Epidemiology and impact of frailty in patients with atrial fibrillation in Europe

BACKGROUND

Frailty is a medical syndrome characterised by reduced physiological reserve and increased vulnerability to stressors. Data regarding the relationship between frailty and atrial fibrillation (AF) are still inconsistent.

OBJECTIVES

We aim to perform a comprehensive evaluation of frailty in a large European cohort of AF patients.

METHODS

A 40-item frailty index (FI) was built according to the accumulation of deficits model in the AF patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry. Association of baseline characteristics, clinical management, quality of life, healthcare resources use and risk of outcomes with frailty was examined.

RESULTS

Among 10,177 patients [mean age (standard deviation) 69.0 (11.4) years, 4,103 (40.3%) females], 6,066 (59.6%) were pre-frail and 2,172 (21.3%) were frail, whereas only 1,939 (19.1%) were considered robust. Baseline thromboembolic and bleeding risks were independently associated with increasing FI. Frail patients with AF were less likely to be treated with oral anticoagulants (OACs) (odds ratio 0.70, 95% confidence interval 0.55-0.89), especially with non-vitamin K antagonist OACs and managed with a rhythm control strategy, compared with robust patients. Increasing frailty was associated with a higher risk for all outcomes examined, with a non-linear exponential relationship. The use of OAC was associated with a lower risk of outcomes, except in patients with very/extremely high frailty.

CONCLUSIONS

In this large cohort of AF patients, there was a high burden of frailty, influencing clinical management and risk of adverse outcomes. The clinical benefit of OAC is maintained in patients with high frailty, but not in very high/extremely frail ones.

483 IMPROVING THE PROVISION OF REGIONAL GERIATRIC MEDICINE TEACHING DURING THE COVID-19 PANDEMIC

Introduction

In Wessex Deanery, prior to the COVID-19 pandemic, Geriatric Medicine trainees from 10 NHS trusts attended face-to-face regional teaching sessions. In response to the pandemic, this teaching was suspended to reduce disruption in service provision and support social distancing. There was a clear need to reintroduce teaching for continued professional development and trainee progression.

Methods

In July 2020, Geriatric Medicine trainees in Wessex completed a questionnaire survey to identify their desire for socially distanced teaching and an acceptable format for delivery. Two half-day pilot teaching sessions via MS Teams were organised in September and October 2020. Trainees provided feedback via a questionnaire survey about the relevance and quality of teaching, and to identify any barriers to attendance. Subsequently, a monthly full-day virtual teaching programme was implemented. We reported reflections of our experiences on our trainee website to support future sessions.

Results

All trainees (n = 15) were eager for regional teaching to recommence through socially distanced education. Trainees had a preference for MS Teams, which can support interactive teaching. Attendance to the pilot sessions exceeded previous face-to-face sessions. 19 trainees attended the first session; 17 provided feedback. 28 trainees attended the second session; 12 provided feedback. Feedback was overwhelmingly positive; all reported the sessions were interesting and 82% (n = 14) that they would lead to changes in their practice. Some trainees expressed that full-day sessions would enhance curriculum coverage. 94% (n = 16) were positive of the virtual platform; it reduced travel and sessions could be recorded. Local trainees attended the second session in-person, which enhanced interactivity.

Conclusion

Virtual teaching has been successful in Wessex Deanery, with high attendance and positive feedback. Trainees can engage remotely without the need for travel and disruption. After the pandemic we hope to develop a regional teaching programme integrating virtual and face-to-face sessions to improve attendance and accessibility.

OP0194 GENERALIZED IMMUNE ACTIVATION IN STRUCTURES RELATED TO PMR OR GCA ON PET/CT ASSESSMENT DOES NOT OCCUR IN IMMUNE CHECKPOINT INHIBITOR-TREATED PATIENTS WHO DO NOT GO ON TO DEVELOP RHEUMATIC IMMUNE-RELATED ADVERSE EVENTS

Background:

The pathogenesis of rheumatic immune-related adverse events (irAEs) from checkpoint inhibitor cancer immunotherapy directed against programmed cell death protein 1 (PD-1) and programmed death ligand 1 (PD-L1) remains unknown, even though they are a consequence of pharmacologic inhibition of a specific immune mechanism. Given that some irAEs resemble polymyalgia rheumatica (PMR) or giant cell arteritis (GCA), a disease whose pathogenesis is poorly understood, observations regarding the pathogenesis of PMR-like or GCA-like irAEs are of significant interest. One proposed pathogenic mechanism involves generalized immune activation leading to a spectrum of subclinical disease. Interrogation of this hypothesis may be aided by PET/CT, which is frequently utilized for oncological staging purposes but is also useful in classical PMR or GCA diagnosis. If PMR or GCA irAEs merely represent a spectrum of generalized immune activation, low-grade subclinical PMR or GCA-related changes on PET/CT might be expected to be seen in patients who receive immunotherapy, irrespective of whether they develop clinically evident rheumatic irAEs.

Objectives:

This study investigated whether such changes occurred in patients receiving immunotherapy who did not develop clinically evident rheumatic irAEs.

Methods:

Consecutive patients exposed to PD-1 or PD-L1 inhibitor immunotherapy at a single center had scintigraphic uptake calculated by a nuclear medicine physician experienced in assessment of vasculitis. Patients were included if they had had 18F-fluorodeoxyglucose (18F-FDG) PET/CT imaging both within the two weeks prior to immunotherapy initiation and after at least eleven weeks of immunotherapy. Patients who went on to develop a rheumatic irAE were excluded, as were patients with scintigraphic evidence of liver metastases owing to their potential influence on scoring of uptake. Quantification of 18F-FDG uptake by maximum standardized uptake values (maximum standard unit value, SUVmax) was performed at sites relevant to PMR or GCA (17 sites relevant to PMR, 17 sites relevant to GCA) in paired scans, and the difference calculated.

Results:

Twenty-four patients receiving nivolumab, pembrolizumab or avelumab met the inclusion criteria, primarily for melanoma, non-small cell lung cancer, or lymphoma. The mean age was 67 at the time of the first scan, 71% were male, and 66% had a complete or partial oncological response at best response. No statistically or clinically significant difference in SUVmax was noted at any PMR or GCA-relevant anatomical site interrogated. Latent class analysis did not reveal clusters identifiable by cancer type, best response, or presence of combination therapy.

Conclusion:

Patients treated with PD-1/PD-L1 inhibitors without clinically evident rheumatic irAEs do not develop subclinical PMR or GCA-like changes on PET/CT. This supports the proposition that PMR-like and GCA-like irAEs are a distinct entity with stochastic onset, and do not simply represent generalized immune activation induced by immunotherapy.

Acknowledgements:

David Liew is the recipient of the Ronald John Gleghorn Bursary from the University of Melbourne.

Disclosure of Interests:

David Liew: None declared, Aurora Poon: None declared, Christopher McMaster: None declared, Claire Owen Speakers bureau: Roche, Jessica Leung Speakers bureau: GIlead, Novartis, Albert Frauman: None declared, Jonathan Cebon: None declared, Andrew Scott: None declared, Russell Buchanan: None declared

AB0371 PATIENTS WITH PROLONGED SYMPTOMS BEFORE GCA DIAGNOSIS DO NOT INCUR HIGHER RATES OF VISUAL LOSS

Background:

Giant cell arteritis (GCA), if left untreated, confers the threat of serious cranial ischaemic complications including permanent visual loss. Although achieving a prompt and accurate diagnosis remains challenging, early diagnosis is viewed as being paramount in preventing significant morbidity.1 This raises the question of whether GCA patients are at greater risk of developing visual sequelae if there is a longer window between symptom onset and presentation.

Objectives:

To compare the frequency of lasting visual loss in patients diagnosed with GCA undergoing temporal artery biopsy (TAB) within three months and after three months of symptom onset.

Methods:

Patients who underwent TAB from January 2011 to November 2020 were identified from the pathology database of an Australian rheumatology referral centre. The diagnosis of GCA was established for each patient based on either positive TAB or, in the setting of negative TAB, clinical diagnosis by a rheumatologist. Baseline demographics, symptoms and major confounders – including age, sex, history of polymyalgia rheumatica or inflammatory arthritis, headache, jaw pain, fatigue, temporal artery tenderness or diminished pulse, and number of 1990 American College of Rheumatology (ACR) classification criteria for GCA2 fulfilled – were manually extracted from electronic medical records, as was the duration between onset of GCA symptoms and TAB, and the presence of visual loss before and after TAB. Logistic regression log-likelihood tests were used to examine the two cohorts presenting before and after three months.

Results:

There were 167 patients who underwent TAB during the study period with accessible clinical information. Of these, 31 (19%) had a delayed presentation of greater than three months from symptom onset. There were no statistical differences in patient demographics between the two groups (Table 1). No patients with delayed presentation experienced lasting, objective visual loss. In contrast, there were three cases in the cohort of patients who presented more promptly; these included two patients who developed permanent unilateral blindness, and one who experienced unilateral vision loss with some improvement at three months of follow-up.

Table 1.

Patient characteristics by time from symptom onset to TAB.

Presentation <3 monthsPresentation ≥3 monthsp-valueAge (years)73.45±10.0669.84±10.750.080Female92 (67.65%)20 (64.52%)0.738History of polymyalgia rheumatica23 (16.91%)4 (12.90%)0.586History of inflammatory arthritis6 (4.41%)2 (6.45%)0.633Headache110 (80.88%)23 (74.19%)0.406Jaw pain37 (27.21%)5 (16.13%)0.206Fatigue28 (20.59%)6 (19.35%)0.878Temporal artery tenderness or diminished pulse46 (33.82%)11 (35.48%)0.860ACR classification criteria2.83±0.992.58±0.890.199

Conclusion:

GCA patients with a lengthier course of symptoms before diagnosis did not experience any enduring visual loss. This may reflect a pattern of more aggressive disease leading to earlier presentation, but further study should explore whether longer symptom duration before diagnosis necessitates a higher degree of clinical concern.

References:

[1]Font C, Cid MC, Coll-Vinent B, López-Soto A, Grau JM. Clinical features in patients with permanent visual loss due to biopsy-proven giant cell arteritis. Br J Rheumatol. 1997 Feb;36(2):251-4. doi: 10.1093/rheumatology/36.2.251. PMID: 9133940.

[2]Hunder GG, Bloch DA, Michel BA, Stevens MB, Arend WP, Calabrese LH, Edworthy SM, Fauci AS, Leavitt RY, Lie JT, et al. The American College of Rheumatology 1990 criteria for the classification of giant cell arteritis. Arthritis Rheum. 1990 Aug;33(8):1122-8. doi: 10.1002/art.1780330810. PMID: 2202311.

Disclosure of Interests:

None declared

POS0806 FINDINGS CONSISTENT WITH SUBCLINICAL VASCULITIS IN PATIENTS WITH NEW ONSET POLYMYALGIA: A SYSTEMATIC LITERATURE REVIEW AND A META-ANALYSIS OF COHORT DATA

Background:

GCA is characterized by cranial symptoms but imaging techniques show that patients with non-specific symptoms such as systemic inflammation or PMR may have undiagnosed large vessel (LV) GCA1. Although silent GCA in patients with clinically isolated PMR may have consequences for patients’ outcome, little is known about its prevalence and characteristics of affected patients.

Objectives:

To review data on the prevalence of silent GCA in newly diagnosed PMR patients without cranial GCA symptoms and to analyze which characteristics are associated with vascular involvement among PMR patients.

Methods:

We systematically screened PubMed, Embase and Web of Science databases and included studies screening for GCA in steroid naïve PMR patients without cranial symptoms consistent with GCA. Authors of the publications that used PET for vasculitis screening were invited to share their individual patient data (IPD) for a meta-analysis. We sought to define patient characteristics that were associated with vasculitis using univariable mixed effects logistic regression models with vascular involvement as the outcome, missing values were imputed using multilevel joint modeling multiple imputation. To fit a multivariable model with the candidate predictors we excluded variables that were hypothesized to have less medical relevance for the outcome and highly correlated inflammation markers (ESR, Lc).

Results:

Out of the 3047 studies screened independently by 2 authors (DG and TD), 13 fulfilled the inclusion criteria. These studies (published 1963-2019) reported on 543 PMR patients examined by temporal artery biopsy (n=175), ultrasound (n=110), PET or PET-CT (n=258). 115 PMR patients were diagnosed with GCA (21.2%), with prevalence ranging from 0-92%.

We collected IPD for 243 patients from 4 cohorts using PET and 3 using PET/CT for GCA diagnosis. The overall median age of patients was 72.3 years (IQR 66.4-78.0) and vasculitis was found in 65 patients (26.7%) (table 1).

Table 1.OverallPMRPMR+GCAn (%)243178 (73.3)65 (26.7)Female sex (%)146 (60.1)98 (55.1)48 (73.8)Shoulder girdle pain (%)236 (97.1)174 (97.8)62 (95.4)Pelvic girdle pain (%)174 (71.6)127 (71.3)47 (72.3)Inflammatory back pain (%)No107 (44.0)83 (46.6)24 (36.9)Yes106 (43.6)70 (39.3)36 (55.4)Lower limb pain (%)No87 (35.8)61 (34.3)26 (40.0)Yes81 (33.3)68 (38.2)13 (20.0)Weight loss (%)112 (46.1)78 (43.8)34 (52.3)CRP (mg/l) (median [IQR])46.0 [19.0, 77.7]44.0 [16.9, 74.2]52.0 [27.9, 85.0]ESR (mm/h) (mean (SD))65.2 (30.3)62.7 (30.2)72.3 (29.7)Hemoglobin (g/dl) (mean (SD))12.1 (1.5)12.2 (1.5)11.7 (1.6)Thrombocytes (1e+09/ml) (mean (SD))341.9 (106.3)323.9 (103.2)375.8 (104.6)

In the univariable analyses the following factors were most strongly associated with vasculitic PET findings: female sex (OR 2.31, CI 1.17-4.58), inflammatory back pain (OR 2.73, CI 1.32-5.64), temperature >37° (OR 1.83, CI 0.90-3.7), weight loss (OR 1.83, CI 0.96-3.51), thrombocytosis (i.e., patients with a thrombocyte count 1 SD above mean have an OR of 1.51, CI 1.05-2.18), anemia (i.e., 1 g/dl decrease in Hb below mean corresponds to an OR of 1.25, CI 1.00-1.56). Patients with lower limb pain were less likely to have vasculitis (OR 0.43, CI 0.19–0.95). The estimated ORs were very similar in the multivariable model although the 95%CIs became wider.

Conclusion:

Although the prevalence across published studies showed substantial variation, 6 out of 13 studies reported a prevalence of silent GCA in 18-40% of all PMR patients. The exploratory analysis of the collected IPD identified female sex, inflammatory back pain, fever, weight loss, absence of lower leg pain, thrombocytosis and anemia as factors associated with LV-GCA. These findings should be validated in future prospective cohort studies. The presence or absence of these factors may further aid in diagnosing LV-GCA in PMR patients.

References:

[1]Buttgereit F, Dejaco C, Matteson EL, Dasgupta B. Polymyalgia Rheumatica and Giant Cell Arteritis: A Systematic Review. JAMA. 2016 Jun 14;315(22):2442–58.

Acknowledgements:

The study is funded by the “Schweizerische Stiftung für die Erforschung der Muskelkrankheiten (SSEM)”.

Disclosure of Interests:

Daniele Silvio Gozzoli: None declared, Andrea Hemmig: None declared, Lars Hemkens: None declared, Laura Werlen: None declared, Hannah Ewald: None declared, Christoph Berger: None declared, Diego Kyburz Grant/research support from: DK reports personal fees from Abbvie, Gilead, Lilly, Novartis and Pfizer, outside of the submitted work, Stephan Imfeld: None declared, Markus Aschwanden: None declared, Mihaela Stegert: None declared, Dario Camellino: None declared, Marco Amedeo Cimmino: None declared, Corrado Campochiaro Grant/research support from: personal fees from Roche, Alessandro Tomelleri: None declared, Liesbet Henckaerts: None declared, Daniel Blockmans Speakers bureau: Paid speaker for Roche, Consultant of: Paid consultant for Roche, Patricia Moya: None declared, Hector Corominas: None declared, Russell Buchanan: None declared, Claire Owen Speakers bureau: CO has received speaking honoraria from Roche, Janssen, Novartis and Pfizer, and meeting sponsorship from Roche, UCB and Janssen, Yannick van Sleen: None declared, Elisabeth Brouwer Speakers bureau: E. Brouwer as an employee of the UMCG received speaker fees and consulting fees from Roche in 2017, 2018 which were paid to the UMCG, Consultant of: E. Brouwer as an employee of the UMCG received speaker fees and consulting fees from Roche in 2017, 2018 which were paid to the UMCG, Hiroyuki Ymashita: None declared, Thomas Daikeler: None declared

Is urinary incontinence associated with lichen sclerosus in females? A systematic review and meta‐analysis

Background

Lichen sclerosus (LS) is a scarring chronic inflammatory disease with a predilection for genital skin in both sexes. The aetiology of LS is controversial, but evidence increasingly suggests that the occluded exposure of susceptible epithelium to urine is involved in the pathogenesis of genital LS in males. This theory has not yet been robustly investigated in females.

Objectives

This review and meta‐analysis examined whether there is an association between urinary incontinence (UI) and genital lichen LS in females.

Methods

We performed a comprehensive search of MEDLINE, Embase and CINAHL to identify observational studies assessing the prevalence of UI in females with LS. DerSimonian and Laird random‐effects models were used to estimate the overall pooled prevalence and risk ratio compared to controls. Heterogeneity was assessed.

Results

In total, eight studies met the inclusion criteria and five studies were included in a meta‐analysis. Three studies were graded as moderate quality and five were poor. The pooled prevalence for UI in LS was 0.35 (95% confidence interval [CI] 0.13–0.58, I² = 98.4%). The risk ratio of UI in LS was 0.97 (95% CI 0.53–1.75, I² = 87.5%).

Conclusion

There appears to be no difference between patients with LS and those without LS in terms of UI. Studies are limited by clinical and methodological quality and heterogeneity is high. Well‐designed prospective studies are needed.

Right-Sided Pneumothorax Associated with Pneumoperitoneum Subsequent to Transverse Colon Perforation: Case Report

Pneumothorax can be spontaneous or secondary to a pre-existing disorder or trauma. Pneumothorax associated with pneumoperitoneum without thoraco-abdominal communication is a rare event poorly described in the literature. We report the case of a 73-year-old patient undergoing abdominal debulking surgery for advanced stage ovarian cancer complicated by a pneumoperitoneum and a right-sided pneumothorax without hernia or evidence of diaphragmatic trauma. Several physio-pathological hypotheses have been suggested, including a potential COVID-19 infection without clear etiology. Our case report emphasizes the possible association of pneumothorax with pneumoperitoneum related to a colon perforation without visible diaphragmatic or mediastinal defects.

AB0470 EOSINOPHILIC GRANULOMATOSIS WITH POLYANGIITIS (EGPA) - ONE-YEAR FOLLOW-UP STUDY USING MEPOLIZUMAB ANTI-IL5 THERAPY AS A STEROID SPARING THERAPEUTIC APPROACH

Background:

EGPA is a small vessel vasculitis characterised by the presence of tissue eosinophilia, necrotising vasculitis and granulomatous inflammation1. Typically, a prodromal asthmatic phase, leads to an eosinophilic stage, which can evolve to include the presence of vasculitis with renal manifestations. In the recent randomised, placebo-controlled MIRRA trial for relapsing and refractory EGPA, adjuvant therapy with anti-IL5 mAB Mepolizumab [MEPO] at 300mg s/c monthly, accrued longer times in remission, reduced steroid exposure and reduced relapse rates2.

Objectives:

The aim of our study was to analyse the response and outcome for EGPA patients who received 100mg s/c of MEPO monthly for a minimum of 52 weeks, with particular focus on the steroid minimisation benefits.

Methods:

This retrospective, descriptive study analysed 13 patients with EGPA, who received 100mg s/m monthly MEPO therapy under the eosinophilic asthma care-pathway. Time points of assessment included MEPO commencement [M0] and 12 [M12] months.

Results:

Table 1.

EGPA patients receiving Mepolizumab therapy for one year [100mg s/c]

DemographicsAll [n=13]Gender ratio M/F4M:9FANCA positive/ negativeANCA: 3MPO, 1 PR3 positive/ 9 ANCA negativeAge of diagnosis of asthma35 yrs [IQR 28.5-40]Age of diagnosis of EGPA47 yrs [IQR 43.5-53.5]Median age51 yrs [IQR 47.5- 60.5]EGPA disease characteristicsN=13 [%]Asthma 13 [100]Serum eosinophilia or biopsy evidence [N= 12] 12 [100]Pulmonary infiltrates, non-fixed 8[61.5]Neuropathy, mono/poly 4[30.7]Sino-nasal abnormality 12[92.3]Glomerulonephritis 3[23]Cardiovascular 4[30.7]Prior ImmunosuppressantsN=13 [%]Steroids13[100%]Cyclophosphamide 6[46%]Rituximab6[46%]Azathioprine10[77%]Mycophenolate mofetil8[62%]Methotrexate4[31%]Campath 1[7%]Response to therapyM0 [%] Post M12 [%]Prednisolone dose N= 13Mean ±SD 18.925 mg ±11.44 10.575mg ± 5.85Eosinophil count X109/L N=13Mean ±SD 0.415mg ±0.25 0.035±0.039Asthma Control Questionnaire [ACQ] N=5Mean ±SD 2.92 ±1.27 1.31± 0.79BVAS N= 13Mean ±SD 7.307±6.29 2.2307±1.69Creatinine N=9Mean ±SD 68.44±15.03 69.11±17.84Continuation of anti-IL5 therapy N=13 12/13 [92.3%]

Conclusion:

The relapsing nature of EGPA places a potential dependency of therapy on steroids for asthmatic and vasculitic flares. This underscores the importance of targeted pathway specific biologic therapy to minimise steroid exposure, prevent tissue damage and ensure early response to therapy. This study demonstrates that anti-IL5 serves as a favourable model with steroid minimisation, improvement in asthma control questionnaire, reduction in BVAS and eosinophil counts at the 100mg s/c dosage. ANCA positive serology normalised in all four patients, independent of subtype. Well tolerated, it demonstrated considerable clinical benefit, with 12 patients [92.3%] continuing anti-IL5 therapy beyond 12 months.

Long term plan > 12 monthsN=13 [%] Current Months Adjuvant therapy 12M1 Continue15 Aza2 Switched Benralizumab 26 MMF [+], IVIG [-]3 Continue 184 Switched Benralizumab 145 Discontinued Rituximab 12 MTX6 Continue 147 Continue 24 MMF Reduced8 Continue 18 MTX [+]9 Continue 15 MMF [-]10 Continue 1411 Continue 1312 Continue 13 Aza13 Continue 12

References:

[1]J.C.Jenette,et alRevised International Chapel Hil Consensus Conference Nomenclature of Vasculitides.65, 1–11 (2013).

[2]Wechsler, M. E.et al.Mepolizumab or Placebo for Eosinophilic Granulomatosis with Polyangiitis.N. Engl. J. Med.376, 1921–1932 (2017).

Disclosure of Interests:

Allyson Egan: None declared, pasupathy Sivasothy: None declared, Robin Gore: None declared, Marcos Martinez Del-Pero: None declared, Caroline Owen: None declared, Lisa Willcocks: None declared, Rona Smith: None declared, Stella Burns: None declared, David Jayne Grant/research support from: ChemoCentryx, GSK, Roche/Genentech, Sanofi-Genzyme, Consultant of: Astra-Zeneca, ChemoCentryx, GSK, InflaRx, Takeda, Insmed, Chugai, Boehringer-Ingelheim

SAT0279 FACTORS PREDICTIVE OF POSITIVE TEMPORAL ARTERY BIOPSY IN TWO AUSTRALIAN COHORTS

Background:

Temporal artery biopsy (TAB) is widely recognised as the diagnostic gold standard for GCA despite having a poor sensitivity due to the presence of ‘skip’ lesions. There is, however, a lack of consensus guiding TAB practice, particularly in relation to optimal length, need for bilateral specimens, and number of segments examined.

Objectives:

To investigate the impact of factors such as total biopsied length, laterality, segment number, and referral centre on histopathological outcomes in an Australian setting.

Methods:

Reports for all available biopsy specimens labelled “temporal artery” were extracted from the pathology service records of two rheumatology referral centres with adjacent geographic catchments. Each histopathology report was manually reviewed to establish length of biopsied artery, laterality, and number of segments, along with patient demographics such as age, sex, and referral centre. Key histopathological findings including intimal hyperplasia, disruption of the internal elastic lamina, presence of giant cells, and adventitial inflammation were recorded. Multivariable logistic regression with site-varying intercept was performed.

Results:

TAB reports from a total of 577 patients were captured, with results available from the two centres from 1999-2019 and 2010-2019 respectively. The mean age in this group was 73, and 69% were female (Table 1). A bilateral TAB was performed in 29%, and the mean total biopsy length was 2.5cm. Of these patients, 122 had positive biopsies (21%), with intimal hyperplasia reported in 100 (17%), giant cells in 83 (14%), and adventitial findings in 68 (12%). Positive biopsy weakly correlated with increased total length of biopsy in centimetres (OR 1.25 [1.06-1.47]) (Figure 1) and increased age in years (OR 1.02 [1.00-1.05]) but not laterality or sex (Table 2). There was a substantial difference between the two centres, which was incompletely accounted for once corrected for total biopsy length and calendar year of biopsy, suggesting either unmeasured differences in patient demographics or a difference in clinical practice. This change was preserved across analysis of different histopathological subtypes.

Table 1.

Patient characteristics by biopsy result.

Negative(n = 455)Positive(n = 122)Total(n = 577)Age (years) Mean (SD)72 (± 11)75 (± 8.9)73 (± 10)Sex Female310 (68%)88 (72%)398 (69%) Male145 (32%)34 (28%)179 (31%)Maximum biopsy length (cm) Mean (SD)1.8 (± 0.86)2.0 (± 1.10)1.9 (± 0.92)Total biopsy length (cm) Mean (SD)2.4 (± 1.6)2.8 (± 2.1)2.5 (± 1.7)Mean biopsy length (cm) Mean (SD)1.7 (± 0.78)1.9 (± 0.97)1.7 (± 0.83)Laterality Bilateral130 (29%)39 (32%)169 (29%) Unilateral325 (71%)83 (68%)408 (71%)Table 2.

Associations with positive TAB on multivariable logistic regression.

Overall positive findingIntimal hyperplasiaGiant cellsAdventitial inflammationTotal biopsy length (cm)1.25(1.06-1.47)1.18(0.98-1.40)1.21(1.00-1.46)1.07(0.87-1.31)Unilateral (vs. bilateral)1.56(0.82-3.07)1.12(0.56-2.30)1.28(0.61-2.77)0.82(0.38-1.82)Age (years)1.02(1.00-1.05)1.02(1.00-1.04)1.03(1.00-1.05)1.00(0.98-1.03)Male (vs. female)0.83(0.52-1.29)0.63(0.37-1.05)0.59(0.32-0.92)0.75(0.41-1.31)Centre 2 (vs. centre 1)0.54(0.34-0.84)0.41(0.24-0.68)0.55(0.32-0.92)0.46(0.25-0.82)Figure 1.

The effect of total biopsy length on result, stratified by laterality.

Conclusion:

Total biopsy length was weakly associated with a positive TAB result, but differences in results between referral centres independent of biopsy length suggest other selection factors may be important in determining TAB yield. Examination of differences in results between a greater number of referral centres would assist in determining the extent of this variability.

Disclosure of Interests:

None declared

Invasive and in situ cervical cancer associated with pregnancy: analysis from the French cancer network (CALG: Cancer Associé à La Grossesse)

PURPOSE

To describe the oncologic and obstetric outcomes of patients diagnosed with invasive cervical cancer (ICC) and in situ adenocarcinoma (ISA) during pregnancy or during the year following delivery.

METHODS

This retrospective observational study involved a cohort of 28 patients diagnosed with invasive cervical cancer (20 patients) or in situ adenocarcinoma (eight patients) during pregnancy or during the year following delivery who received expert opinion from physicians of the Cancer Associé à La Grossesse (CALG) network between 2005 and 2018. Descriptive results were expressed in median, range and interquartile range (IQR).

RESULTS

Between 2005 and 2018, 20 patients with ICC and eight with ISA received expert opinion from physicians of the CALG network. Both ICC and ISA were mostly diagnosed during pregnancy with a median term at diagnosis of 23.3 weeks of gestation (WG) for ICC and 7.3 WG for ISA. Overall, the median age at diagnosis for both ICC and ISA was 33 years. Most ICCs (n = 9) had FIGO stage ≥ IB2 and five underwent neoadjuvant chemotherapy at a median term of 22.5 WG. Seventeen patients with ICC underwent surgery. Three patients had medical termination of the pregnancy. Two patients experienced recurrence and three died. Median time of follow-up was 59.3 months (IQR 30.5-129.2).

CONCLUSION

Management of cervical cancer during pregnancy is challenging especially in terms of maternal outcomes with a relative poor prognosis requiring a multidisciplinary expert advice.

Review of Bruton tyrosine kinase inhibitors for the treatment of relapsed or refractory mantle cell lymphoma

Mantle cell lymphoma (mcl) is a rare subtype of aggressive B-cell non-Hodgkin lymphoma that remains incurable with standard therapy. Patients typically require multiple lines of therapy, and those with relapsed or refractory (r/r) disease have a very poor prognosis. The Bruton tyrosine kinase (btk) inhibitor ibrutinib has proven to be an effective agent for patients with r/r mcl. Although usually well tolerated, ibrutinib can be associated with unique toxicities, requiring discontinuation in some patients. Effective and well-tolerated alternatives to ibrutinib for patients with r/r mcl are therefore needed. Novel btk inhibitors such as acalabrutinib, zanubrutinib, and tirabrutinib are designed to improve on the safety and efficacy of first-generation btk inhibitors such as ibrutinib. Data from single-arm clinical trials suggest that, compared with ibrutinib, second-generation btk inhibitors have comparable efficacy and might have a more favourable toxicity profile. Those newer btk inhibitors might therefore provide a viable treatment option for patients with r/r mcl.

Canadian evidence-based guideline for the first-line treatment of chronic lymphocytic leukemia

Chronic lymphocytic leukemia (cll) is the most common adult leukemia in North America. In Canada, no unified national guideline exists for the front-line treatment of cll; provincial guidelines vary and are largely based on funding. A group of clinical experts from across Canada developed a national evidence-based treatment guideline to provide health care professionals with clear guidance on the first-line management of cll. Consensus recommendations based on available evidence are presented for the first-line treatment of cll.

Updates from the 2017 American Society of Hematology Annual Meeting: Practice-Changing Studies in Relapsed and Refractory Mantle Cell Lymphoma

The 2017 annual meeting of the American Society of Hematology took place 9–12 December in Atlanta, Georgia. At the meeting, results from key studies in the treatment of relapsed and refractory mantle cell lymphoma were presented. Of those studies, oral presentations focused on the efficacy and safety of therapy with Bruton tyrosine kinase (BTK) inhibitors. One study presented pooled data from three trials using ibrutinib, with a median follow-up of 3.5 years. A second phase ii study presented data on the efficacy and safety of acalabrutinib, a highly selective BTK inhibitor with minimal off-target activity. The final study presented early phase ib data on the efficacy and safety of zanubrutinib, a novel, highly selective BTK inhibitor, in patients with non-Hodgkin lymphoma. Our meeting report describes the foregoing studies and presents interviews with investigators and commentaries by Canadian hematologists about potential effects on Canadian practice.

Updates from the 2017 American Society of Hematology Annual Meeting: Practice-Changing Studies in Untreated Chronic Lymphocytic Leukemia

The 2017 annual meeting of the American Society of Hematology took place 9–12 December in Atlanta, Georgia. At the meeting, the oral presentations included results from key studies on the first-line treatment of chronic lymphocytic leukemia. A series of phase ii studies focusing on the efficacy and safety of novel treatment strategies were especially notable. One concerned the health-related quality of life results from the gibb study, which had examined the combination of obinutuzumab and bendamustine. A second evaluated the venetoclax–ibrutinib regimen in patients with high-risk disease. The third assessed the combination of ibrutinib, fludarabine, cyclophosphamide, and obinutuzumab in patients with mutated immunoglobulin heavy-chain variable region genes. The fourth examined the combination of ibrutinib, fludarabine, cyclophosphamide, and rituximab in younger patients. And the final study evaluated obinutuzumab–ibrutinib followed by a minimal residual disease strategy in fit patients. Our meeting report describes the foregoing studies and presents interviews with investigators and commentaries by Canadian hematologists about the potential effects on Canadian practice.

Metagenomic Investigation of Idiopathic Meningoencephalomyelitis in Dogs

BACKGROUND

Meningoencephalomyelitis of unknown origin (MUO) is a common and life-threatening neuroinflammatory disease in dogs. Features of the disease are suggestive of an underlying immune-mediated process, but the association of this disease with a pathogen is still unknown.

HYPOTHESIS/OBJECTIVES

To search for candidate etiologic agent associated with cases if MUO using next generation metagenomic sequencing.

ANIMALS

Twenty-two dogs diagnosed with either MUO (11/22; 10 CSF and 3 brain), or noninflammatory CNS diseases inconsistent with MUO (11/22; 11 CSF and 2 brain) that served as negative controls.

METHODS

A case control study was performed by identifying MUO and non-MUO cases. Samples were blindly processed and then unblinded for comparative analyses. Inclusion criteria for MUO cases included consistent MRI lesions and inflammatory CSF with a negative PCR panel for infectious agents or histopathologic diagnosis. Dogs with glucocorticoid therapy within 2 weeks of sample collection were excluded. Fresh-frozen cerebrospinal fluid (CSF; 21) and brain (5) samples were collected and RNA and DNA were extracted separately for shotgun metagenomic sequencing. Known positive samples were used as controls to validate our sequencing and analysis pipelines and to establish limits of detection. Sequencing results were analyzed at a nucleotide and protein level for broad comparison to known infectious organisms.

RESULTS

No candidate etiologic agents were identified in dogs with MUO.

CONCLUSIONS AND CLINICAL IMPORTANCE

These results support but do not prove the hypothesis that MUO is not associated with infectious agents and might be an autoimmune disease.

Updates from the 2016 American Society of Hematology Annual Meeting: Practice-Changing Studies in Untreated Follicular Lymphoma

The 2016 annual meeting of the American Society of Hematology took place in San Diego, California, 3–6 December. At the meeting, results from key studies on the first-line treatment of follicular lymphoma were presented. Of those studies, key oral presentations included two analyzing data from the gallium study, which evaluated the efficacy and safety of obinutuzumab plus chemotherapy (G-chemo) compared with rituximab plus chemotherapy (R-chemo), followed, in responding patients with follicular lymphoma, by obinutuzumab or rituximab maintenance; results from the sabrina study, which evaluated the efficacy and safety of subcutaneous compared with intravenous rituximab; results of a cost-effectiveness analysis of first-line treatment with bendamustine and rituximab from a Canadian perspective; and results from the SAKK 35/10 study, which evaluated the safety and efficacy of rituximab plus lenalidomide compared with rituximab monotherapy. Our meeting report describes the foregoing studies and includes interviews with the Canadian investigators, plus commentaries by those investigators about the potential impact on Canadian practice.

Morphoea with prominent plasma cell endoneuritis

Morphoea (localized scleroderma) is a cutaneous inflammatory condition characterized by the development of indurated and discoloured plaques. The histological features of morphoea typically include a superficial and deep perivascular and periadnexal chronic inflammatory infiltrate associated with variable degrees of dermal and/or subcutaneous sclerosis. The infiltrate is typically composed of lymphocytes, macrophages and conspicuous plasma cells. The early stages of morphoea may have a very prominent inflammatory infiltrate associated with subtle sclerosis. In addition, the inflammatory infiltrate may show a perineural and rarely intraneural distribution. We report two cases of morphoea that histologically showed plasma cell endoneuritis associated with subtle dermal sclerosis. These two cases highlight the potential for diagnostic confusion with infectious and inflammatory diseases, particularly leprosy and lupus.

Regulation of growth hormone induced JAK2 and mTOR signalling by hepatic protein tyrosine phosphatase 1B

Protein tyrosine phosphatase 1B (PTP1B) regulates various signalling pathways including insulin, leptin, IGF-1 and growth hormone (GH) signalling. Transmission of the GH signal depends on Janus kinase 2 (JAK2), which is how PTP1B is thought to modulate GH signalling in the liver, based on studies utilising global PTP1B knockout mice (Ptp1b(-/-)). Here, we investigated the liver-specific role of PTP1B in GH signalling, using liver-specific Ptp1b(-/-) mice (alb-crePtp1b(-/-)), under physiological (chow) or insulin resistant (high-fat diet [HFD]) feeding conditions. Body weight and adiposity were comparable between female alb-crePtp1b(-/-) and Ptp1b(fl/fl) control mice. On chow diet, under 48-hour fasting GH-resistant conditions, GH stimulation in vivo led to a robust stimulation of the JAK-STAT signalling pathway. Alb-crePtp1b(-/-) mice exhibited significantly higher GH-induced JAK2 phosphorylation and SOCS3 gene expression post-GH stimulation. However, STAT3, STAT5 and ERK1/2 phosphorylation and SOCS2 gene expression were similar between groups. Interestingly, GH-induced mTOR phosphorylation was significantly higher in alb-crePtp1b(-/-) mice 5-min post-GH stimulation compared to controls, revealing this part of the pathway under direct control of PTP1B. Under ad lib HFD-fed conditions, GH-induced STAT5 phosphorylation significantly increased in alb-crePtp1b(-/-) mice only, with no alterations in the controls. Overall, our data demonstrate that liver-specific PTP1B deletion leads to significant alterations in GH signalling with increased JAK2, STAT5 and mTOR phosphorylation and SOCS3 gene expression.

Inducible liver-specific knockdown of protein tyrosine phosphatase 1B improves glucose and lipid homeostasis in adult mice

AIMS/HYPOTHESIS

Protein tyrosine phosphatase 1B (PTP1B) is a key negative regulator of insulin signalling. Hepatic PTP1B deficiency, using the Alb-Cre promoter to drive Ptp1b deletion from birth in mice, improves glucose homeostasis, insulin sensitivity and lipid metabolism. The aim of this study was to investigate the therapeutic potential of decreasing liver PTP1B levels in obese and insulin-resistant adult mice.

METHODS

Inducible Ptp1b liver-specific knockout mice were generated using SA-Cre-ER(T2) mice crossed with Ptp1b floxed (Ptp1b(fl/fl)) mice. Mice were fed a high-fat diet (HFD) for 12 weeks to induce obesity and insulin resistance. Tamoxifen was administered in the HFD to induce liver-specific deletion of Ptp1b (SA-Ptp1b(-/-) mice). Body weight, glucose homeostasis, lipid homeostasis, serum adipokines, insulin signalling and endoplasmic reticulum (ER) stress were examined.

RESULTS

Despite no significant change in body weight relative to HFD-fed Ptp1b(fl/fl) control mice, HFD-fed SA-Ptp1b(-/-) mice exhibited a reversal of glucose intolerance as determined by improved glucose and pyruvate tolerance tests, decreased fed and fasting blood glucose and insulin levels, lower HOMA of insulin resistance, circulating leptin, serum and liver triacylglycerols, serum NEFA and decreased HFD-induced ER stress. This was associated with decreased glycogen synthase, eukaryotic translation initiation factor-2α kinase 3, eukaryotic initiation factor 2α and c-Jun NH2-terminal kinase 2 phosphorylation, and decreased expression of Pepck.

CONCLUSIONS/INTERPRETATION

Inducible liver-specific PTP1B knockdown reverses glucose intolerance and improves lipid homeostasis in HFD-fed obese and insulin-resistant adult mice. This suggests that knockdown of liver PTP1B in individuals who are already obese/insulin resistant may have relatively rapid, beneficial therapeutic effects.

Mental health impairment associated with eating-disorder features in a community sample of women

BACKGROUND AND AIMS

 Impairment in mental health associated with eating-disorder features was examined in a large, general population sample of women aged 18 to 42 years.

METHOD

 Participants (n = 5255) completed self-report measures of eating-disordered behaviour, mental health functioning, height and weight and socio-demographic information.

RESULTS

The most common eating-disorder features were extreme concerns about weight or shape (14.6%), subjective overeating (12.7%), objective overeating (10.6%) and extreme concerns about dietary intake (10.4%). In multivariable analysis, in which mental health functioning was regressed on eating-disorder features, while also controlling for age and body weight, objective overeating (β  =  -0.07), subjective overeating (β   = -0.07), extreme dietary restriction (β  =  -0.06) and extreme concerns about eating (β  =  -0.04) showed small, but statistically significant associations with mental health impairment, whereas extreme weight or shape concerns showed a very strong association (β  =  -0.24).

CONCLUSIONS

From a clinical perspective, the findings are consistent with the importance attached to the "over-evaluation" of weight or shape as a core component of eating-disorder psychopathology. From a public health perspective, the findings indicate the need to conceive of body dissatisfaction as a target for health promotion in its own right.

Long-range epigenetic silencing of chromosome 5q31 protocadherins is involved in early and late stages of colorectal tumorigenesis through modulation of oncogenic pathways

Loss of tumour suppressor gene function can occur as a result of epigenetic silencing of large chromosomal regions, referred to as long-range epigenetic silencing (LRES), and genome-wide analyses have revealed that LRES is present in many cancer types. Here we utilize Illumina Beadchip methylation array analysis to identify LRES across 800 kb of chromosome 5q31 in colorectal adenomas and carcinomas (n=34) relative to normal colonic epithelial DNA (n=6). This region encompasses 53 individual protocadherin (PCDH) genes divided among three gene clusters. Hypermethylation within these gene clusters is asynchronous; while most PCDH hypermethylation occurs early, and is apparent in adenomas, PCDHGC3 promoter methylation occurs later in the adenoma-carcinoma transition. PCDHGC3 was hypermethylated in 17/28 carcinomas (60.7%) according to methylation array analysis. Quantitative real-time reverse transcription-polymerase chain reaction showed that PCDHGC3 is the highest expressed PCDH in normal colonic epithelium, and that there was a strong reciprocal relationship between PCDHGC3 methylation and expression in carcinomas (R=-0.84). PCDH LRES patterns are reflected in colorectal tumour cell lines; adenoma cell lines are not methylated at PCDHGC3 and show abundant expression at the mRNA and protein level, while the expression is suppressed in hypermethylated carcinoma cell lines (R=-0.73). Short-interfering RNA-mediated reduction of PCDHGC3 led to a decrease of apoptosis in RG/C2 adenoma cells, and overexpression of PCDHGC3 in HCT116 cells resulted in the reduction of colony formation, consistent with tumour suppressor capabilities for PCDHGC3. Further functional analysis showed that PCDHGC3 can suppress Wnt and mammalian target of rapamycin signalling in colorectal cancer cell lines. Taken together, our data suggest that the PCDH LRES is an important tumour suppressor locus in colorectal cancer, and that PCDHGC3 may be a strong marker and driver for the adenoma-carcinoma transition.