2– 3 days.

Management of Staphylococcus aureus bacteraemia (SAB) in the oncology patient: Further evidence supports prompt removal of central venous catheters and shorter duration of intravenous antimicrobial therapy

Background

Staphylococcus aureus bacteraemia (SAB) is associated with relatively high risk of complications and high levels of mortality. Internationally, SAB management guidelines lack consensus and especially so regarding oncology patients. This is likely a reflection of insufficient randomised control trials (RCT) and the diversity of SAB patient populations. However, there are 2011 guidelines recommending a minimum of 14 days of appropriate IV antibiotic therapy for SAB.

Objective

We wished to determine whether our practice of shortened duration of intravenous antimicrobial therapy in favour of oral administration proved as effective as recommended guidelines in a mixed oncology patient cohort.

Methods

Retrospective review of patient records that included any SAB episode among oncology patients from January 2002 to December 2015. Medical chart reviews were undertaken to determine patient demographics, clinical management & antimicrobial therapy, duration of stay, presence of a central venous catheter (CVC) and outcome.

Results

Our CVC removal rate was just 73% in SAB where CVC was the identified source of infection, with an attributable mortality rate (<4%) far lower than would be expected. Antimicrobial therapy durations were considerably lower (10 days) than current recommendations of 14 days IV therapy. The recurrence rate of 15% was also significantly lower than has been reported previously.

Conclusions

Our observations contribute new insights concerning the management of SAB in oncology patients. Our findings suggest that therapeutic approaches should perhaps remain individualised and reflective of patient characteristics taking into consideration the complex nature of oncology patients.

Hospital effluent: A reservoir for carbapenemase-producing Enterobacterales?

Antimicrobial resistance is a major public health concern. Carbapenemase-producing Enterobacterales (CPE) represent a significant health threat as some strains are resistant to almost all available antibiotics. The aim of this research was to examine hospital effluent and municipal wastewater in an urban area in Ireland for CPE. Samples of hospital effluent (n = 5), municipal wastewater before (n = 5) and after (n = 4) the hospital effluent stream joined the municipal wastewater stream were collected over a nine-week period (May-June 2017). All samples were examined for CPE by direct plating onto Brilliance CRE agar. Isolates were selected for susceptibility testing to 15 antimicrobial agents in accordance with EUCAST criteria. Where relevant, isolates were tested for carbapenemase-encoding genes by real-time PCR. CPE were detected in five samples of hospital effluent, one sample of pre-hospital wastewater and three samples of post-hospital wastewater. Our findings suggest hospital effluent is a major contributor to CPE in municipal wastewater. Monitoring of hospital effluent for CPE could have important applications in detection and risk management of unrecognised dissemination of CPE in both the healthcare setting and the environment.

Lanreotide vs octreotide LAR for patients with advanced gastroenteropancreatic neuroendocrine tumors: An observational time and motion analysis

BACKGROUND

Lanreotide and octreotide acetate suspension for injectable (LAR) are both recommended for clinical use in patients with locally advanced or metastatic gastroenteropancreatic neuroendocrine tumors. However, each agent possesses unique attributes in terms of their drug-delivery characteristics. The study objective was to compare overall drug-delivery efficiency between lanreotide and octreotide LAR in gastroenteropancreatic neuroendocrine tumor patients.

METHODS

This study employed an observational time and motion design among patients treated with lanreotide or octreotide LAR across five US cancer centers. Baseline patient data collection included age, disease grade and duration, prior therapies and performance status. Drug-delivery time (drug preparation and administration), total patient time and resource use data were collected for gastroenteropancreatic neuroendocrine tumors receiving lanreotide (n = 22) or octreotide LAR (n = 22). Following each administration, qualitative data on the drug-delivery experience was collected from patients and nurses.

RESULTS

Lanreotide was associated with a significant reduction in mean delivery time (2.5 min; 95% CI:2.0 to 3.1) compared to octreotide LAR (6.2 min; 95%CI: 4.4 to 7.9; p = 0.004). The mean total patient time for lanreotide and octreotide LAR was comparable between groups (32.1 vs. 36.6 minutes; p = 0.97). Nurses reported increased concerns with octreotide LAR related to needle clogging (p = 0.034) and device failures (p = 0.057). Overall, lanreotide had a median satisfaction score of 5.0 compared to a score of 4.0 with octreotide LAR (p = 0.03).

CONCLUSIONS

Lanreotide was associated with significant reductions in drug-delivery time compared to octreotide LAR, which contributed to an improvement in overall healthcare efficiency.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT03017690.

Ovine model as a surgical simulator for pediatric laryngotracheal reconstruction

OBJECTIVES

There are increasing pressures on the health system and training programs to provide adequate training opportunities for surgical trainees. This is particularly true with respect to complex procedures that are performed less commonly. We sought to develop an ovine model for the simulation of pediatric laryngotracheal reconstruction (LTR) and validate its use for training.

METHODS

Knee-high lamb specimens were sourced from an accredited Australian abattoir that included structures of the neck, cervical spine and subcutaneous tissues from the thyroid cartilage to the carina. Specimens were positioned and draped to simulate surgical exposure. Otorhinolaryngology residents and consultants performed two LTRs on separate specimens that were video recorded for assessment of performance.

RESULTS

Sixteen LTRs were performed by eight participants. Performance of experienced (advanced) participants was significantly better than novice participants (p = 0.001). There was a strong linear association between general surgical competence and procedural performance (r = 0.88). The developed assessment scales demonstrated strong reliability and internal consistency (Cronbach's α = 0.83).

CONCLUSIONS

The complexity of pediatric airway surgery makes simulation an attractive option for developing skills that are transferrable to the operating setting. The ovine model presented here has similarities in size, structure and tissue characteristics to the pediatric airway that make it an ideal model for simulating pediatric LTR. It is a low-cost, readily available option for otorhinolaryngology residents to develop and refine essential skills throughout their training.

From resilience thinking to Resilience Planning: Lessons from practice

Resilience thinking has frequently been proposed as an alternative to conventional natural resource management, but there are few studies of its applications in real-world settings. To address this gap, we synthesized experiences from practitioners that have applied a resilience thinking approach to strategic planning, called Resilience Planning, in regional natural resource management organizations in Australia. This case represents one of the most extensive and long-term applications of resilience thinking in the world today. We conducted semi-structured interviews with Resilience Planning practitioners from nine organizations and reviewed strategic planning documents to investigate: 1) the key contributions of the approach to their existing strategic planning, and 2) what enabled and hindered the practitioners in applying and embedding the new approach in their organizations. Our results reveal that Resilience Planning contributed to developing a social-ecological systems perspective, more adaptive and collaborative approaches to planning, and that it clarified management goals of desirable resource conditions. Applying Resilience Planning required translating resilience thinking to practice in each unique circumstance, while simultaneously creating support among staff, and engaging external actors. Embedding Resilience Planning within organizations implied starting and maintaining longer-term change processes that required sustained multi-level organizational support. We conclude by identifying four lessons for successfully applying and embedding resilience practice in an organization: 1) to connect internal "entrepreneurs" to "interpreters" and "networkers" who work across organizations, 2) to assess the opportunity context for resilience practice, 3) to ensure that resilience practice is a learning process that engages internal and external actors, and 4) to develop reflective strategies for managing complexity and uncertainty.

Persistently altered liver test results in hepatitis C patients after sustained virological response with direct-acting antivirals

Guidelines recommend evaluating persistent alteration of liver tests in HCV-infected patients after sustained virological response (SVR) and its influence on liver disease progression. We studied the prevalence, etiology, associated factors and evolutionary implications of persistent alteration of liver tests in HCV patients after direct-acting antivirals (DAA)-induced SVR. This was a prospective study of HCV-infected patients and SVR after DAA. Those with another previously diagnosed liver disease were excluded. Persistent alteration of liver tests was defined as any increase in ALT, AST or GGT at SVR12 and SVR24. Causes were determined according to standard clinical practice, including liver biopsy and follow-up transient elastography. A total of 1112 patients were included (70.8% males, median age 53 years, 38.8% cirrhosis, 34.9% interferon-experienced, 56.8% HIV-coinfected). Persistent alteration of liver tests was detected in 130/1112 patients (11.7% [95%CI: 9.7-13.6]). Its frequency differed between HCV-monoinfected (45/480: 9.4% [95%CI: 6.7-12.1]) and HIV-coinfected (85/632: 13.5% [95%CI: 10.7-16.2]) (P = .046). In multivariable analysis, cirrhosis (OR 2.12; 95%CI: 1.28-3.53; P = .004) and baseline transient elastography values (OR 1.03; 95%CI: 1.01-1.04; P = .000) were associated with persistent alteration of liver tests. The main etiologies were clinical diagnosis suggestive of nonalcoholic fatty liver disease in 47 (36.2%), alcohol in 30 (23.1%) and drug consumption in 19 (14.6%). Baseline and follow-up transient elastography was performed in 594 patients and showed a significantly different decrease in patients who did or did not have a persistent alteration of liver tests (-21.1% vs -30%, respectively; P = .003), independently of sex, HIV status or baseline TE value. In conclusion, persistent alteration of liver tests is not infrequent after SVR. It is associated with cirrhosis and baseline transient elastography, and the main cause is fatty liver. According to transient elastography changes, persistent alteration of liver tests seems to affect the course of liver disease.

Optimising perioperative care for hip and knee arthroplasty in South Africa: a Delphi consensus study

Background

A structured approach to perioperative patient management based on an enhanced recovery pathway protocol facilitates early recovery and reduces morbidity in high income countries. However, in low- and middle-income countries (LMICs), the feasibility of implementing enhanced recovery pathways and its influence on patient outcomes is scarcely investigated. To inform similar practice in LMICs for total hip and knee arthroplasty, it is necessary to identify potential factors for inclusion in such a programme, appropriate for LMICs.

Methods

Applying a Delphi method, 33 stakeholders (13 arthroplasty surgeons, 12 anaesthetists and 8 physiotherapists) from 10 state hospitals representing 4 South African provinces identified and prioritised i) risk factors associated with poor outcomes, ii) perioperative interventions to improve outcomes and iii) patient and clinical outcomes necessary to benchmark practice for patients scheduled for primary elective unilateral total hip and knee arthroplasty.

Results

Thirty of the thirty-three stakeholders completed the 3 months Delphi study. The first round yielded i) 36 suggestions to preoperative risk factors, ii) 14 (preoperative), 18 (intraoperative) and 23 (postoperative) suggestions to best practices for perioperative interventions to improve outcomes and iii) 25 suggestions to important postsurgical outcomes. These items were prioritised by the group in the consecutive rounds and consensus was reached for the top ten priorities for each category.

Conclusion

The consensus derived risk factors, perioperative interventions and important outcomes will inform the development of a structured, perioperative multidisciplinary enhanced patient care protocol for total hip and knee arthroplasty. It is anticipated that this study will provide the construct necessary for developing pragmatic enhanced care pathways aimed at improving patient outcomes after arthroplasty in LMICs.

Suicide amongst people with intellectual disability: An Australian online study of disability support staff experiences and perceptions

BACKGROUND

Individuals with intellectual disability (ID) have a higher likelihood of exposure to identified risk factors for suicide when compared with the general community and have been recognised as being both capable of forming intent for suicide and acting on this intent. However, in spite of research outlining these concerns from the 1970s, there remains a dearth of studies that examine suicide amongst the population of people with ID.

METHOD

An online cross-sectional survey was purposively developed, with questions aimed at identifying both the experiences and current practices of support staff who assist people with ID in relation to suicide, suicidal behaviour and suicide assessment. It was undertaken across both rural and metropolitan areas in Australia. The survey was open for a period of 12 months. A total of 139 respondents (109 female/30 male), with a mean age of 41 and an average 12 years of experience in supporting people with ID, completed the tool.

RESULTS

A total of nine suicides by people with ID were reported. Seventy-seven per cent of the respondents reported that they had individuals with ID display suicidal behaviours, and 76% noted that a person had specifically talked about wishing to end their life. Only four participants (3%) noted that they did not support individuals with a dual diagnosis of ID and mental health concern. Sixty per cent of participants reported that no one in their organisation had ever completed a suicide risk assessment, and only 28% reported that they would do a suicide risk assessment if an individual that they supported was diagnosed with a mental health issue.

CONCLUSIONS

The current findings indicate that support staff recognise the capacity of people with ID to conceptualise suicide, note the existence of suicidal discussions and behaviours and report on actual suicides. This represents one of the few Australian studies that has specifically considered suicide amongst this cohort of people and reinforces the fact that suicide is not unknown in this population. The data indicate a possible divide between the reports of people with ID actively talking about and acting on suicidal thoughts and the lack of any proactive use of any tools to assess for this risk.

Observation and understanding of anisotropic strain relaxation in selectively grown SiGe fin structures

The performance of heterogeneous 3D transistor structures critically depends on the composition and strain state of the buffer, channel and source/drain regions. In this paper we used an in-line high resolution x-ray diffraction (HRXRD) tool to study in detail the composition and strain in selectively grown SiGe/Ge fin structures with widths down to 20 nm. For this purpose we arranged fins of identical dimensions into larger arrays which were then analyzed using an x-ray beam several tens of micrometers in size. Asymmetric reciprocal space maps measured both parallel and perpendicular to the fins allowed us to extract the lattice parameters in all three spatial directions. Our results demonstrate an anisotropic in-plane strain state of the selectively grown SiGe buffer in case of narrower fins with significantly reduced relaxation in the direction along the fin. This observation was verified using nano-beam electron diffraction, and is explained based on the reduced probability for dislocation half-loops to evolve in trenches narrower than a few times the critical radius. Moreover, we introduce and discuss in detail a methodology for the determination of the composition in case of an anisotropic in-plane strain state which differs from the procedure commonly used for blanket layers. Our findings verify the importance of in-line HRXRD measurements for process development and monitoring as well as the fundamental study of relaxation and defect formation in confined volumes.

Evaluation of fixed and variable hospital costs due to Clostridium difficile infection: institutional incentives and directions for future research

BACKGROUND

Economic analysis of Clostridium difficile infection (CDI) should consider the incentives facing institutional decision-makers. To avoid overstating the financial benefits of infection prevention, fixed and variable costs should be distinguished.

AIM

To quantify CDI fixed and variable costs in a tertiary referral hospital during August 2015.

METHODS

A micro-costing analysis estimated CDI costs per patient, including the additional costs of a CDI outbreak. Resource use was quantified after review of patient charts, pharmacy data, administrative resource input, and records of salary and cleaning/decontamination expenditure.

FINDINGS

The incremental cost of CDI was €75,680 (mean: €5,820 per patient) with key cost drivers being cleaning, pharmaceuticals, and length of stay (LOS). Additional LOS ranged from 1.75 to 22.55 days. For seven patients involved in a CDI outbreak, excluding the value of the 58 lost bed-days (€34,585); costs were 30% higher (€7,589 per patient). Therefore, total spending on CDI was €88,062 (mean: €6,773 across all patients). Potential savings from variable costs were €1,026 (17%) or €1,768 (26%) if outbreak costs were included. Investment in an antimicrobial pharmacist would require 47 CDI cases to be prevented annually. Prevention of 5%, 10% and 20% CDI would reduce attributable costs by €4,403, €8,806 and €17,612. Increasing the incremental LOS attributable to CDI to seven days per patient would have increased costs to €7,478 or €8,431 (if outbreak costs were included).

CONCLUSION

As much CDI costs are fixed, potential savings from infection prevention are limited. Future analysis must consider more effectively this distinction and its impact on institutional decision-making.

Spatial and Temporal Variation in Aedes aegypti and Aedes albopictus (Diptera: Culicidae) Numbers in the Yogyakarta Area of Java, Indonesia, With Implications for Wolbachia Releases

of mosquito vector populations, particularly through Wolbachia endosymbionts. The success of these strategies depends on understanding the dynamics of vector populations. In preparation for Wolbachia releases around Yogyakarta, we have studied Aedes populations in five hamlets. Adult monitoring with BioGent- Sentinel (BG-S) traps indicated that hamlet populations had different dynamics across the year; while there was an increase in Aedes aegypti (L.) and Aedes albopictus (Skuse) numbers in the wet season, species abundance remained relatively stable in some hamlets but changed markedly (>2 fold) in others. Local rainfall a month prior to monitoring partly predicted numbers of Ae. aegypti but not Ae. albopictus. Site differences in population size indicated by BG-S traps were also evident in ovitrap data. Egg or larval collections with ovitraps repeated at the same location suggested spatial autocorrelation (<250 m) in the areas of the hamlets where Ae. aegypti numbers were high. Overall, there was a weak negative association (r<0.43) between Ae. aegypti and Ae. albopictus numbers in ovitraps when averaged across collections. Ae. albopictus numbers in ovitraps and BG-S traps were positively correlated with vegetation around areas where traps were placed, while Ae. aegypti were negatively correlated with this feature. These data inform intervention strategies by defining periods when mosquito densities are high, highlighting the importance of local site characteristics on populations, and suggesting relatively weak interactions between Ae. aegypti and Ae. albopictus. They also indicate local areas within hamlets where consistently high mosquito densities may influence Wolbachia invasions and other interventions.

151 COMPARATIVE ANALYSIS OF FRESH AND CRYOPRESERVED BOAR SPERMATOZOA USING RNA SEQUENCING

Fertility of cryopreserved spermatozoa is significantly reduced compared with that of their fresh counterparts, which is certainly due to the inflicted sublethal damage to spermatozoa that is observed at various molecular and cellular levels. The identification and characterisation of this damage will help us better understand sperm cryobiology and therefore develop suitable media and procedures to improve sperm cryopreservation and fertility outcomes, especially in swine. Here, we present our preliminary assessment of RNA pools of fresh and frozen‐thawed spermatozoa using RNA-sequencing technology. Semen ejaculates of 8 fertile boars were harvested and divided into 2 fractions for each ejaculate. Fraction 1 was freshly extended in commercial diluent (FD) and fraction 2 was frozen in 5-mL plastic straws (FT). Both specimens were shipped to our laboratory for analyses. The samples were purified through Percoll gradient centrifugation and resulting motile spermatozoa were washed in cold PBS. Pelleted spermatozoa were used for total RNA extraction, followed by an in-column DNase digestion. Purity and integrity of RNA samples were checked and rRNA depleted. After random priming, 40 million short cDNA reads were produced using Illumina RNA-Seq technology (Illumina Inc., San Diego, CA, USA). All reads were aligned to the pig reference genome and the produced genome-scale transcription maps consisted of both the transcript structure and the expression level of each gene mapped. Analysis of FD sperm RNA revealed a total of 18 357 sequence tags that were successfully mapped to all pig chromosomes and the mitochondrial genome. Frozen‐thawed spermatozoa showed only 16 864 sequence tags. In both FD and FT samples, chromosomes 1, 2, 6, 7, and 13 contained, in total, the highest density of mapped transcripts (>42%). Chromosome Y and mitochondrial RNAs had the lowest sequence tags mapped (<0.08%). A comparative analysis of FD and FT datasets revealed a net decrease in the total number of sequence tags (1493) with each chromosome being affected, except mitochondria. Chromosomes of FT samples showed a strong (>10%; 17, 7, 4, Y, and X) to moderate (10 to 5%) or weak (≤5%) reduction in RNA numbers. Structural annotation revealed a diverse population of sperm transcripts comprising both coding (mRNA) and noncoding (rRNA, snRNA, and mtRNA) RNAs. In both FD and FT samples, noncoding RNAs were among the most abundant sequence tags. Approximately 12 355 of sequence tags in FD v. 10 948 in FT spermatozoa were annotated with ENSEMBL and the selected genes are under investigation for comparative analyses using RT-PCR. In conclusion, mature boar spermatozoa contain a large pool of coding and non-coding RNAs that can be affected by the freezing-thawing procedure. Inflicted damage affects RNAs of all chromosomes with a great effect being seen on chromosome X. Generated datasets have the potential to lead to further study of the cryo-damage associated with reduced fertility of cryopreserved spermatozoa. Study was supported by USDA-ARS Biophotonics initiative grant # 58-6402-3-0120 and MAFES-SRI grants.

187 EXPLOITATION OF IN VITRO CAPACITATION FOR NANOPARTICLE INCORPORATION WITHIN MAMMALIAN SPERMATOZOA

Migration and interactions of mammalian gametes occur in deep body tissues after mating, rendering difficult any in situ noninvasive evaluation of their performances with current methods. In our effort to develop an effective and real-time in vivo imaging approach, we have successfully labelled porcine gametes with self-illuminating bioluminescent and red-shifted quantum dot nanoparticles (QD) in our previous studies (Feugang et al. 2012 J. Nanobiotechnol. 10, 45; Feugang et al. 2015, J. Nanobiotechnol. 13, 38). The present effort aimed at investigating whether QD could be incorporated into spermatozoa through induced in vitro capacitation, which increases sperm plasma membrane fluidity. Fresh extended boar semen was placed on top of a Percoll gradient and centrifuged. Purified motile spermatozoa were collected and washed with pre-warmed PBS. Pelleted spermatozoa were resuspended in the modified Tris-buffered medium with BSA fraction-V (1 mg mL–1; modified Tween medium B with milk powder and BSA). Sperm aliquots (108) were supplemented or not (control) with QD only (QD+; 1 nM), QD+caffeine (2 mM), or QD+heparin (10 µg mL–1); with caffeine and heparin being used as routine capacitant agents in fertilization media. All aliquots were incubated at 38.5°C, under 5% CO2 for 0.5, 1, or 3 h. Spermatozoa were then analysed for motility characteristics and imaged for confirmation of QD-sperm interactions (bioluminescence emission) and localization (transmission electron microscope; TEM). Motility data of 5 replicates were analysed with ANOVA-2, and P < 0.05 was set as threshold of significance. Total sperm motility (TSM) significantly improved with the presence of either or both QDs and capacitant agents after 0.5 and 1 h incubations. With exception of the QD+heparin, all other groups had significantly decreased TSM after 3 h of incubation, when compared with TSM at 0.5 and 1 h. Higher proportions of progressive and rapid (≥45 µm s–1) spermatozoa were observed in the presence of both capacitant agents (P < 0.05), and only QD+heparin maintained greater proportions after 3 h. Sperm straight-line velocity significantly increased in the QD+caffeine at 0.5 h and in both QD+caffeine and QD+heparin thereafter. Sperm straightness data were increased by both caffeine and heparin during incubations. Strong bioluminescence signals were observed in spermatozoa incubated with QDs compared to the background signal seen in the control group. The TEM images revealed consistent surface membrane attachment of QDs in all QD+ groups, whereas transmembrane and intra-spermatic localizations were visible in both QD+caffeine and QD+heparin groups. We concluded that supplementations of medium containing QDs with caffeine or heparin allow the crossing of sperm plasma membrane by QD. No toxic effect of QD on sperm motility was observed, which confirmed our previous report using a similar ratio of QDs over spermatozoa. Exploration of efficient incorporation of QD into spermatozoa as a promising approach for noninvasive molecular imaging is still ongoing, as well as further sperm viability assessments. Supported by the NIH grant #5T35OD010432 and USDA-ARS Biophotonics Initiative grant #58–6402–3-0120.