Sport-related concussion attitudes and knowledge in elite English female footballers

BACKGROUND

Sport-related concussions (SRC) are more common and more severe in women's football than men's yet the knowledge and attitudes of SRC in the women's game are not well understood. The objective of this study was to assess the SRC knowledge and attitude in elite female footballers.

METHODS

An online questionnaire was sent to all registered players in the English Football Association Women's Super League (WSL) and Championship. Respondents completed an amended version of the Rosenbaum Concussion Knowledge and Attitudes Survey (RoCKAS). Concussion Knowledge Index (CKI) and Concussion Attitudes Index (CAI) scores were derived for all respondents.

RESULTS

One hundred and twenty-three players completed the survey with 111 fitting the inclusion criteria. The mean CKI score was 20.5 ± 2.3 and the mean CAI score was 63.3 ± 6.3. A weak positive correlation was shown between the CKI and CAI (r = 0.20; p = 0.03). Previous concussion education had a significant impact on increased knowledge (U = 1198; p = 0.04). There was no significant difference in concussion attitudes and knowledge between the WSL and Championship or in those with a previous concussion history and no previous concussion (p > 0.05).

CONCLUSION

Previous SRC education demonstrated an increased knowledge around concussion but a limited impact towards concussion attitudes. It is suggested that concussion education should be mandated across the professional game to enhance player welfare.

Sport-related concussion knowledge and attitudes of staff working in English elite women's football: a survey-based study

BACKGROUND

Sport-related concussion (SRC) remains an injury of concern in sport, including football(soccer). There has been little investigation into SRC knowledge and attitudes of support staff working in the professional setting.

METHODS

An amended version of the Rosenbaum Concussion Knowledge and Attitudes Survey(RoCKAS) was distributed online to coaching staff, and medical and performance staff, working at clubs in the English Football Association Women's SuperLeague (WSL) and Championship. Completion of the survey generated two scores: concussion knowledge index (CKI) and concussion attitudes index (CAI).

RESULTS

Sixty-three completed surveys were returned. Eighteen respondents were coaching staff, and 45 were medical and performance staff. The median CKI in medical and performance staff was significantly greater than in coaching staff. There was no significant difference in CAIbetween coaching staff and medical and performance staff. There was no correlation between CKI and CAI across all staff.

CONCLUSION

Medical and performance staff working in elite women's football have greater knowledge of SRC than coaching staff. However, this does not always translate into safe behaviours on the field. Education should continue to be mandated across the professional game amongst support staff in order to maximise player welfare and enhance injury outcomes, whilst also reinforcing present SRC guidance.

Year-round injury and illness surveillance in UK summer paralympic sport athletes: 2016-2019

OBJECTIVE

To identify the priority injuries and illnesses across UK summer Paralympic World Class Programmes (WCP).

METHODS

Four years (2016-2019) of electronic medical records from 360 athletes across 17 Paralympic WCP sports were analysed. Methods were based on the 2021 International Paralympic Committee translation of the original 2020 International Olympic Committee consensus statement for epidemiological recording and reporting. This included reporting incidence (count of injury per athlete year) and burden (time loss days per athlete year) of injuries by impairment category.

RESULTS

836 injuries and 453 illnesses were recorded during the surveillance period, accounting for 34 638 and 10 032 time-loss days, respectively. 216 (60%) athletes reported at least one injury, while 171 (47.5%) reported at least one illness. There were 0.9 injuries per athlete year, resulting in a mean injury burden of 38.1 days per athlete year. The lumbar/pelvis, shoulder and thoracic/ribs body region had the greatest incidence whereas the shoulder, lumbar/pelvis and wrist had the greatest injury burden. All impairment categories had shoulder or lumbar/pelvis as the body region with the greatest incidence, however the burden of body areas did not always reflect the incidence. Athletes reported 0.5 illnesses per athlete year, resulting in an average illness burden of 11.3 days per athlete year. The respiratory, gastrointestinal, dermatological and genitourinary organ systems had the greatest illness incidence.

CONCLUSIONS

To optimise health and performance in Paralympic sport athletes, system-wide mitigation initiatives should target priority injury problems occurring in the lumbar/pelvis, shoulder, thoracic spine/ribs and wrist. Illness types causing the greatest burden vary with impairment group, and illness mitigation initiatives should consider athlete impairment types in their design, while continuing to note the high incidence of respiratory and gastrointestinal illness across all impairments. Further research should examine associated risk factors and the influence of impairment categorisation.

New Zealand rickettsia-like organism and Tenacibaculum maritimum vaccine efficacy study

A cohort of Chinook salmon juveniles was vaccinated, with an autogenous bivalent vaccine against New Zealand RLOs (NZ-RLO1) and Tenacibaculum maritimum. A proportion of the cohort was not vaccinated to act as controls. At smoltification, the fish were challenged with NZ-RLO1, NZ-RLO2, or T. maritimum. We found that challenge with T. maritimum by immersion in (7.5 × 105  cfu/mL of water) did not yield any pathology. Challenge with RLOs produced clinical signs that were more or less severe depending on the challenge route, dose or vaccination status. Survival was significantly higher for vaccinated fish within the groups challenged with NZ-RLO1 by intraperitoneal injection with a relative percent survival (RPS) of 48.84%. Survival was not significantly different between vaccinated and non-vaccinated fish for groups challenged with NZ-RLO2 by intraperitoneal injection or by NZ-RLO1 by immersion. Yet, anecdotally the clinical disease presentation (manifesting as haemorrhagic, ulcerative skin lesions) was more severe for the non-vaccinated fish. This study demonstrates that autogenous vaccine against NZ-RLO is protective against severe disease and death by NZ-RLO1 challenge which warrants implementation and further evaluation under field conditions. Yet, this study also highlights the importance of the route of administration and dose when evaluating pathogenicity and vaccine efficacy.

The incidence and burden of injuries in elite English youth female soccer players

This study aimed to investigate the incidence, severity and burden of injury in English elite youth female soccer players. Qualified therapists at six English girls' academies prospectively recorded all injuries that required medical attention or caused time loss for matches and training in 375 elite youth female soccer players (under-10 [U10], U12, U14 and U16) during the 2019/2020 season. One hundred- and eleven time-loss injuries (52 from training, 59 from matches) were sustained, resulting in 1,946 days absent (779 days from training injuries, 1,167 days from match injuries) from soccer activities. The injury incidence for matches (9.3/1000 hours, 95% CIs: 7.2-11.9) was significantly greater than training (1.1/1000 hours, 95% CIs: 0.9-1.5, p < 0.001). Additionally, the injury burden for matches (183 days lost/1000 hours, 95% CIs: 142-237) was significantly greater than training (17 days lost/1000 hours, 95% CIs: 13-22, p < 0.001). Injury incidence and burden were greatest in the U16 age group and were found to increase with age. Whilst injury incidence and burden are greater in matches than training, a large proportion of preventable injuries, soft-tissue and non-contact in nature, were sustained in training. Findings provide comparative data for elite youth female soccer players.

O-252 Next generation sequencing analysis of the seminal microbiome in male partners of women with idiopathic recurrent pregnancy loss: results of a prospective cohort study

Study question

Is there an association between the semen microbiome, seminal reactive oxygen species (ROS) and DNA fragmentation in men with recurrent pregnancy loss (RPL)?

Summary answer

This pilot study outlines the subtle role that microbiota play in influencing ROS and sperm DNA damage for male partners of women with RPL

What is known already

RPL is defined as the loss of two or more consecutive pregnancies. This devastating condition impacts approximately 1% of couples. Paternal causes are not routinely screened for and an underlying cause is not found in up to 50% of cases. Recent studies have reported an association between elevated seminal ROS and sperm DNA fragmentation in the male partner, and RPL. We hypothesised that seminal microbiota contribute to increased ROS and sperm DNA damage. To test this, we investigated the relationship between seminal bacterial composition and ROS levels in men with proven fertility versus men with a history of RPL.

Study design, size, duration

We conducted a prospective, case-control study and recruited participants between November 2018 and March 2020 at Imperial College Healthcare NHS Trust. A total of 109 men participated in the study; 46 men with RPL and 63 men with proven fertility and no history of RPL. Each participant attended for a single study visit which consisted of a full medical history, assessment of testicular volume, height, weight, blood samples and production of a semen sample.

Participants/materials, setting, methods

Routine semen analysis (WHO) and endocrine and lipid profiles were performed for all patients. Semen ROS and DNA fragmentation were performed (luminol and TUNEL methodologies, respectively). ROS were classified as high (&gt;3.77 RLU/s) or low (&lt;3.77 RLU/s). Metataxonomic profiling of samples was performed using Illumina Miseq-based sequencing of the V1-V2 hypervariable regions of bacterial 16S rRNA gene amplicons. Multivariate and univariate modelling was performed to explore associations between metataxonomic profiles, ROS levels and clinical metadata.

Main results and the role of chance

Men with RPL had higher mean semen volume (p = 0.02) and increased prevalence of high ROS (p = 0.02, Fisher's exact) compared with controls; but other clinical characteristics were similar between groups. A total of 3,700,136 high quality sequence reads were generated for the dataset with an average of 33,946 reads/sample. Hierarchical clustering of bacterial genera relative abundances identified 4 distinct microbial signatures characterised by high relative abundance of 1. Streptococcus, 2. Lactobacillus and Gardnerella, 3. polymicrobial (including Prevotella), and 4. Corynebacterium and Finegoldia. Prevalences of these groups were similar in control and RPL groups (p = 0.11). Additionally, no association between the bacterial genera groups and elevated ROS, DNA fragmentation, or clinical factors such as age, ethnicity, or semen volume were observed (chi-square tests). At species taxonomy level relative abundance of L. crispatus was higher in controls compared to RPL, but did not withstand false discovery rate correction for multiple testing (p = 0.006, q = 0.67). Higher relative abundance of Microbacterium was detected in semen samples with high DNA fragmentation (p = 8.7E-4, q = 0.08). This relationship was even stronger within the RPL cohort (p = 2.8E-5, q = 0.002). No significant enrichment of specific taxa was observed between high or low ROS samples however, low ROS was associated with Corynebacterium relative abundance &gt;20%.

Limitations, reasons for caution

More patients are required to enhance statistical power. Duplicate sample collection may establish the robustness of seminal compositions observed. Time since last sexual intercourse samples may affect the analysis. Concomitant analysis of the vaginal microbiome of female partners may improve our understanding of how partners may affect each other’s fertility.

Wider implications of the findings

Our data suggests interactions between microbiota composition, ROS and sperm DNA damage which may be implicated in the pathogenesis of recurrent miscarriage. Further studies are needed to determine if seminal microbiota play causal roles in RPL, and whether interventions modifying the seminal microbiome may modify pregnancy outcomes in affected couples

Trial registration number

not applicable

Effect of initiating biologics compared to intensifying conventional DMARDs on clinical and MRI outcomes in established rheumatoid arthritis patients in clinical remission: Secondary analyses of the IMAGINE-RA trial

Objectives: To compare the effect of treat-to-target-based escalations in conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) and biologics on clinical disease activity and magnetic resonance imaging (MRI) inflammation in a rheumatoid arthritis (RA) cohort in clinical remission.Method: One-hundred patients with established RA, Disease Activity Score based on 28-joint count-C-reactive protein (DAS28-CRP) < 3.2, and no swollen joints (hereafter referred to as 'in clinical remission') who received csDMARDs underwent clinical evaluation and MRI of the wrist and second to fifth metacarpophalangeal joints every 4 months. They followed a 2 year MRI treatment strategy targeting DAS28-CRP ≤ 3.2, no swollen joints, and absence of MRI osteitis, with predefined algorithmic treatment escalation: first: increase in csDMARDs; second: adding a biologic; third: switch biologic. MRI osteitis and Health Assessment Questionnaire (HAQ) (co-primary outcomes) and MRI combined inflammation and Simplified Disease Activity Index (SDAI) (key secondary outcomes) were assessed 4 months after treatment change and expressed as estimates of group differences. Statistical analyses were based on the intention-to-treat population analysed using repeated-measures mixed models.Escalation to first biologic compared to csDMARD escalation more effectively reduced MRI osteitis (difference between least squares means 1.8, 95% confidence interval 1.0-2.6), HAQ score (0.08, 0.03-0.1), MRI combined inflammation (2.5, 0.9-4.1), and SDAI scores (2.7, 1.9-3.5).Treat-to-target-based treatment escalations to biologics compared to escalation in csDMARDs more effectively improved MRI inflammation, physical function, and clinical disease activity in patients with established RA in clinical remission. Treatment escalation in RA patients in clinical remission reduces clinical and MRI-assessed disease activity.Trial registration: Clinicaltrials.gov identifier: NCT01656278.

P–385 The relationship between systemic oestradiol and vaginal microbiota composition in miscarriage and normal pregnancy

Study question

Is there an association between serum oestradiol, vaginal microbial composition and pregnancy outcome in the early first trimester?

Summary answer

In women with a vaginal microbiome deplete of Lactobacillus species at the time of Pregnancy of Uncertain Viability (IPUV), higher serum oestradiol associates with livebirth.

What is known already

During pregnancy, oestradiol mediates vaginal mucosal properties and increases glycogen deposition in epithelial cells which is thought to support colonisation of Lactobacillus species. Low levels of Lactobacillus associates with adverse outcomes such as miscarriage and preterm birth. The direct relationship between systemic oestradiol and the vaginal microbiome has never been studied in pregnancy. However studies have shown a positive correlation between serum oestrone, vaginal glycogen and Lactobacillus abundance in menopausal women.

Study design, size, duration

This was a prospective cohort study where one-hundred women were recruited in early pregnancy at the time of IPUV and donated paired blood and vaginal samples. 40 women had an eventual miscarriage, 58 had a livebirth and two pregnancies were terminated. All 100 women donated one paired serum and vaginal sample at this time point, and 22 women with Lactobacillus depletion at the time of IPUV donated further longitudinal vaginal samples.

Participants/materials, setting, methods

Participants were recruited from an Early Pregnancy Unit and underwent transvaginal ultrasound assessment of their pregnancy. Serum samples were analysed with an immunoassay on a ROCHE COBAS E411 analyser for Oestradiol (pg/ml) and Progesterone (ng/ml). Bacterial DNA was extracted from paired vaginal swabs and sequenced using Illumina MiSeq sequencing of 16S rRNA gene amplicons.

Main results and the role of chance

Lactobacillus dominance of the vagina was associated with higher serum levels of E2 and progesterone compared to depletion (E2=398pg/ml vs 302pg/ml(p = 0.02), P4=23.1ng/ml vs 17ng/ml(p = 0.02)). E2 and P4 were positively correlated (r = 0.6, p &lt; 0.05). At species level, L. crispatus dominance associated with significantly higher levels of E2 compared to high-diversity communities (468pg/ml vs 302pg/ml(p = 0.03) but no such relationship was observed for P4. Both E2 and P4 levels were lower in women who eventually miscarried. However there was no significant difference in the vaginal bacterial composition at genera or species level at this early gestational age (P = 0.08) regardless of per vaginal bleeding. However in women with Lactobacillus depleted microbiota, livebirth was associated with significantly higher E2 levels compared to women suffering miscarriage (212pg/ml in miscarriage vs 395pg/ml in livebirth, p = 0.003) (OR = 22.4 P = 0.004). In 22 women who had Lactobacillus depletion at the time of IPUV (7 with an eventual outcome of miscarriage, and 15 with an eventual outcome of livebirth), longitudinal vaginal bacterial DNA sequencing was performed. In 7/15 women with livebirth, and higher E2 levels, the microbial composition changed to become more Lactobacillus dominant during pregnancy, whereas in those with miscarriage, only 1/7 changed to become Lactobacillus dominant.

Limitations, reasons for caution

In this study, serum oestradiol levels were compared to the local vaginal bacterial environment. The ideal would be to study local vaginal oestradiol, glycogen and the bacterial composition.

Wider implications of the findings: In contrast to previous studies in menopause where low oestrogen levels associate with the vaginal microbial composition, this study uses the high oestradiol environment of early pregnancy to study the mechanistic relationship between oestradiol and vaginal Lactobacillus abundance.

Trial registration number

NA

O-129 Lactobacillus deplete vaginal microbial composition is associated with chromosomally normal miscarriage and local inflammation

Study question

To investigate the vaginal microbial composition and the local immune response in chromosomally normal and abnormal miscarriages and compare this to uncomplicated pregnancies delivering at term.

Summary answer

We show that euploid miscarriage is associated with a significantly higher prevalence of Lactobacillus spp. deplete vaginal microbial communities compared to aneuploid miscarriage.

What is known already

Emerging evidence supports the role of the vaginal microbiota in adverse pregnancy outcome, but the underlying mechanisms are poorly understood. A dominance of Lactobacillus spp. in pregnancy provides protection against pathogenic bacteria by producing lactic acid and antimicrobial compounds. A depletion in Lactobacillus spp. is often linked to adverse pregnancy outcomes.Current work also implicates the reproductive tract microbiota as a key modulator of local inflammatory and immune pathways. We have previously shown that miscarriage is associated with vaginal dysbiosis but without knowledge of the cytogenetic status of those miscarriages or the local immune profile.

Study design, size, duration

This study was a prospective observational cohort study based at Queen Charlotte’s & Chelsea Hospital, Early Pregnancy Unit, London between March 2014-February 2019. Vaginal swabs were collected from the posterior vaginal fornix of 167 patients.

Participants/materials, setting, methods

We used 16S rRNA gene based metataxonomics to interrogate the vaginal microbiota in a cohort of 167 women, 93 miscarriage patients (54 euploid and 39 aneuploid using molecular cytogenetics) and 74 women who delivered at term and correlate this with the aneuploidy status of the miscarriages. We also measured the concentrations of IL-2, IL-4, IL-6, IL-8, TNF-α, IFN-γ, IL-1β, IL-18 and IL-10 in cervical vaginal fluid using Human Magnetic Luminex Screening Assay (8-plex).

Main results and the role of chance

We show that euploid miscarriage is associated with a significantly higher prevalence of Lactobacillus spp. deplete vaginal microbial communities compared to aneuploid miscarriage (P=0.008). In women having Lactobacillus spp. deplete vaginal microbial communities, euploid miscarriage associates with higher concentrations of pro-inflammatory cytokines IL-1β, IL-8, IL-6 (P&lt;0.001, P=0.01 and P&lt;0.001 respectively) and lower concentrations of anti-inflammatory cytokines IL10 (P&lt;0.001) when compared to viable term pregnancy. We identified Prevotella bivia and Streptococcus as particularly common in euploid miscarriage and as drivers of pro-inflammatory cytokines (IL-1β, IL-6 and TNF-α). Co-occurrence network analyses revealed low levels of co-occurrence between Lactobacillus crispatus and other organisms and strong co-occurrence between Streptococcal species. Our data show a combination of both an adverse vaginal microbiota and a cytokine response to it influences early pregnancy outcome. Although this may be a reflection of intrinsic maternal immune response, it appears that the cytokine response is largely driven by the bacterial taxa present in the vagina, which presents an opportunity for specific, directed intervention. The negative co-occurrence between L.crispatus and all other organisms suggests a possible therapeutic role for probiotics containing this organism. The influence of Streptococci also suggests a potential benefit of targeted antibiotics with probiotics for some patients.

Limitations, reasons for caution

There were no longitudinal samples in this cohort and our results are based on the assumption that the vaginal microbial composition is stable throughout the first trimester.Future longitudinal studies with larger sample sizes are needed to corroborate these findings and provide insights to the mechanisms that trigger the inflammatory response.

Wider implications of the findings

These findings support the hypothesis that the vaginal microbiota plays an important aetiological role in euploid miscarriage and may represent a target to modify the risk of pregnancy loss.

Trial registration number

n/a

Morbidity after local excision of the transformation zone for cervical intra-epithelial neoplasia and early cervical cancer

The awareness that cervical intra-epithelial neoplasia (CIN) treatment increases the risk of preterm birth has led to major changes in clinical practice. Women with CIN have a higher baseline risk of prematurity but local treatment further increases this risk. The risk further increases with increasing cone length and multiplies for repeat excisions; it is unclear whether small cones confer any additional risk to CIN alone. There is no evidence to suggest that fertility is affected by local treatment, although this increases the risk of mid-trimester loss. Caution should prevail when deciding to treat women with CIN of reproductive age. If treatment is offered, this should be conducted effectively to optimise the clearance of disease and minimise the risk of recurrence. Colposcopists should alert women undergoing treatment that this may increase the risk of preterm birth and that they may be offered interventions when pregnant. The cone length should be clearly documented and used as a risk stratifier.

Interassociation consensus recommendations for pitch-side emergency care and personal protective equipment for elite sport during the COVID-19 pandemic

The COVID-19 pandemic has necessitated many novel responses in healthcare including sport and exercise medicine. The cessation of elite sport almost globally has had significant economic implications and resulted in pressure to resume sport in very controlled conditions. This includes protecting pitch-side medical staff and players from infection. The ongoing prevalence of SARS-CoV-2 and the desire to resume professional sport required urgent best practice guidelines to be developed so that sport could be resumed as safely as possible. This set of best practice recommendations assembles early evidence for managing SARS-CoV-2 and integrates expert opinion to provide a uniform and pragmatic approach to enhance on-field and pitch-side safety for the clinician and player. The nature of SARS-CoV-2 transmission creates new hazards during resuscitation and emergency care and procedures. Recommendations for the use and type of personal protective equipment during on-field or pitch-side emergency medical care is provided based on the clinical scenario and projected risk of viral transmission.

AB0209 PREDICTORS OF ACHIEVING STRINGENT REMISSION IN PATIENTS WITH ESTABLISHED RHEUMATOID ARTHRITIS IN CLINICAL REMISSION FOLLOWING A TREAT-TO-TARGET STRATEGY

Background:

Achieving remission according to stringent criteria such as Simplified Disease Activity Index (SDAI) and ACR/EULAR Boolean remission is associated with a better long-term outcome in patients with RA1. Possible predictors of achieving stringent remission in patients in clinical remission, following targeted treatment strategies, have not been investigated.

Objectives:

To investigate the predictive value of clinical, radiographic and MRI variables on achieving more stringent remission in RA patients in clinical remission, following MRI and conventional treat-to-target (T2T) strategies.

Methods:

In this post-hoc study, data were used from 171 RA patients in clinical remission (DAS28-CRP< 3.2 and no swollen joints) on conventional synthetic DMARDs, included in the IMAGINE-RA randomized clinical trial2, where they followed an MRI T2T strategy (targeting absence of osteitis) combined with clinical remission (DAS28-CRP≤3.2 and no swollen joints) or a conventional T2T strategy (targeting clinical remission only). Baseline contrast-enhanced MRIs of the dominant wrist and 2nd-5thMCP joints and radiographs of hands and feet were evaluated according to the OMERACT RAMRIS scoring system and Sharp/van der Heijde method, respectively, by two experienced readers. Potential clinical, radiographic and MRI baseline predictors of remission were first tested in univariate logistic regression analyses with achievement of Clinical Disease Activity Index (CDAI), SDAI, and ACR/EULAR Boolean remission at 24 months as dependent variables. Variables with p<0.25 were subsequently tested in multivariate logistic regression analyses with backward selection, adjusted for age, gender and strategy group. Missing values of covariates were imputed using chained equations.

Results:

Based on the univariate analyses, tender joint count, patient VAS global, VAS pain, VAS fatigue, physician VAS global, HAQ, MRI osteitis, radiographic and MRI erosion and joint space narrowing scores were included in multivariate analyses (Table).

Following the MRI T2T strategy was a positive predictor and high patient VAS global a negative predictor of achieving all definitions of remission. Furthermore, high patient VAS pain was negatively associated with achieving SDAI and ACR/EULAR Boolean remission and high tender joint count negatively associated with achieving CDAI and SDAI remission.

Multivariate logistic regression analyses with backward selection, final modelsDependent variables, remission at 24 monthsCDAISDAIACR/EULAR BooleanOR95% CIp-valueOR95% CIp-valueOR95% CIp-valueCovariatesMRI T2T strategy group2.941.25-7.520.0132.461.03-6.350.0435.472.33-14.11<0.001Female0.900.36-2.250.820.800.31-2.050.640.800.32-1.970.63Age1.020.98-1.070.321.020.98-1.070.331.030.99-1.070.15Tender joint count (0-28)0.330.12-0.860.0230.290.10-0.780.013Patient VAS global0.910.88-0.94<0.0010.930.88-0.97<0.0010.930.88-0.980.003Patient VAS pain0.950.91-1.000.0490.920.87-0.980.004

Conclusion:

In RA patients in clinical remission, poor patient reported outcomes and tender joint count were associated with decreased chance of achieving stringent remission, while following an MRI T2T strategy predicted stringent remission across all definitions thereof.

References:

[1]Smolen et al. Ann Rheum Dis 2017

[2]Møller-Bisgaard et al. JAMA 2019

Disclosure of Interests:

Signe Møller-Bisgaard Grant/research support from: AbbVie, Consultant of: BMS, Speakers bureau: BMS, Celgene, Pfizer, Stylianos Georgiadis Grant/research support from: Novartis, Kim Hørslev-Petersen: None declared, Bo Ejbjerg: None declared, Merete L. Hetland Grant/research support from: BMS, MSD, AbbVie, Roche, Novartis, Biogen and Pfizer, Consultant of: Eli Lilly, Speakers bureau: Orion Pharma, Biogen, Pfizer, CellTrion, Merck and Samsung Bioepis, Lykke Ørnbjerg: None declared, Daniel Glinatsi: None declared, Jakob Møllenbach Møller: None declared, Mikael Boesen Consultant of: AbbVie, AstraZeneca, Eli Lilly, Esaote, Glenmark, Novartis, Pfizer, UCB, Paid instructor for: IAG, Image Analysis Group, AbbVie, Eli Lilly, AstraZeneca, esaote, Glenmark, Novartis, Pfizer, UCB (scientific advisor)., Speakers bureau: Eli Lilly, Esaote, Novartis, Pfizer, UCB, Kristian Stengaard-Pedersen: None declared, Ole Rintek Madsen: None declared, Bente Jensen: None declared, Jan Villadsen: None declared, Ellen Margrethe Hauge: None declared, Philip Bennett: None declared, Oliver Hendricks: None declared, Karsten Asmussen: None declared, Marcin Kowalski: None declared, Hanne Merete Lindegaard: None declared, Henning Bliddal Grant/research support from: received research grant fra NOVO Nordic, Consultant of: consultant fee fra NOVO Nordic, Niels Steen Krogh: None declared, Torkell Ellingsen: None declared, Agnete Nielsen: None declared, Lone Balding: None declared, Anne Grethe Jurik: None declared, Henrik Thomsen: None declared, Mikkel Ǿstergaard Grant/research support from: AbbVie, Bristol-Myers Squibb, Celgene, Merck, and Novartis, Consultant of: AbbVie, Bristol-Myers Squibb, Boehringer Ingelheim, Celgene, Eli Lilly, Hospira, Janssen, Merck, Novartis, Novo Nordisk, Orion, Pfizer, Regeneron, Roche, Sandoz, Sanofi, and UCB, Speakers bureau: AbbVie, Bristol-Myers Squibb, Boehringer Ingelheim, Celgene, Eli Lilly, Hospira, Janssen, Merck, Novartis, Novo Nordisk, Orion, Pfizer, Regeneron, Roche, Sandoz, Sanofi, and UCB

FRI0019 MRI INFLAMMATION, DISEASE ACTIVITY AND FUNCTIONAL IMPAIRMENT ARE MORE EFFECTIVELY REDUCED BY ESCALATION TO BIOLOGICS COMPARED TO CSDMARD-ESCALATION IN RHEUMATOID ARTHRITIS PATIENTS IN CLINICAL REMISSION FOLLOWING A TREAT-TO-TARGET STRATEGY: SECONDARY ANALYSES OF THE IMAGINE-RA TRIAL

Background:

The effect of different treatment escalations on MRI inflammation in rheumatoid arthritis (RA) patients following an MRI treat-to-target (T2T) strategy has not previously been investigated.

Objectives:

To compare the effect of different treatment escalations on MRI inflammation, physical function and disease activity in RA patients in clinical remission, following an MRI T2T strategy.

Methods:

One hundred RA patients in clinical remission (DAS28-CRP<3.2 and no swollen joints), on conventional synthetic (cs) DMARDs following an MRI T2T strategy targeting DAS28-CRP≤3.2, no swollen joints plus absence of MRI osteitis, were followed for 2 years with clinical and MRI (wrist and 2nd-5thMCP joints) evaluation every 4 months1. If target was not met, a predefined treatment escalation algorithm dictated: First: increase in csDMARDs (A), second: adding a TNF inhibitor (TNFi) (B), third and onwards: switch between biologics (C). If target was met, no change in baseline csDMARDs was done (D). Outcomes were assessed 4 months after treatment change. MRIs were evaluated with known chronology by one experienced reader. Repeated measures mixed linear models were used to express estimates of group differences on predefined co-primary outcomes (MRI osteitis, HAQ) and key secondary outcomes (MRI combined inflammation, Simplified Disease Activity Index (SDAI)).

Results:

Escalation to first TNFi (B) or to 2ndor later biologic (C) compared to csDMARDs (A) was consistently more effective on all outcomes (e.g. in group B osteitis was reduced with 1.8 units more than A) (Table). Unchanged (D) compared to escalation in csDMARD (A) treatment did not differ, except for HAQ-score. Escalation to a 2ndor later biologics (C) compared to the first TNFi (B) was more effective suppressing MRI inflammation. Escalation to TNFi treatment (B) or to 2ndor later biologic (C) compared to unchanged treatment (D) was more effective on all outcomes except from HAQ-score (no difference between groups).

Comparisons of treatment escalations1A: Increment in csDMARD mono/combination therapy (n=73)); B: Switch from csDMARD combination therapy to TNFi (n=39); C: Switch from TNFi to 2ndbiologic/switch between biologics (n=21); D: No change in csDMARDs from baseline (n=58)A vs BA vs CA vs DB vs CB vs DC vs DOutcomesPrimaryMRIOsteitis1.8 (1.0; 2.6) p<.00013.6 (2.3; 4.8) p<.00010.3 (−0.3; 1.0)p=.321.8 (0.8; 2.9) p=.0006−1.4 (−2.4; −0.5) p=.0045−3.3 (−4.6; −1.9) p<.0001HAQ0.081(0.033; 0.13) p=.00110.091(0.031; 0.15) p=.00320.054(0.014; 0.095) p=.00910.0092(−0.051; 0.070) p=.77−0.027(−0.082; 0.028) p=.33−0.037(−0.10; 0.031) p=.29Key secondaryMRI combined inflammationa2.5 (0.9; 4.1) p=.00185.4 (3.1; 7.7) p<.00010.4 (−0.9; 1.8)p=.522.9 (0.8; 4.9) p=.0064−2.1 (−4.0; −0.2) p=.032−5.0 (−7.5; −2.4) p=.0002SDAI2.7 (1.9; 3.5) p<.00012.4 (1.4; 3.4) p<.00010.5 (−0.2; 1.2)p=.14−0.3 (−1.3; 0.7)p=.60−2.2 (−3.1; −1.3) p<.0001−1.9 (−3.0; 0.8) p=.0006

1Estimates of group differences (least squares means (95% CI)).

aSum score of synovitis, osteitis and tenosynovitis

Conclusion:

T2T-based treatment escalations to biologics compared to csDMARD-escalations more effectively improved MRI inflammation, physical function and disease activity. Further optimization of the treatment in RA patients in clinical remission may improve long-term outcomes.

References:

[1]Møller-Bisgaard et al. JAMA 2019

Disclosure of Interests:

Signe Møller-Bisgaard Grant/research support from: AbbVie, Consultant of: BMS, Speakers bureau: BMS, Celgene, Pfizer, Kim Hørslev-Petersen: None declared, Bo Ejbjerg: None declared, Merete L. Hetland Grant/research support from: BMS, MSD, AbbVie, Roche, Novartis, Biogen and Pfizer, Consultant of: Eli Lilly, Speakers bureau: Orion Pharma, Biogen, Pfizer, CellTrion, Merck and Samsung Bioepis, Robin Christensen: None declared, Lykke Ørnbjerg: None declared, Daniel Glinatsi: None declared, Jakob Møllenbach Møller: None declared, Mikael Boesen Consultant of: AbbVie, AstraZeneca, Eli Lilly, Esaote, Glenmark, Novartis, Pfizer, UCB, Paid instructor for: IAG, Image Analysis Group, AbbVie, Eli Lilly, AstraZeneca, esaote, Glenmark, Novartis, Pfizer, UCB (scientific advisor)., Speakers bureau: Eli Lilly, Esaote, Novartis, Pfizer, UCB, Kristian Stengaard-Pedersen: None declared, Ole Rintek Madsen: None declared, Bente Jensen: None declared, Jan Villadsen: None declared, Ellen Margrethe Hauge: None declared, Philip Bennett: None declared, Oliver Hendricks: None declared, Karsten Asmussen: None declared, Marcin Kowalski: None declared, Hanne Merete Lindegaard: None declared, Henning Bliddal Grant/research support from: received research grant fra NOVO Nordic, Consultant of: consultant fee fra NOVO Nordic, Niels Steen Krogh: None declared, Torkell Ellingsen: None declared, Agnete Nielsen: None declared, Anne Grethe Jurik: None declared, Lone Balding: None declared, Henrik Thomsen: None declared, Mikkel Ǿstergaard Grant/research support from: AbbVie, Bristol-Myers Squibb, Celgene, Merck, and Novartis, Consultant of: AbbVie, Bristol-Myers Squibb, Boehringer Ingelheim, Celgene, Eli Lilly, Hospira, Janssen, Merck, Novartis, Novo Nordisk, Orion, Pfizer, Regeneron, Roche, Sandoz, Sanofi, and UCB, Speakers bureau: AbbVie, Bristol-Myers Squibb, Boehringer Ingelheim, Celgene, Eli Lilly, Hospira, Janssen, Merck, Novartis, Novo Nordisk, Orion, Pfizer, Regeneron, Roche, Sandoz, Sanofi, and UCB

First-trimester intrauterine hematoma and pregnancy complications

OBJECTIVE

To assess whether sonographic diagnosis of intrauterine hematoma (IUH) in the first trimester of pregnancy is associated with first-trimester miscarriage and antenatal, delivery and neonatal complications.

METHODS

This was a prospective observational cohort study of women with an intrauterine singleton pregnancy between 5 and 14 weeks' gestation recruited at Queen Charlotte's and Chelsea Hospital, London, UK, between March 2014 and March 2016. Participants underwent serial ultrasound examinations in the first trimester, and the presence, location, size and persistence of any IUH was evaluated. First-trimester miscarriage was defined as pregnancy loss before 14 weeks' gestation. Clinical symptoms, including pelvic pain and vaginal bleeding, were recorded at each visit using validated symptom scores. Antenatal, delivery and neonatal outcomes were obtained from hospital records. Logistic regression analysis and the chi-square test were used to assess the association between the presence and features of IUH and the incidence of adverse pregnancy outcome. Odds ratios (OR) were first adjusted for maternal age (aOR) and then further adjusted for the presence of vaginal bleeding or pelvic pain in the first trimester.

RESULTS

Of 1003 women recruited to the study, 946 were included in the final analysis and of these, 268 (28.3%) were diagnosed with an IUH in the first trimester. The presence of IUH was associated with the incidence of preterm birth (aOR, 1.94 (95% CI, 1.07-3.52)), but no other individual or overall antenatal, delivery or neonatal complications. No association was found between the presence of IUH in the first trimester and first-trimester miscarriage (aOR, 0.81 (95% CI, 0.44-1.50)). These findings were independent of the absolute size of the hematoma and the presence of vaginal bleeding or pelvic pain in the first trimester. When IUH was present in the first trimester, there was no association between its size, content or position in relation to the gestational sac and overall antenatal, delivery and neonatal complications. Diagnosis of a retroplacental IUH was associated with an increased risk of overall antenatal complications (P = 0.04).

CONCLUSIONS

Our findings demonstrate that there is no association between the presence of IUH in the first trimester and first-trimester miscarriage. However, an association with preterm birth, independently of the presence of symptoms of pelvic pain and/or vaginal bleeding, is evident. Women diagnosed with IUH in the first trimester should be counseled about their increased risk of preterm birth and possibly be offered increased surveillance during the course of their pregnancy. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Incidence and mortality from cervical cancer and other malignancies after treatment of cervical intraepithelial neoplasia: a systematic review and meta-analysis of the literature

BACKGROUND

Although local treatments for cervical intraepithelial neoplasia (CIN) are highly effective, it has been reported that treated women remain at increased risk of cervical and other cancers. Our aim is to explore the risk of developing or dying from cervical cancer and other human papillomavirus (HPV)- and non-HPV-related malignancies after CIN treatment and infer its magnitude compared with the general population.

MATERIALS AND METHODS

Design: Systematic review and meta-analysis. Eligibility criteria: Studies with registry-based follow-up reporting cancer incidence or mortality after CIN treatment.

DATA SYNTHESIS

Summary effects were estimated using random-effects models.

OUTCOMES

Incidence rate of cervical cancer among women treated for CIN (per 100 000 woman-years). Relative risk (RR) of cervical cancer, other HPV-related anogenital tract cancer (vagina, vulva, anus), any cancer, and mortality, for women treated for CIN versus the general population.

RESULTS

Twenty-seven studies were eligible. The incidence rate for cervical cancer after CIN treatment was 39 per 100 000 woman-years (95% confidence interval 22-69). The RR of cervical cancer was elevated compared with the general population (3.30, 2.57-4.24; P < 0.001). The RR was higher for women more than 50 years old and remained elevated for at least 20 years after treatment. The RR of vaginal (10.84, 5.58-21.10; P < 0.001), vulvar (3.34, 2.39-4.67; P < 0.001), and anal cancer (5.11, 2.73-9.55; P < 0.001) was also higher. Mortality from cervical/vaginal cancer was elevated, but our estimate was more uncertain (RR 5.04, 0.69-36.94; P = 0.073).

CONCLUSIONS

Women treated for CIN have a considerably higher risk to be later diagnosed with cervical and other HPV-related cancers compared with the general population. The higher risk of cervical cancer lasts for at least 20 years after treatment and is higher for women more than 50 years of age. Prolonged follow-up beyond the last screening round may be warranted for previously treated women.

Early-pregnancy events and subsequent antenatal, delivery and neonatal outcomes: prospective cohort study

OBJECTIVE

To assess prospectively the association between pelvic pain, vaginal bleeding, and nausea and vomiting occurring in the first trimester of pregnancy and the incidence of later adverse pregnancy outcomes.

METHODS

This was a prospective observational cohort study of consecutive women with confirmed intrauterine singleton pregnancy between 5 and 14 weeks' gestation recruited at Queen Charlotte's & Chelsea Hospital, London, UK, from March 2014 to March 2016. Serial ultrasound scans were performed in the first trimester. Participants completed validated symptom scores for vaginal bleeding, pelvic pain, and nausea and vomiting. The key symptom of interest was any pelvic pain and/or vaginal bleeding during the first trimester. Pregnancies were followed up until the final outcome was known. Antenatal, delivery and neonatal outcomes were obtained from hospital records. Logistic regression analysis was used to assess the association between first-trimester symptoms and pregnancy complications by calculating adjusted odds ratios (aOR) with correction for maternal age.

RESULTS

Of 1003 women recruited, 847 pregnancies were included in the final analysis following exclusion of cases due to first-trimester miscarriage (n = 99), termination of pregnancy (n = 20), loss to follow-up (n = 32) or withdrawal from the study (n = 5). Adverse antenatal complications were observed in 166/645 (26%) women with pelvic pain and/or vaginal bleeding in the first trimester (aOR = 1.79; 95% CI, 1.17-2.76) and in 30/181 (17%) women with no symptoms. Neonatal complications were observed in 66/634 (10%) women with and 11/176 (6%) without pelvic pain and/or vaginal bleeding (aOR = 1.73; 95% CI, 0.89-3.36). Delivery complications were observed in 402/615 (65%) women with and 110/174 (63%) without pelvic pain and/or vaginal bleeding during the first trimester (aOR = 1.16; 95% CI, 0.81-1.65). For 18 of 20 individual antenatal complications evaluated, incidence was higher among women with pelvic pain and/or vaginal bleeding, despite the overall incidences being low. Nausea and vomiting in pregnancy showed little association with adverse pregnancy outcomes.

CONCLUSIONS

Our study suggests that there is an increased incidence of antenatal complications in women experiencing pelvic pain and/or vaginal bleeding in the first trimester. This should be considered when advising women attending early-pregnancy units. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Ten-year follow-up of two cohorts with an increased risk of variant CJD: donors to individuals who later developed variant CJD and other recipients of these at-risk donors

BACKGROUND

Transmission of variant Creutzfeldt-Jakob disease (vCJD) through blood transfusion is implicated in three deaths and one asymptomatic infection. Based on this evidence, individuals assessed to be at increased risk of vCJD through donating blood transfused to individuals who later developed vCJD, or through being other recipients of such donors, are followed up to further understand the risks of vCJD transmission through blood.

OBJECTIVES

To provide a ten-year follow-up of these at-risk cohorts.

METHODS

Blood donors to patients who later died from vCJD were identified by the Transfusion Medicine Epidemiological Review (TMER) study. A reverse risk probability assessment quantified the risk of blood transfusion or exposure through diet as the source of vCJD in the recipients. Donors to these recipients, and these donors' other recipients, with a probability risk above 1%, are classified as at increased risk of vCJD for public health purposes. These cohorts are monitored for any vCJD occurrences.

RESULTS

A total of 112 donors and 33 other recipients of their donated blood have been classified as at increased risk. After 2397 and 492 vCJD-free years of follow-up, respectively, no deaths in either at-risk cohort were of vCJD-related causes.

CONCLUSIONS

The at-risk cohorts have survived disease-free far longer than the estimated incubation time for dietary-acquired vCJD (donors) and transfusion-acquired disease (other recipients). However, due to our still limited understanding of, and a lack of a reliable test for, asymptomatic vCJD infection, public health follow-up is necessary for continued monitoring of at-risk cohorts.

Are fetuses that fail to achieve their growth potential at increased risk of intrapartum compromise?

OBJECTIVE

The true growth potential of a fetus is difficult to predict but recently a new definition, independent of fetal weight, using cerebroplacental (cerebro-umbilical) ratio (CPR) < 0.6765 multiples of the median (MoM), was reported. We applied this definition to a cohort of low-risk pregnancies recruited prospectively to determine if fetuses with CPR < 0.6765 are at increased risk of developing signs of intrapartum fetal compromise.

METHODS

Recruitment to this prospective observational study took place between March 2011 and March 2014. All women with low-risk singleton pregnancies at term were eligible. Women with known or suspected placental dysfunction were excluded, as were women with fetuses with an estimated fetal weight < 10(th) centile. All participants underwent ultrasound examination prior to active labor (≤ 4 cm cervical dilatation), during which fetal biometry as well as umbilical artery and fetal middle cerebral artery blood flow were assessed. Following delivery, intrapartum and neonatal outcomes were compared between fetuses that had a CPR < 0.6765 MoM and those that had a CPR ≥ 0.6765 MoM.

RESULTS

In total, 775 women were recruited. Fetuses with CPR < 0.6765 MoM were significantly more likely to require Cesarean delivery because of presumed fetal compromise (P < 0.001). These fetuses were also at increased risk of compromise at any time during labor and were less likely to be delivered vaginally, spontaneously or otherwise, than were those with CPR ≥ 0.6765 MoM. CPR < 0.6765 MoM gave a positive predictive value (PPV) for Cesarean delivery because of presumed fetal compromise of 36.7% and a negative predictive value of 88.7%, with a sensitivity of 18% and a specificity of 95.4%.

CONCLUSION

Fetuses that failed to achieve their growth potential (defined as CPR < 0.6765 MoM) were at increased risk of intrapartum compromise and were less likely to be delivered vaginally. However, a low negative predictive value was observed for fetal compromise and further studies are required to support the translation of this technique into clinical practice.

The effect of gestational age and cervical length measurements in the prediction of spontaneous preterm birth in twin pregnancies: an individual patient level meta-analysis

OBJECTIVE

To assess the effect of gestational age (GA) and cervical length (CL) measurements at transvaginal ultrasound (TVUS) in the prediction of preterm birth in twin pregnancy.

DESIGN

Individual patient data (IPD) meta-analysis.

SETTING

International multicentre study.

POPULATION

Asymptomatic twin pregnancy.

METHODS

MEDLINE and EMBASE searches were performed and IPD obtained from authors of relevant studies. Multinomial logistic regression analysis determined probabilities for birth at ≤28(+0) , 28(+1) to 32(+0) , 32(+1) to 36(+0) , and ≥36(+1) weeks as a function of GA at screening and CL measurements.

MAIN OUTCOME MEASURES

Predicted probabilities for preterm birth at ≤28(+0) , 28(+1) to 32(+0) , and 32(+1) to 36(+0) .

RESULTS

A total of 6188 CL measurements were performed on 4409 twin pregnancies in 12 studies. Both GA at screening and CL had a significant and non-linear effect on GA at birth. The best prediction of birth at ≤28(+0) weeks was provided by screening at ≤18(+0) weeks (P < 0.001), whereas the best prediction of birth between 28(+1) and 36(+0) weeks was provided by screening at ≥24(+0) weeks (P < 0.001). Negative prediction value of 100% for birth at ≤28(+0) weeks is achieved at CL 65 mm and 43 mm at ultrasound GA at ≤18(+0) weeks and at 22(+1) to 24(+0) weeks, respectively.

CONCLUSION

In twin pregnancies, prediction of preterm birth depends on both CL and the GA at screening. When CL is <30 mm, screening at ≤18(+0) weeks is most predictive for birth at ≤28(+0) weeks. Later screening at >22(+0) weeks is most predictive of delivery at 28(+1) to 36(+0) weeks. In twins, we recommend CL screening in twins to commence from ≤18(+0) weeks.

TWEETABLE ABSTRACT

An individual patient meta-analysis assessing gestation and CL in the prediction of preterm birth in twins.

Evidence of horsemanship and dogmanship and their application in veterinary contexts

This review collates peer-reviewed evidence for desirable attributes for those who work with dogs and horses. It is written with a particular focus on the veterinary profession. Although veterinarians and veterinary nurses (VNs) occupy variable roles when interacting with their patients, several behavioural attributes emerge as helpful across the range of such roles. In light of recent research on the value of considering animals' arousal and affective state as predictors of behaviour and welfare, best practice in human-horse and human-dog-interactions is outlined. The attributes of affiliation, safety and positive reinforcement seem to contribute greatly to the development and maintenance of moderate arousal and positive affect in animals. The information in this review article is offered in an attempt to show why veterinary professionals with good horsemanship are likely to remain safe, and to introduce the concept of dogmanship. In the light of the peer-reviewed evidence assembled here, it is arguable that veterinary teams, comprising both veterinarians and VNs, can become scholars in these areas. The benefits of this approach for practitioner safety, animal welfare and client satisfaction are likely to be significant.

Influence of parity on fetal hemodynamics and amniotic fluid volume at term

OBJECTIVES

Pregnancy complications, particularly those associated with placental dysfunction, occur more frequently in nulliparous than in parous women. This difference may be a consequence of improved trophoblastic invasion and, as a result, improved placental function following previous pregnancy. Placental dysfunction in cases of fetal growth restriction may be identified by ultrasound assessment of fetoplacental hemodynamics and amniotic fluid volume. In this prospective observational study, we investigated whether differences in these measures of placental function exist between nulliparous and parous women, prior to active labor.

METHODS

Over a 2-year period, 456 nulliparous and 152 parous women with uncomplicated singleton pregnancies were recruited to this prospective observational study. Each participant underwent an ultrasound assessment prior to active labor, during which fetal biometry, umbilical artery, middle cerebral artery and umbilical venous Dopplers, as well as amniotic fluid volume, were assessed. All cases were followed up within 48 h of delivery. Ultrasound parameters and intrapartum outcomes were then compared between the nulliparous and parous groups.

RESULTS

Compared with nulliparous women, parous women had significantly higher fetal middle cerebral artery pulsatility index, cerebroplacental ratio and amniotic fluid volume. In nulliparous women, middle cerebral artery flow rate was also significantly higher and represented a greater percentage of umbilical venous flow than was observed in parous women.

CONCLUSION

Prior to the active phase of labor, ultrasound parameters indicative of placental function differ significantly between nulliparous and parous pregnancy, even amongst an uncomplicated, low-risk cohort.

Type a behaviours and heart disease: epidemiological and experimental foundations

This paper critically examines three strands of evidence that concern the relationship between type A behaviours and coronary heart disease; prospective epidemiological studies of healthy populations, studies of those at high risk for coronary heart disease, and angiographic studies of atherosclerosis. The first of these would seem to provide the strongest test. Methodological and conceptual issues mean that the results of studies using the other methods should be interpreted with care. It is concluded that there is relatively strong evidence of an association between Type A behaviour as measured by Structured Interview and coronary heart disease. Hostility and anger appear to be the most powerful determinants of CHD. However, it is likely that they interact with other type A behaviours and related environmental factors in determining risk.