Efficacy and safety of a four-drug, quarter-dose treatment for hypertension: the QUARTET USA randomized trial

New approaches are needed to lower blood pressure (BP) given persistently low control rates. QUARTET USA sought to evaluate the effect of four-drug, quarter-dose BP lowering combination in patients with hypertension. QUARTET USA was a randomized (1:1), double-blinded trial conducted in federally qualified health centers among adults with hypertension. Participants received either a quadpill of candesartan 2 mg, amlodipine 1.25 mg, indapamide 0.625 mg, and bisoprolol 2.5 mg or candesartan 8 mg for 12 weeks. If BP was >130/>80 mm Hg at 6 weeks in either arm, then participants received open label add-on amlodipine 5 mg. The primary outcome was mean change in systolic blood pressure (SBP) at 12 weeks, controlling for baseline BP. Secondary outcomes included mean change in diastolic blood pressure (DBP), and safety included serious adverse events, relevant adverse drug effects, and electrolyte abnormalities. Among 62 participants randomized between August 2019-May 2022 (n = 32 intervention, n = 30 control), mean (SD) age was 52 (11.5) years, 45% were female, 73% identified as Hispanic, and 18% identified as Black. Baseline mean (SD) SBP was 138.1 (11.2) mmHg, and baseline mean (SD) DBP was 84.3 (10.5) mmHg. In a modified intention-to-treat analysis, there was no significant difference in SBP (-4.8 mm Hg [95% CI: -10.8, 1.3, p = 0.123] and a -4.9 mmHg (95% CI: -8.6, -1.3, p = 0.009) greater mean DBP change in the intervention arm compared with the control arm at 12 weeks. Adverse events did not differ significantly between arms. The quadpill had a similar SBP and greater DBP lowering effect compared with candesartan 8 mg. Trial registration number: NCT03640312.

Nivolumab in sorafenib-naive and sorafenib-experienced patients with advanced hepatocellular carcinoma: 5-year follow-up from CheckMate 040

BACKGROUND

Patients with advanced hepatocellular carcinoma (aHCC) have a poor prognosis and high mortality. Nivolumab monotherapy demonstrated clinical benefit with an acceptable safety profile in patients with aHCC in the CheckMate 040 study. Five-year follow-up of the sorafenib-naive and sorafenib-experienced groups of CheckMate 040 is presented here.

PATIENTS AND METHODS

Patients received nivolumab monotherapy at dose levels of 0.1-10.0 mg/kg (dose-escalation phase) or 3 mg/kg (dose-expansion phase) every 2 weeks until disease progression or unacceptable toxicity. Primary endpoints were safety and tolerability (dose escalation), and objective response rate (ORR) by blinded independent central review (BICR) and by investigator as per RECIST version 1.1 (dose expansion).

RESULTS

Eighty sorafenib-naive and 154 sorafenib-experienced patients were treated. Minimum follow-up in both groups was 60 months. ORR as per BICR was 20% [95% confidence interval (CI) 12% to 30%] and 14% (95% CI 9% to 21%) in the sorafenib-naive and sorafenib-experienced groups, respectively. Responses occurred regardless of HCC etiology or baseline tumor cell programmed death-ligand 1 (PD-L1) expression levels. Median overall survival (OS) was 26.6 months (95% CI 16.6-30.6 months) and 15.1 months (95% CI 13.0-18.2 months) in sorafenib-naive and sorafenib-experienced patients, respectively. The 3-year OS rates were 28% in the sorafenib-naive and 20% in the sorafenib-experienced groups; 5-year OS rates were 14% and 12%, respectively. No new safety signals were identified; grade 3/4 treatment-related adverse events were observed in 33% and 21% of patients in the sorafenib-naive and sorafenib-experienced groups, respectively. Biomarker analyses showed that baseline PD-L1 expression ≥1% was associated with higher ORR and longer OS compared with PD-L1 <1%. In the sorafenib-naive group, patients with OS ≥3 years exhibited higher baseline CD8 T-cell density compared with those with OS <1 year.

CONCLUSION

With 5 years of follow-up, nivolumab monotherapy continued to provide durable clinical benefit with manageable safety in sorafenib-naive and sorafenib-experienced patients with aHCC.

Evaluation of Primary Healthcare Centers' Service Availability and Readiness for Implementing Diabetes Care in Abuja, Nigeria: A Cross-Sectional, Formative Assessment

Introduction

Noncommunicable diseases (NCDs) are associated with a high and rising burden of morbidity and mortality in sub-Saharan Africa, including Nigeria. Diabetes mellitus (DM) is among the leading causes of NCD-related deaths worldwide and is a foremost public health problem in Nigeria. As part of the National Multi-Sectoral Action Plan for the Prevention and Control of NCDs, Nigeria has committed to implementing the World Health Organization (WHO) Package of Essential NCD control interventions. Implementing the intervention requires the availability of essential elements, including guidelines, trained staff, health management information systems, equipment, and medications, in primary healthcare centers (PHCs). This study assessed the availability of the WHO package components and the readiness of PHCs to implement a DM screening, evaluation, and management program.

Methods

This cross-sectional formative assessment adapted the WHO Service Availability and Readiness Assessment (SARA) tool to survey 30 PHCs selected by multistage sampling for readiness to deliver DM diagnosis and care in Abuja, Nigeria, between August 2021 and October 2021. The service availability and readiness indicator scores were calculated based on the proportion of PHCs with available DM care services, minimum staff requirement, diagnostic tests, equipment, medications, and national guidelines/protocols for DM care within the defined SARA domain.

Results

All 30 PHCs reported the availability of at least two full-time staff (median [interquartile range] staff = 5 [4-9]), which were mostly community health extension workers (median [interquartile range]) = 3 [1-4]. At least one staff member was recently trained in DM care in only 11 (36%) of the PHCs. The study also reported high availability (100%) of paper-based health management information systems (HMIS) and DM screening services using a glucometer (87%), but low availability of DM treatment (23%), printed job aids (27%), and national guidelines/protocols (0%).

Conclusion

This systematic assessment of PHCs' readiness to implement a DM screening, evaluation, and management program in Abuja demonstrated readiness to integrate DM care into PHCs in terms of equipment, paper-based HMIS, and nonphysician health workers' availability. However, strategies are needed to promote DM health workforce training, provide DM management guidelines, and ensure a reliable supply of essential DM medications.

miRNAs from Inflamed Gingiva Link Gene Signaling to Increased MET Expression

Several array-based microRNA (miRNA) expression studies independently showed increased expression of miRNAs hsa-miR-130a-3p, -142-3p, -144-3p, -144-5p, -223-3p, -17-5p, and -30e-5p in gingiva affected by periodontal inflammation. We aimed to determine direct target genes and signaling pathways regulated by these miRNAs to identify processes relevant to gingival inflammatory responses and tissue homeostasis. We transfected miRNA mimics (mirVana) for each of the 7 miRNAs separately into human primary gingival fibroblasts cultured from 3 different donors. Following RNA sequencing, differential gene expression and second-generation gene set enrichment analyses were performed. miRNA inhibition and upregulation was validated at the transcript and protein levels using quantitative reverse transcriptase polymerase chain reaction, Western blotting, and reporter gene assays. All 7 miRNAs significantly increased expression of the gene MET proto-oncogene, receptor tyrosine kinase (MET). Expression of known periodontitis risk genes CPEB1, ABCA1, and ATP6V1C1 was significantly repressed by hsa-miR-130a-3p, -144-3p, and -144-5p, respectively. The genes WASL, ENPP5, ARL6IP1, and IDH1 showed the most significant and strongest downregulation after hsa-miR-142-3p, -17-5p, -223-3p, and -30e-5p transfection, respectively. The most significantly regulated gene set of each miRNA related to cell cycle (hsa-miRNA-144-3p and -5p [Padj = 4 × 10-40 and Padj = 4 × 10-6], -miR-17-5p [Padj = 9.5 × 10-23], -miR-30e-5p [Padj = 8.2 × 10-18], -miR-130a-3p [Padj = 5 × 10-15]), integrin cell surface interaction (-miR-223-3p [Padj = 2.4 × 10-7]), and interferon signaling (-miR-142-3p [Padj = 5 × 10-11]). At the end of acute inflammation, gingival miRNAs bring together complex regulatory networks that lead to increased expression of the gene MET. This underscores the importance of mesenchymal cell migration and invasion during gingival tissue remodeling and proliferation in restoring periodontal tissue homeostasis after active inflammation. MET, a receptor of the mitogenic hepatocyte growth factor fibroblast secreted, is a core gene of this process.

Fixed-dose combination therapy-based protocol compared with free pill combination protocol: Results of a cluster randomized trial

Fixed-dose combination (FDC) therapy is recommended for hypertension management in Nigeria based on randomized trials at the individual level. This cluster-randomized trial evaluates effectiveness and safety of a treatment protocol that used two-drug FDC therapy as the second and third steps for hypertension control compared with a protocol that used free pill combinations. From January 2021 to June 2021, 60 primary healthcare centers in the Federal Capital Territory of Nigeria were randomized to a protocol using FDC therapy as second and third steps compared with a protocol that used the same medications in free pill combination therapy for these steps. Eligible patients were adults (≥18 years) with hypertension. The primary outcome was the odds of a patient being controlled at their last visit between baseline to 6-month follow-up in the FDC group compared to the free pill group. 4427 patients (mean [SD] age: 49.0 [12.4] years, 70.5% female) were registered with mean (SD) baseline systolic/diastolic blood pressure 155 (20.6)/96 (13.1) mm Hg. Baseline characteristics of groups were similar. After 6-months, hypertension control rate improved in the two treatment protocols, but there were no differences between the groups after adjustment (FDC = 53.9% versus free pill combination = 47.9%, cluster-adjusted p = .29). Adverse events were similarly low (<1%) in both groups. Both protocols improved hypertension control rates at 6-months in comparison to baseline, though no differences were observed between groups. Further work is needed to determine if upfront FDC therapy is more effective and efficient to improve hypertension control rates.

Nigeria healthcare worker SARS-CoV-2 serology study: Results from a prospective, longitudinal cohort

Healthcare workers, both globally and in Nigeria, have an increased risk for SARS-CoV-2 infection compared with the general population due to higher risk contacts, including occupational exposures. In addition, primary healthcare workers represent an important group for estimating prior infection to SARS-CoV-2 because they work at the first point-of-contact for most patients yet have not been included in prior COVID-19 seroepidemiology research in Nigeria. We sought to evaluate baseline seroprevalence, rates of seroconversion (IgG- to IgG+) and seroreversion (IgG+ to IgG-), change in IgG concentration at 3- and 6-month follow-up, and factors associated with seropositivity. From June 2020 to December 2020, we conducted a longitudinal seroepidemiology study among frontline health care workers in Nigeria using a validated dried blood spot assay. Among 525 participants, mean (SD) age was 39.1 (9.7) years, 61.0% were female, and 45.1% were community health workers. The six-month follow-up rate was 93.5%. Seropositivity rates increased from 31% (95% CI: 27%, 35%) at baseline to 45% (95% CI: 40%, 49%) at 3-month follow-up, and 70% (95% CI: 66%, 74%) at 6-month follow-up. There was a corresponding increase in IgG levels from baseline (median = 0.18 ug/mL) to 3-month (median = 0.35 ug/mL) and 6-month follow-up (median = 0.59 ug/mL, Ptrend < .0001). A minority of participants reported symptoms from February 2020 until baseline (12.2%) or during 3-month (6.6%) or 6-month (7.5%) follow-up. only 1 participant was hospitalized. This study demonstrated high baseline, 3-month and 6-month follow-up prevalence of IgG antibodies to SARS-CoV-2 during the first two waves of the COVID-19 pandemic in Nigeria among a cohort of unvaccinated frontline healthcare workers, including primary healthcare workers despite low symptomatology. These results may have implications in state- and national-level disease pandemic modeling. Trial registration: NCT04158154.

Efficacy and safety of a quadruple ultra-low-dose treatment for hypertension (QUARTET USA): Rationale and design for a randomized controlled trial

BACKGROUND

Over half of patients with elevated blood pressure require multi-drug treatment to achieve blood pressure control. However, multi-drug treatment may lead to lower adherence and more adverse drug effects compared with monotherapy.

OBJECTIVE

The Quadruple Ultra-low-dose Treatment for Hypertension (QUARTET) USA trial was designed to evaluate whether initiating treatment with ultra-low-dose quadruple-combination therapy will lower office blood pressure more effectively, and with fewer side effects, compared with initiating standard dose monotherapy in treatment naive patients with SBP < 180 and DBP < 110 mm Hg and patients on monotherapy with SBP < 160 and DBP < 100 mm Hg.

METHODS/DESIGN

QUARTET USA was a prospective, randomized, double-blind trial (ClinicalTrials.gov NCT03640312) conducted in federally qualified health centers in a large city in the US. Patients were randomly assigned (1:1) to either ultra-low-dose quadruple combination therapy or standard dose monotherapy. The primary outcome was mean change from baseline in office systolic blood pressure at 12-weeks, adjusted for baseline values. Secondary outcomes included measures of blood pressure change and variability, medication adherence, and health related quality of life. Safety outcomes included occurrence of serious adverse events, relevant adverse drug effects, and electrolyte abnormalities. A process evaluation aimed to understand provider experiences of implementation and participant experiences around side effects, adherence, and trust with clinical care.

DISCUSSION

QUARTET USA was designed to evaluate whether a novel approach to blood pressure control would lower office blood pressure more effectively, and with fewer side effects, compared with standard dose monotherapy. QUARTET USA was conducted within a network of federally qualified healthcare centers with the aim of generating information on the safety and efficacy of ultra-low-dose quadruple-combination therapy in diverse groups that experience a high burden of hypertension.

Characteristics and Patterns of Retention in Hypertension Care in Primary Care Settings From the Hypertension Treatment in Nigeria Program

BACKGROUND

More than 1.2 billion adults worldwide have hypertension. High retention in clinical care is essential for long-term management of hypertension, but 1-year retention rates are less than 50% in many resource-limited settings.

OBJECTIVE

To evaluate short-term retention rates and associated factors among patients with hypertension in primary health care centers in the Federal Capital Territory of Nigeria.

DESIGN, SETTING, AND PARTICIPANTS

In this cohort study, data were collected by trained study staff from adults aged 18 years or older at 60 public, primary health care centers in Nigeria between January 2020 and July 2021 as part of the Hypertension Treatment in Nigeria (HTN) Program. Patients with hypertension were registered.

EXPOSURES

Follow-up visit for hypertension care within 37 days of the registration visit.

MAIN OUTCOMES AND MEASURES

The main outcome was the 3-month rolling average 37-day retention rate in hypertension care, calculated by dividing the number of patients who had a follow-up visit within 37 days of their first (ie, registration) visit in the program by the total number of registered patients with hypertension during multiple consecutive 3-month periods. Interrupted time series analyses evaluated trends in retention rates before and after the intervention phase of the HTN Program. Mixed-effects, multivariable regression models evaluated associations between patient-, site-, and area council-level factors, hypertension treatment and control status, and 37-day retention rate.

RESULTS

In total, 10 686 patients (68.3% female; mean [SD] age, 48.8 [12.7] years) were included in the analysis. During the study period, the 3-month rolling average 37-day retention rate was 41% (95% CI, 37%-46%), with wide variability among sites. The retention rate was higher among patients who were older (adjusted odds ratio [aOR], 1.01 per year; 95% CI, 1.01-1.02 per year), were female (aOR, 1.11; 95% CI, 1.01-1.23), had a higher body mass index (aOR, 1.01; 95% CI, 1.00-1.02), were in the Kuje vs the Abaji area council (aOR, 2.25; 95% CI, 1.25-4.04), received hypertension treatment at the registration visit (aOR, 1.27; 95% CI, 1.07-1.50), and were registered during the postintervention period (aOR, 1.16; 95% CI, 1.06-1.26).

CONCLUSIONS AND RELEVANCE

The findings suggest that retention in hypertension care is suboptimal in primary health care centers in Nigeria, although large variability among sites was found. Potentially modifiable and nonmodifiable factors associated with retention were identified and may inform multilevel, contextualized implementation strategies to improve retention.

Hypertension Treatment in Nigeria (HTN) Program: rationale and design for a type 2 hybrid, effectiveness, and implementation interrupted time series trial

Background

Hypertension is the most common cardiovascular disease in Nigeria and contributes to a large non-communicable disease burden. Our aim was to implement and evaluate a large-scale hypertension treatment and control program, adapted from the Kaiser Permanent Northern California and World Health Organization HEARTS models, within public primary healthcare centers in the Federal Capital Territory, Nigeria.

Methods

A type 2 hybrid, interrupted time series design was used to generate novel information on large-scale implementation and effectiveness of a multi-level hypertension control program within 60 primary healthcare centers in the Federal Capital Territory, Nigeria. During the formative phase, baseline qualitative assessments were held with patients, health workers, and administrators to inform implementation package adaptation. The package includes a hypertension patient registry with empanelment, performance and quality reporting, simplified treatment guideline emphasizing fixed-dose combination therapy, reliable access to quality essential medicines and technology, team-based care, and health coaching and home blood pressure monitoring. Strategies to implement and adapt the package were identified based on barriers and facilitators mapped in the formative phase, previous implementation experience, mid-term qualitative evaluation, and ongoing stakeholder and site feedback. The control phase included 11 months of sequential registration of hypertensive patients at participating primary healthcare centers, followed by implementation of the remainder of the package components and evaluation over 37 subsequent, consecutive months of the intervention phase.

The formative phase was completed between April 2019 and August 2019, followed by initiation of the control phase in January 2020. The control phase included 11 months (January 2020 to November 2020) of sequential registration and empanelment of hypertensive patients at participating primary healthcare centers. After completion of the control phase in November 2020, the intervention phase commenced in December 2020 and will be completed in December 2023.

Discussion

This trial will provide robust evidence for implementation and effectiveness of a multi-level implementation package more broadly throughout the Federal Capital Territory, which may inform hypertension systems of care throughout Nigeria and in other low- and middle-income countries. Implementation outcome results will be important to understand what system-, site-, personnel-, and patient-level factors are necessary for successful implementation of this intervention.

Trial registration

ClinicalTrials.gov NCT04158154. The trial was prospectively registered on November 8, 2019.

Supplementary Information

The online version contains supplementary material available at 10.1186/s43058-022-00328-9.

Burden of osteoarthritis in India and its states, 1990-2019: findings from the Global Burden of disease study 2019

OBJECTIVE

To describe the burden of osteoarthritis (OA) in India from 1990 to 2019.

DESIGN

Data from Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019 were used. The burden of OA -knee OA, hip OA, hand OA, and other OA- was estimated for India and its states from 1990 to 2019 through a systematic analysis of prevalence, incidence, years lived with disability (YLD), and disability-adjusted life years (DALY) using methods reported in GBD 2019 study.

RESULT

Around 23.46 million individuals in India had OA in 1990; this increased to 62.35 million in 2019. The age-standardised prevalence of OA increased from 4,895 (95% uncertainty interval (UI):4,420-5,447) in 1990-5313 (95%UI:4,799-5,898) in 2019, per 100,000 persons. Similarly, DALYs due to OA increased from 0.79 million (95%UI:0.40-1.55) to 2.12 million (95%UI:1.07-4.23); while age-standardised DALYs increased from 164 (95%UI:83-325) to 180 (95%UI:91-361) per 100,000 persons from 1990 to 2019. OA was the 20^th most common cause of YLDs in India in 2019, accounting for 1.48% (95%UI:0.88-2.78) of all YLDs; increasing from 23rd most common cause in 1990 (1.25%(95%UI:0.74-2.34)). Knee OA was the most common form of OA, followed by hand OA. The prevalence, incidence, and DALYs for OA and knee OA were consistently higher in females than males.

CONCLUSION

The burden and impact of OA in India are substantial and is increasing. Adopting suitable control and preventive community measures to reduce modifiable risk factors (obesity, injuries, occupational stress) are needed to reduce the current and future burden of OA in India.

POS1425 THE BURDEN OF OSTEOARTHRITIS ACROSS THE STATES OF INDIA, 1990–2019: FINDINGS FROM THE GLOBAL BURDEN OF DISEASE STUDY 2019

Background

Few studies have reported the burden of osteoarthritis (OA) in different parts of India. However, no study has reported the detailed estimates of incidence, prevalence, and years lived with disability (YLDs) and its trends for OA (and its various sites) across the states of India over a long period of time.

Objectives

We aim to describe the state-wise prevalence, incidence, and YLDs for osteoarthritis (OA) in India from 1990 to 2019 according to age and sex.

Methods

Data from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019 were used. The burden of OA –including knee OA, hip OA, hand OA, and other OA– was estimated for India and its states from 1990 to 2019 through a systematic analysis of prevalence, incidence, and YLDs modelled data using the methods reported in the GBD 2019 Study. All estimates are presented as counts and age-standardised rates per 100,000 population, with uncertainty intervals (UIs).

Results

Around 23.46 million individuals in India had OA in 1990; this increased to 62.35 million in 2019. The age-standardised prevalence of OA increased from 4,895 (95% uncertainty interval (UI): 4,420–5,447) in 1990 to 5313 (95%UI: 4,799–5,898) in 2019, per 100,000. OA was the 20th most common cause of YLDs in India in 2019, accounting for 1·48% (95%UI: 0·88–2·78) of all YLDs; increasing from 23rd most common cause in 1990 (1·25% (95%UI: 0·74–2·34)). Knee OA was the most common form of OA, followed by hand OA. The prevalence, incidence, and YLDs for OA and knee OA were consistently higher in females than males. Uttar Pradesh (8.53 million (95%UI: 7.63–9.53), Maharashtra (6.37 million (95%UI: 5.75–7.06), and West Bengal (4.90 million (95%UI: 4.39–5.46) had the three highest levels of OA prevalence. Goa (5689 (95%UI: 5,125–6,282)), Rajasthan (5667 (95%UI: 5,097–6,305)), and Kerala (5658 (95%UI: 5,107–6,263)) had the highest age-standardised prevalence of OA in 2019, per 100,000 (Figure 1 A and B).

Conclusion

The burden and impact of OA in India are substantial and is increasing; however, it varied among states. Females were affected more commonly than males. Knee OA was the most prevalent site. With improvement in life expectancy and population ageing, greater increases are expected. Adopting suitable control and preventive community measures to reduce modifiable risk factors (such as obesity, injuries, occupational stress) are needed now to reduce the current and future burden of OA in India.

Disclosure of Interests

None declared

OP0035 WHAT EXPLAINS THE WORLDWIDE GRADIENT OF AGE AT ONSET OF RHEUMATOID ARTHRITIS ALONG LATITUDE? A MULTILEVEL ANALYSIS IN THE METEOR REGISTRY

Background

It has been suggested that rheumatoid arthritis (RA) starts at a younger age in cities with a lower latitude (closer to both sides of the equator). This consistent finding still remains to be explained. It has been hypothesized that latitude is a proxy for presence of genetic (eg. ACPA) and environmental risk factors (eg. smoking) for RA onset.

Objectives

To study how age at RA onset varies with latitude worldwide and to what extent patient and country level factors explain this variability.

Methods

RA patients from the worldwide METEOR registry were included. Age at diagnosis as a proxy for age at RA onset, measured at the patient level, was the main outcome. The explanatory variable was the absolute value of latitude, measured as the latitude of the hospital (hospital level). Patient factors considered potentially relevant were gender, RF and ACPA positivity, smoking status, symptom duration (months), year of first visit and BMI (all patient level). Country level factors were socioeconomic indicators (physician density, health expenditure, life expectancy, GDP per capita and gross enrolment in secondary school), derived from country statistics. We hypothesized that both patient and country level factors explain (ie. mediate) a relationship between latitude and age at diagnosis (Figure 1).

We applied Bayesian multilevel linear structural equations models, which not only quantify effects at multiple levels but also disentangle at which level the effects take place. For example, they can differentiate whether hospital or country latitude affects age at diagnosis.

We examined: 1. the total effect of latitude on age at diagnosis at hospital and country level (Main model); 2. the amount of the total effect that is mediated by patient factors at the patient and hospital level (Model A); and 3. the amount of the total effect that is mediated by country factors at the country level (Model B). In each model we disentangle the effect in different measurement levels. For example, a patient level variable can vary at the patient, hospital and country level.

Results

We included 39 782 patients nested in 94 hospitals nested in 17 countries. The mean age at diagnosis per country ranged from 39 to 55 years. The study spanned a range of latitude between 9.9 and 55.8 degrees (ie. from Nigeria to the United Kingdom). In the main model, we confirmed the association between latitude and age at diagnosis and found that it only occurred at the country level (not at the hospital level). Per degree increase in country latitude, the average age at diagnosis per country increased by 0.23 years (95% credibility interval 0.07; 0.40). At the hospital level however, this effect was negligible: β= 0.040 (-0.16; 0.31). Associations between latitude and several patient factors were found at the country level, but these patient factors only associated with age at diagnosis at the patient level, not at the country (or hospital) level (Model A). This means patient-factors did not explain the association between latitude and age at diagnosis at the country level (main effect changed from 0.23 before to 0.37 after inclusion of patient factors). In model B latitude associated with most country factors (except GDP per capita). Even though none of these variables separately were significantly associated with age at diagnosis, inclusion of the set of country level factors reduced the country level effect of latitude on age at diagnosis from 0.23 to almost zero: β=-0.033 (-0.51; 0.37). Sensitivity analyses with age at symptom onset as outcome provided similar results.

Conclusion

Patients living close at the equator indeed get RA far earlier than those living closer to the poles. We here suggest that, rather than due to variation in patients’ characteristics, this latitude gradient is a country level phenomenon explained by indicators of countries’ socioeconomic status, and not by patient specific genetic or environmental factors. This big data analysis in a worldwide prevalence cohort provides a direct link between countries’ levels of welfare and the onset of RA.

Disclosure of Interests

Sytske Anne Bergstra Grant/research support from: Pfizer, Alexandre Sepriano Speakers bureau: Novartis, Consultant of: UCB, Arvind Chopra: None declared, Lai-Ling Winchow: None declared, David Vega-Morales: None declared, Karen Solomon-Escoto: None declared, Xanthe Matthijssen: None declared, Robert B.M. Landewé Shareholder of: Director of Rheumatology Consultancy BV, Consultant of: Honoraria from AbbVie, AstraZeneca, BMS, Boehringer Ingelheim, Celgene, Galapagos, Gilead, Glaxo-Smith-Kline, Janssen, Eli-Lilly, Novartis, Pfizer, UCB Pharma.

Characteristics, treatment, and control of hypertension in public primary healthcare centers in Nigeria: baseline results from the Hypertension Treatment in Nigeria Program

BACKGROUND

There are limited data on large-scale, multilevel implementation research studies to improve hypertension diagnosis, treatment, and control rates at the primary healthcare (PHC) level in Africa. We describe the characteristics, treatment, and control rates of patients with hypertension in public PHC centers in the Hypertension Treatment in Nigeria Program.

METHODS

Data were collected from adults at least 18 years at 60 public PHC centers between January 2020 and November 2020. Hypertension treatment rates were calculated at registration and upon completion of the initial visit. Hypertension control rates were calculated based on SBP and DBPs less than 140/90 mmHg. Regression models were created to evaluate factors associated with hypertension treatment and control status.

RESULTS

Four thousand, nine hundred and twenty-seven individuals [66.7% women, mean (SD) age = 48.2 (12.9) years] were included. Mean (SD) SBP was higher in men compared with women [152.9 (20.0) mmHg versus 150.8 (21) mmHg, P = 0.001]. Most (58.3%) patients were on treatment at the time of registration, and by the end of the baseline visit, 89.2% of patients were on treatment. The baseline hypertension control rate was 13.1%, and control was more common among patients who were older [adjusted OR (95% CI) 1.01 [1.01 -1.02)], women [adjusted OR (95% CI) 1.30 (1.05- 1.62)], who used fixed dose combination therapy [adjusted OR (95% CI) 1.83 (1.49 -2.26)], and had higher education levels.

CONCLUSION

This baseline report of the largest facility-based hypertension study in Africa demonstrates high hypertension treatment rates but low control rates.

BACH1 Binding Links the Genetic Risk for Severe Periodontitis with ST8SIA1

Genome-wide association studies identified various loci associated with periodontal diseases, but assigning causal alleles remains difficult. Likewise, the generation of biological meaning underlying a statistical association has been challenging. Here, we characterized the genetic association at the gene ST8SIA1 that increases the risk for severe periodontitis in smokers. We used CRISPR/dCas9 activation and RNA-sequencing to identify genetic interaction partners of ST8SIA1 and to determine its function in the cell. We used reporter gene assays to identify regulatory elements at the associated single-nucleotide polymorphisms (SNPs) and to determine effect directions and allele-specific changes of enhancer activity. Antibody electrophoretic mobility shift assays proved allele-specific transcription factor binding at the putative causal SNPs. We found the reported periodontitis risk gene ABCA1 as the top upregulated gene following ST8SIA1 activation. Gene set enrichment analysis showed highest effects on integrin cell surface interactions (area under the curve [AUC] = 0.85; q = 4.9 × 10-6) and cell cycle regulation (AUC = 0.89; q = 1.6 × 10-5). We identified 2 associated repressor elements in the introns of ST8SIA1 that bind the transcriptional repressor BACH1. The putative causative variant rs2012722 decreased BACH1 binding by 40%. We also pinpointed ST8SIA1 as the target gene of the association. ST8SIA1 inhibits cell adhesion with extracellular matrix proteins, integrins, and cell cycle, as well as enhances apoptosis. Likewise, tobacco smoke reportedly results in an inhibition of cell adhesion and a decrease in integrin-positive cells and cell growth. We conclude that impaired ST8SIA1 repression, independently caused by reduced BACH1 binding at the effect T allele, as well as by tobacco smoke, contributes to higher ST8SIA1 levels, and in smokers who carry the effect T allele, both factors would be additive with damaging effects on the gingival barrier integrity. The activity of ST8SIA1 is also linked with the periodontitis risk gene ABCA1.

Periodontitis Risk Variants at SIGLEC5 Impair ERG and MAFB Binding

Periodontitis is a common complex inflammatory disease of the oral cavity. It is characterized by inflammation of gingival tissues and alveolar bone loss. Recently, a genome-wide association study and 2 genome-wide association study meta-analyses found 2 associated regions (haplotype blocks) at the inhibitory immune receptor gene SIGLEC5 to increase the risk for periodontitis. The aims of the current study were the identification of the putative causal variants underlying these associations, characterization of their molecular biological effects, and validation of SIGLEC5 as the target gene. We mapped the associated single-nucleotide polymorphisms to DNA elements with predictive features of regulatory functions and screened the associated alleles for transcription factor (TF) binding sites. Antibody electrophoretic mobility shift assays (EMSAs) with allele-specific probes were used to identify TF binding and to quantify allele-specific effects on binding affinities. Luciferase reporter assays were used to quantify the effect directions and allele-specific strength of the associated regulatory elements. We used CRISPR-dCas9 gene activation to validate SIGLEC5 as a target of the association. EMSA in peripheral blood mononuclear cells showed that E-26 transformation-specific TF-related gene (ERG) binds at rs11084095, with almost complete loss of binding at the minor A-allele. Allele-specific reporter genes showed enhancer function of the DNA sequence at rs11084095, which was abrogated in the background of the A-allele. EMSA in B lymphocytes showed that TF MAF bZIP (MAFB) binds at the common G-allele of rs4284742, whereas the minor A-allele reduced TF binding by 69%, corresponding to 9-fold reduction of luciferase reporter gene activity by the A-allele. Using CRISPR-dCas9, we showed that the enhancer at rs4284742 strongly activated SIGLEC5 expression, validating this gene as the target gene of the association. We conclude that rs11084095 and rs4284742 are putatively causal for the genome-wide significant associations with periodontitis at SIGLEC5 that impair ERG and MAFB binding, respectively.

Presentation, Management, and In-Hospital Outcomes of Patients with Acute Heart Failure in South India by Sex: A Secondary Analysis of a Prospective, Interrupted Time Series Study

Background

Sex differences in presentation, management, and outcomes of heart failure (HF) have been observed, but it is uncertain whether these differences exist in South India.

Objective

We describe sex differences in presentation, management, and in-hospital outcomes in patients hospitalized with HF in South India and explore sex-based differences in the effect of the quality improvement intervention in a secondary analysis of a prospective, interrupted time series study.

Methods

The Heart Failure Quality Improvement in Kerala (HF QUIK) study evaluated the effect of a quality improvement toolkit on process of care measures and clinical outcomes in patients hospitalized with HF in eight hospitals in Kerala using an interrupted time series design from February 2018 to August 2018. The primary outcome was guideline-directed medical therapy (GDMT) at hospital discharge for patients with HF with reduced ejection fraction (HFrEF). We performed sex-stratified analyses using mixed effect logistic regression models.

Results

Among 1,400 patients, 536 (38.3%) were female. Female patients were older (69.6 vs. 65 years, p < 0.001), were less likely to have an ischemic etiology of HF (control period: 78.2% vs. 87.5%; intervention period: 83.6% vs. 91.5%; p < 0.05 for both) and were less likely to undergo coronary angiography or percutaneous coronary intervention. The quality improvement intervention had similar effects on the odds of GDMT at discharge in females with HFrEF (adjusted OR 1.79, 95% CI 0.92, 3.47) and males with HFrEF (adjusted OR 1.68, 95% CI 1.07, 2.64, pinteraction = 0.69).

Conclusions

We observed sex-specific differences in presentation and procedural management of patients with HF but no differences in the effect of the quality improvement intervention on discharge GDMT rates. Both male and female patients with HFrEF remained undertreated in the study intervention period, demonstrating the need for implementation strategies to close the HFrEF treatment gap in South India.

THYROIDITIS DEVELOPING POST INITIATION OF OCTREOTIDE IN A CASE OF TSH SECRETING TUMOR

Thyroiditis developing post pituitary surgery in a case of TSH secreting tumor has been reported, albeit rarely. A 46 year old female was treated as a case of hypothyroidism for almost five years, however, TSH levels remained unsuppressed in spite of increasing thyroxine doses. A cyclic pattern of TSH with T3 secretion was observed after stopping thyroxine, though T4 levels were normal. T3 suppression test revealed a non suppressed TSH and MRI sella revealed a pituitary mass with Grade 1 cavernous sinus invasion. With a diagnosis of TSH secreting tumor, the patient was initiated on octreotide therapy. TFT normalized within 4 days of initiation of octreotide, tumor size reduced by about 30% within 2 months of therapy and goiter size reduced to almost half with octreotide therapy. Anti TPO levels which were initially negative became positive within a month of octreotide therapy and FNAC thyroid revealed thyroiditis. To the best of our knowledge, this is the second case report of development of thyroiditis after octreotide therapy. The immunomodulatory role of TSH and somatostatin may have a role in the development of thyroiditis in this case.

AB0641 MANAGING ANKYLOSING SPONDYLITIS (AS) WITH SHORT TERM BIOSIMILAR ADALIMUMAB REGIMEN IN A RESOURCE STRAPPED SETTING: A PROTOCOL DRIVEN COMMUNITY CLINIC ORIENTED STUDY

Background:

We were handicapped by the exorbitant cost of innovator anti-Tumour Necrosis Factor (TNF) drugs. Despite limited use, we sometimes observed long-term benefits following short term induction like use. Emboldened by advent of biosimilars, we carried out an investigational study.

Objectives:

To evaluate the effectiveness of a short regimen of biosimilar (Bs) Adalimumab in AS

Methods:

50 consenting patients (86% B27+) naïve for biologics and negative for latent TB screen were enrolled into an observational design study of one year; Baseline mean values for age, duration, ASDAS and CRP was 31 years, 98.8 months, 4.6 and 64 mg per dl respectively. During the first year, patients were begun with 40 mg Bs Adalimumab (Bs-ADL) (Exemptia™), injected fortnight, for 12-16 weeks. No patient received DMARD or steroid in the first year of study. Patients continued standard of care follow up program in the clinic. The ASAS (Assessment Spondyloarthritis International Society) improvement indices were used. Standard intention-to-treat analysis was performed; significant p <0.05.

Results:

Optimum ASAS 40 improvement was observed at week 12 (68%); substantial improvement lasted till week 36. At one year, the ASAS 40 was 38%; ASAS partial remission 22% patients. Pro-inflammatory cytokines (IL-6, TNF α and IL-17) showed conspicuous reduction; maximum drop in IL-6 at week 24 (See Figure). 11 patients withdrew in the first year. 30 patients completed two years and 22 patients completed 3 year follow up. Over time, there was substantial loss in the ASAS 20 and 40 responses but patients seemed satisfied with the on-going symptomatic relief and improved function. Admittedly, patients showed more adherences to advice on physical exercise and stress reduction. Flares were more frequent after 1 year requiring short term round the clock NSAID; only 5 patients could afford to repeat a short term Bs-ADL regimen and one patient underwent hip arthroplasty. None received steroids and 5 patients were begun on Sulfasalazine in the second year and monitored. We could not evaluate structural modification (AS). Selected outcomes over 2 and 3 years from the current study will be compared to matched control (derived from the clinic database). None developed TB or any serious drug related toxicity. 2 patients developed recurrent uveitis.

Conclusion:

This real life documented experience unravelled impressive long term benefits following a kick start short term induction regimen of Biosimilar Adalimumab in AS. Though contrary to standard practice, this seemed a practical solution in our setting. We speculate a psychological and motivational boost rather than a prolonged real time biological effect (Bs-ADL) for this phenomenon. Our study has important socioeconomic bearing and merits validation.

Acknowledgement:

This was essentially a non-commercial investigator-initiated study. Zydus Cedilla India provided a generous research grant with free of cost Bs_ADL to several patients and a large concession in the cost to the rest.

Disclosure of Interests:

Arvind Chopra Grant/research support from: Zydus Pharamceutical Ltd India, Nagnath Khadke: None declared, Manjit Saluja: None declared, Toktam Kianifard: None declared, Anuradha Venugopalan: None declared

AB0585 SINGLE CENTER EXPERIENCE OF CLINICAL PROFILE OF INFLAMMATORY MYOSITIS FROM INDIA

Background:

Clinical profile of myositis differs in respect of the setting. We present a single center experience from a community based referral center

Objectives:

STUDY CLINICAL PROFILE OF INFLAMMATORY MYOSITIS (IM)

Methods:

We present data from 114 patients of connective tissue disorders (CTD) with dominant Inflammatory Myopathy(IM) evaluated in CRD where we have patient database since 1996. Standard investigations & ELISA, immunoblot and nephlometry to assay autoantibodies (AAb) were done. Data extraction done from 2005-2017

Results:

36 and 28 patients respectively diagnosed as dominant idiopathic dematomyositis (DM) and polymyositis (PM); remaining 41 patients showed overlap (OCTD). Mean onset age range 33-40 years in each subset with women dominance. Exclusive proximal muscle involvement seen 64% DM, 67% PM and 43% OCTD. 12 of OCTD showed classical DM rash. Raynauds’s phenomenon was seen in 38% (25% DM, 10% PM, 65% OCTD). 83% OCTD showed inflammatory polyarthritis; DM 29% and PM 42%. Two patients DM also diagnosed malignancy (ovarian CA). 25% DM, nil PM and 31.7% OCTD showed CT based lung findings. Mean creatinine phosphokinase at diagnosis were DM 1580, PM 2239 & OCTD 830. EMG required in 48 patients confirmed diagnosis (DM 17, PM 16 and OCTD 15). Seven patients with diagnostic dilemma/ poor therapy response required muscle histopathology confirmation. 59% DM,69% PM and 84% OCTD were seropositive ANA positive in 71%(ENA profile available for most). All Patients received steroids. Methotrexate prescribed in (92%), Azthioprine in (28%), hydroxychloroquine in (88%) with majority showing good response. Mycophenolate prescribed in (6%) for aggressive disease, IVIG in 2 patients for acute IIM with interstitial pneumonitis. Rituximab was prescribed in 4 resistant cases; all responding favourably. Mortality data of 4 patients(severe myositis(1), interstitial pneumonitis(1), ovarian cancer(1), septic shock(1)) was available. Antesynthatase syndrome noted in 9 patients.

Conclusion:

Overlap CTD with myositis seems more common profile than DM or PM. Response to therapy was satisfactory with steroids and methotrexate being the mainstay. Rituximab is a promising biological agent in chronic resistant cases.

References:

[1]A Kumar. Idiopathic Inflammatory Myopathies. Suppliment to JAPI, JUNE 2006, VOL. 54; Pg 62-66

[2]R Porkodi et al Clinical Spectrum of Inflammatory Myositis in South India - A Ten Year Study. J Assoc Physicians India 2002;50:1255-1258

[3]Chowdhary V, Aggarwal A, Misra R. Prevalence and clinical association of myositis-specific autoantibodies in North Indian patients with idiopathic inflammatory myopathy. APLAR J Rheumatol 2 001.

Acknowledgments :

STAFF AND PATIENTS OF CENTER FOR RHEUMATIC DISEASES, PUNE

Disclosure of Interests: :

NACHIKET KULKARNI Speakers bureau: PFIZER, NOVARTIS, YANSEN, Anuradha Venugopalan: None declared, MANJIT SALUJA: None declared, Arvind Chopra Grant/research support from: Zydus Pharamceutical Ltd India

SAT0158 EFFICACY AND SAFETY OF FILGOTINIB IN METHOTREXATE-NAÏVE PATIENTS WITH RHEUMATOID ARTHRITIS: FINCH 3 52-WEEK RESULTS

Background:

Filgotinib (FIL) is a potent, selective JAK 1 inhibitor. FINCH 3 assessed FIL efficacy and safety in methotrexate (MTX)-naïve patients (pts) with rheumatoid arthritis (RA); week (W)24 primary outcome results were previously presented.1

Objectives:

To report FINCH 3 (NCT02886728) results through W52.

Methods:

This global, phase 3, double-blind, active-controlled study randomised MTX-naïve pts with moderately to severely active RA 2:1:1:2 to oral FIL 200 mg once daily + MTX ≤20 mg weekly, FIL 100 mg + MTX, FIL 200 mg monotherapy (mono) + placebo (PBO), or PBO + MTX up to W52. Comparisons at W52 were not adjusted for multiplicity. Safety was assessed from adverse events and laboratory abnormalities.

Results:

Of 1249 treated pts, 975 received study drug through W52. FIL efficacy was sustained up to W52. Treatment with FIL + MTX or FIL mono increased proportions of pts achieving ACR20/50/70 and clinical disease remission by DAS28(CRP) <2.6 (FIL 200 mg + MTX, 53%; FIL mono, 46%), CDAI, SDAI, and Boolean criteria; improved HAQ-DI; and halted radiographic progression vs MTX alone (Table 1 andFigure). Safety was consistent with W24 data (Table 2).

Table 1.

Efficacy outcomes at week 52

FIL 200 mg + MTX (n = 416)FIL 100 mg + MTX (n = 207)FIL 200 mg(n = 210)MTX(n = 416)ACR20, %75.0***73.4**74.8***61.8ACR50, %62.3***59.4**61.4**48.3ACR70, %47.8***40.1*45.2***29.8mTSSa0.21***0.27*0.23**0.74HAQ-DIb−1.00***−0.97−0.95*−0.88

aLeast-squares mean change from baseline.

bMean change from baseline.

*, p <0.05;**, p <0.01;***, p <0.001 vs MTX alone; not adjusted for multiplicity.

FIL, filgotinib; mTSS, van der Heijde modified total Sharp score; MTX, methotrexate.

Table 2.

Safety outcomes through week 52

Event, n (%)FIL 200 mg + MTX(n = 416)FIL 100 mg + MTX(n = 207)FIL 200 mg(n = 210)MTX(n = 416)All AEs318 (76.4)164 (79.2)143 (68.1)305 (73.3)Serious AEs26 (6.3)13 (6.3)17 (8.1)28 (6.7)Infection148 (35.6)76 (36.7)75 (35.7)157 (37.7)Serious infection5 (1.2)3 (1.4)5 (2.4)8 (1.9)Herpes zoster6 (1.4)3 (1.4)4 (1.9)4 (1.0)VTE0004 (1.0)MACE (adjudicated)4 (1.0)1 (0.5)2 (1.0)2 (0.5)Malignancya1 (0.2)004 (1.0)NMSC2 (0.5)001 (0.2)Death3 (0.7)b1 (0.5)c00

aExcluding NMSC.

b1 lupus cardiomyopathy, 1 atypical interstitial pneumonia, 1 non–treatment-emergent cardiovascular death.

cDissecting cerebral and vertebral aneurysm.

AE, adverse event; FIL, filgotinib; MACE, major adverse cardiovascular event; MTX, methotrexate; NMSC, nonmelanoma skin cancer; VTE, venous thromboembolism.

Conclusion:

Efficacy of FIL 200 mg + MTX, FIL 100 mg + MTX, and FIL 200 mg mono was sustained through W52, with faster onset1and consistently numerically greater efficacy for FIL 200 vs 100 mg. No new safety signals were observed.

References:

[1]Westhovens, et al.Ann Rheum Dis.2019;78(Suppl2):259–60.

Disclosure of Interests:

Rene Westhovens Grant/research support from: Celltrion Inc, Galapagos, Gilead, Consultant of: Celltrion Inc, Galapagos, Gilead, Speakers bureau: Celltrion Inc, Galapagos, Gilead, William Rigby Consultant of: Gilead Sciences, Inc., Désirée van der Heijde Consultant of: AbbVie, Amgen, Astellas, AstraZeneca, BMS, Boehringer Ingelheim, Celgene, Cyxone, Daiichi, Eisai, Eli-Lilly, Galapagos, Gilead Sciences, Inc., Glaxo-Smith-Kline, Janssen, Merck, Novartis, Pfizer, Regeneron, Roche, Sanofi, Takeda, UCB Pharma; Director of Imaging Rheumatology BV, Daniel Ching Grant/research support from: AbbVie, Gilead Sciences, Inc., Pfizer, Sanofi, Consultant of: AbbVie, Pfizer, Speakers bureau: AbbVie, William Stohl Grant/research support from: GlaxoSmithKline, Consultant of: Janssen Research & Development, Jonathan Kay Grant/research support from: Gilead Sciences, Inc., Pfizer, Novartis Pharmaceuticals Corporation, Consultant of: Alvotech Suisse AG; Arena Pharmaceuticals, Inc.; Boehringer Ingelheim GmbH; Celltrion Healthcare Co. Ltd.; Merck Sharp & Dohme Corp.; Mylan Inc.; Novartis AG; Samsung Bioepis; Sandoz, Inc; UCB, Inc., Arvind Chopra Grant/research support from: Zydus Pharamceutical Ltd India, Beatrix Bartok Shareholder of: Gilead Sciences Inc., Employee of: Gilead Sciences Inc., Franziska Matzkies Shareholder of: Gilead Sciences, Inc., Employee of: Gilead Sciences, Inc., Zhaoyu Yin Shareholder of: Gilead Sciences, Inc., Employee of: Gilead Sciences, Inc., Ying Guo Shareholder of: Gilead Sciences, Inc., Employee of: Gilead Sciences, Inc., Chantal Tasset Shareholder of: Galapagos (share/warrant holder), Employee of: Galapagos, John Sundy Shareholder of: Gilead Sciences, Inc., Employee of: Gilead Sciences, Inc., Angelika Jahreis Shareholder of: Gilead Sciences, Inc., Employee of: Gilead Sciences, Inc., Neelufar Mozaffarian Shareholder of: Gilead, Employee of: Gilead, Osvaldo Messina Speakers bureau: Amgen; Americas Health Foundation; Pfizer, Robert B.M. Landewé Consultant of: AbbVie; AstraZeneca; Bristol-Myers Squibb; Eli Lilly & Co.; Galapagos NV; Novartis; Pfizer; UCB Pharma, Tatsuya Atsumi Grant/research support from: Eli Lily Japan K.K., Alexion Pharmaceuticals, Inc., Bristol-Myers Squibb Co., AbbVie Inc., Daiichi Sankyo Co., Ltd., Pfizer Inc., Chugai Pharmaceutical Co., Ltd., Mitsubishi Tanabe Pharma Co., Astellas Pharma Inc., Consultant of: Gilead Sciences, Inc., Eli Lilly Japan K.K., UCB Japan Co. Ltd., AbbVie Inc., Daiichi Sankyo Co., Ltd., Pfizer Inc., Chugai Pharmaceutical Co., Ltd., Speakers bureau: Eli Lilly Japan K.K., UCB Japan Co. Ltd., Bristol-Myers Squibb Co., AbbVie Inc., Eisai Co. Ltd., Otsuka Pharmaceutical Co., Ltd., Daiichi Sankyo Co., Ltd., Pfizer Inc., Chugai Pharmaceutical Co., Ltd., Mitsubishi Tanabe Pharma Co., Takeda Pharmaceutical Co., Ltd., Astellas Pharma Inc., Gerd Rüdiger Burmester Consultant of: AbbVie Inc, Eli Lilly, Gilead, Janssen, Merck, Roche, Pfizer, and UCB Pharma, Speakers bureau: AbbVie Inc, Eli Lilly, Gilead, Janssen, Merck, Roche, Pfizer, and UCB Pharma

Development of methods for the preparation of radiopure 82Se sources for the SuperNEMO neutrinoless double-beta decay experiment

A radiochemical method for producing 82Se sources with an ultra-low level of contamination of natural radionuclides (40K, decay products of 232Th and 238U) has been developed based on cation-exchange chromatographic purification with reverse removal of impurities. It includes chromatographic separation (purification), reduction, conditioning (which includes decantation, centrifugation, washing, grinding, and drying), and 82Se foil production. The conditioning stage, during which highly dispersed elemental selenium is obtained by the reduction of purified selenious acid (H2SeO3) with sulfur dioxide (SO2) represents the crucial step in the preparation of radiopure 82Se samples. The natural selenium (600 g) was first produced in this procedure in order to refine the method. The technique developed was then used to produce 2.5 kg of radiopure enriched selenium (82Se). The produced 82Se samples were wrapped in polyethylene (12 μm thick) and radionuclides present in the sample were analyzed with the BiPo-3 detector. The radiopurity of the plastic materials (chromatographic column material and polypropylene chemical vessels), which were used at all stages, was determined by instrumental neutron activation analysis. The radiopurity of the 82Se foils was checked by measurements with the BiPo-3 spectrometer, which confirmed the high purity of the final product. The measured contamination level for 208Tl was 8–54 μBq/kg, and for 214Bi the detection limit of 600 μBq/kg has been reached.

Comparative reliability and diagnostic performance of conventional 3T magnetic resonance imaging and 1.5T magnetic resonance arthrography for the evaluation of internal derangement of the hip

Objective

To compare the diagnostic accuracy of conventional 3T MRI against 1.5T MR arthrography (MRA) in patients with clinical femoroacetabular impingement (FAI).

Methods

Sixty-eight consecutive patients with clinical FAI underwent both 1.5T MRA and 3T MRI. Imaging was prospectively analysed by two musculoskeletal radiologists, blinded to patient outcomes and scored for internal derangement including labral and cartilage abnormality. Interobserver variation was assessed by kappa analysis. Thirty-nine patients subsequently underwent hip arthroscopy and surgical results and radiology findings were analysed.

Results

Both readers had higher sensitivities for detecting labral tears with 3T MRI compared to 1.5T MRA (not statistically significant p=0.07). For acetabular cartilage defect both readers had higher statistically significant sensitivities using 3T MRI compared to 1.5T MRA (p=0.02). Both readers had a slightly higher sensitivity for detecting delamination with 1.5T MRA compared to 3T MRI, but these differences were not statistically significant (p=0.66). Interobserver agreement was substantial to perfect agreement for all parameters except the identification of delamination (3T MRI showed moderate agreement and 1.5T MRA substantial agreement).

Conclusion

Conventional 3T MRI may be at least equivalent to 1.5T MRA in detecting acetabular labrum and possibly superior to 1.5T MRA in detecting cartilage defects in patients with suspected FAI.

Key Points

• Conventional 3T MRI is equivalent to 1.5T MRA for diagnosing labral tears.

• Conventional 3T MRI is superior to 1.5T MRA for diagnosing acetabular cartilage defect.

• Conventional 3T MRI is equivalent to 1.5T MRA for diagnosing cartilage delamination.

• Symptom severity score was significantly higher (p<0.05) in group proceeding to surgery.

Association of heat stress protein 90 and 70 gene polymorphism with adaptability traits in Indian sheep (Ovis aries)

Heat stress proteins assist cellular proteins in the acquisition of native structure. The present research was conducted to study how thermo-tolerance is modulated by HSP90 and HSP70 gene polymorphism and its association with hemato-physio-biochemical parameters, supported by their expression profiles in Chokla, Magra, Marwari, and Madras Red sheep breeds. Least square analysis revealed significant effect (P < 0.05) of season and breed on all the physiological parameters, i.e., temperature, respiratory rate, and pulse rate (a.m. and p.m.), as well as hematological parameters like Hb, packed cell volume, total erythrocyte count (TEC), neutrophil/lymphocyte (N/L) ratio, and total leukocyte count (TLC). There was a significant influence (P < 0.05) of breed on biochemical parameters such as glucose, SGOT, phosphorous, triglyceride, and cholesterol. Eight fragments were amplified and sequenced in HSP90, and 70 genes and 13 single-nucleotide polymorphisms (SNPs) were identified. Tetra-primer amplification refractory mutation system PCR, PCR-RFLP, and allele-specific PCR genotyping protocols were developed for large-scale genotyping of five SNPs. A significant difference (P < 0.05) of rectal temperature (a.m.), respiratory rate (p.m.), triglyceride, and total protein was observed at SNP01; albumin at SNP2; pulse rate (p.m.) at SNP3; and rectal temperature (p.m.), pulse rate (p.m.), Hb (g/dL), and N/L ratio at SNP4 and TLC at SNP5. Gene expression analysis revealed higher expression in less adapted animals with Madras Red < Magra < Chokla < Marwari expression pattern [corrected]. Predominant allele was found to be superior in most of the SNPs (SNP1-4) indicating the selection acting in directional manner (positive selection). Finally, it is concluded that TACCA haplotype combination of SNP1-SNP2-SNP3-SNP4-SNP5 might be of some selection advantage for the identification of animals more adaptable to heat stress.

Search for Neutrinoless Quadruple-β Decay of ^{150}Nd with the NEMO-3 Detector

We report the results of a first experimental search for lepton number violation by four units in the neutrinoless quadruple-β decay of ^{150}Nd using a total exposure of 0.19 kg yr recorded with the NEMO-3 detector at the Modane Underground Laboratory. We find no evidence of this decay and set lower limits on the half-life in the range T_{1/2}>(1.1-3.2)×10^{21}  yr at the 90% C.L., depending on the model used for the kinematic distributions of the emitted electrons.

The BiPo-3 detector

The BiPo-3 detector is a low radioactive detector dedicated to measuring ultra-low natural contaminations of ²⁰⁸Tl and ²¹⁴Bi in thin materials, initially developed to measure the radiopurity of the double β decay source foils of the SuperNEMO experiment at the μBq/kg level. The BiPo-3 technique consists in installing the foil of interest between two thin ultra-radiopure scintillators coupled to low radioactive photomultipliers. The design and performances of the detector are presented. In this paper, the final results of the ²⁰⁸Tl and ²¹⁴Bi activity measurements of the first enriched ⁸²Se foils are reported for the first time, showing the capability of the detector to reach sensitivities in the range of some μBq/kg.