Characteristics of Drug Poisonings Seen in the Emergency Department of an Urban Hospital

Background

Drug poisoning, either intentional or non-intentional, is a frequent diagnosis in the emergency department (ED), necessitating patient management from multiple services.

Objective

To describe the drug poisonings seen in the ED of a large academic urban hospital.

Methods

This retrospective descriptive study used 3 years of data (2018-2020) abstracted from the hospital's electronic medical record system and linked to validated, coded extracts from the Canadian Institute for Health Information Discharge Abstract Database. Patients with a diagnosis of acute drug poisoning who presented to the ED were identified on the basis of International Statistical Classification of Diseases and Related Health Problems, 10th revision, Canada (ICD-10-CA) codes, and data were collected for demographic characteristics, the drugs involved, in-hospital management, and inpatient outcomes. Patients with diagnosis of an acute drug reaction, inebriation, or nondrug or in-hospital poisoning were excluded. Data were stratified and analyzed in relation to the intent of drug poisoning.

Results

A total of 2983 visits for drug poisoning, involving 2211 unique patients (mean age 38.3 [standard deviation 16.2] years, 54.7% female), were included, yielding an overall incidence rate of 15.7 drug poisonings per 1000 ED visits (8.1 intentional, 6.4 non-intentional, and 1.3 unknown intent). Among the 1505 intentional drug poisonings, the most prevalent drug sources were antidepressants (n = 405, 26.9%), benzodiazepines (n = 375, 24.9%), and acetaminophen (n = 329, 21.9%); in contrast, opioids (n = 594, 48.1%) were most prevalent for the 1236 non-intentional poisonings. For 716 (24.0%) of the poisoning visits, the patient was admitted to acute care services, and the in-hospital mortality rate was 1.0% (n = 31). In addition, 111 patients (9.0%) with non-intentional drug poisoning left against medical advice. Finally, for 772 (25.9%) of the poisoning visits, the patient returned to the ED after discharge with a subsequent drug poisoning.

Conclusions

Drug poisonings are a common cause of visits to urban EDs. They are rarely fatal but are associated with substantial utilization of hospital resources and considerable recidivism.

Opioid reduction and enhanced recovery in orthopaedic surgery (OREOS): a protocol for a feasibility randomised controlled trial in patients undergoing total knee arthroplasty

BACKGROUND

Knee arthritis is a leading cause of limited function and long-term disability in older adults. Despite a technically successful total knee arthroplasty (TKA), around 20% of patients continue to have persisting pain with reduced function, and low quality of life. Many of them continue using opioids for pain control, which puts them at risk for potential long-term adverse effects such as dependence, overdose and risk of falls. Although persisting pain and opioid use after TKA have been recognised to be important issues, individual strategies to decrease their burden have limitations and multi-component interventions, despite their potential, have not been well studied. In this study, we propose a multi-component pathway including personalized pain management, facilitated by a pain management coordinator. The objectives of this pilot trial are to evaluate feasibility (recruitment, retention, and adherence), along with opioid-free pain control at 8 weeks after TKA.

METHODS

This is a protocol for a multicentre pilot randomised controlled trial using a 2-arm parallel group design. Adult participants undergoing unilateral total knee arthroplasty will be considered for inclusion and randomised to control and intervention groups. Participants in the intervention group will receive support from a pain management coordinator who will facilitate a multicomponent pain management pathway including (1) preoperative education on pain and opioid use, (2) preoperative risk identification and mitigation, (3) personalized post-discharge analgesic prescriptions and (4) continued support for pain control and recovery up to 8 weeks post-op. Participants in the control group will undergo usual care. The primary outcomes of this pilot trial are to assess the feasibility of participant recruitment, retention, and adherence to the interventions, and key secondary outcomes are persisting pain and opioid use.

DISCUSSION

The results of this trial will determine the feasibility of conducting a definitive trial for the implementation of a multicomponent pain pathway to improve pain control and reduce harms using a coordinated approach, while keeping an emphasis on patient centred care and shared decision making.

TRIAL REGISTRATION

Prospectively registered in Clinicaltrials.gov (NCT04968132).

An exploration of simulation-based education from other health professionals, to create an informed and effective simulation delivery in a new diagnostic radiography programme

INTRODUCTION

The recent validation of three Diagnostic Radiography programmes in the south of England involved a rigorous approval process with multiple Professional and Statutory Regulatory Bodies (PSRB's). Part of the validation process was evidencing that approximately 50% of each programme is spent undertaking practice-based learning. As well as clinical placements, practice-based learning includes simulation-based education (SBE).

METHODOLOGY

From May 2022 to June 2022, a questionnaire was sent to all 22 simulation education facilitators from health courses belonging to the University School Simulation Group. Ethical approval was reviewed and approved by the Learning and Teaching Hub Research Ethics Panel.

RESULTS

Of the initial 22 participants invited, the response rate was 59% (13 participants). The main themes arising from the analysis was the use of a theoretical or conceptual framework, a breakdown of the simulation session components and the role of simulation training.

CONCLUSION

This questionnaire study demonstrated that there was a need for a standardised guide on how to deliver SBE. There is also a lack of feedback, training, and reassurance for facilitators. However, facilitators would welcome training or further training and HEE and the University have taken steps to prioritise SBE.

IMPLICATIONS FOR PRACTICE

The study highlighted how health professionals are delivering SBE within their subjects in innovative and creative ways. These ideas have helped to structure SBE within the new diagnostic radiography courses at the University.

Solvothermal synthesis of soluble, surface modified anatase and transition metal doped anatase hybrid nanocrystals

Titanium dioxide, or titania, is perhaps the most well-known and widely studied photocatalytic material, with myriad applications, due to a high degree of tunability achievable through the incorporation of dopants and control of phase composition and particle size. Many of the applications of titanium dioxide require particular forms, such as gels, coatings, or thin films, making the development of hybrid solution processable nanoparticles increasingly attractive. Here we report a simple solvothermal route to highly dispersible anatase phase titanium dioxide hybrid nanoparticles from amorphous titania. Solvothermal treatment of the amorphous titania in trifluoroacetic acid leads to the formation of anatase phase nanoparticles with a high degree of size control and near complete surface functionalisation. This renders the particles highly dispersible in simple organic solvents such as acetone. Dopant ions may be readily incorporated into the amorphous precursor by co-precipitation, with no adverse effect on subsequent crystallisation and surface modification.

Need for tracheostomy in major head and neck ablative surgery: a paradigm shift during the COVID-19 pandemic

INTRODUCTION

Management of the airway in the perioperative period for patients requiring major head and neck ablative surgery has commonly included the performance of elective surgical tracheostomy. This has been standard practice in most maxillofacial units across the UK, including ours. However, the COVID-19 pandemic and emerging guidelines on aerosol-generating procedures required us to revisit the need for a perioperative tracheostomy.

METHODS

We present our series of 29 consecutive cases, cared for during the first wave of the COVID-19 pandemic, that were managed either using surgical tracheostomy or overnight tracheal intubation.

RESULTS

Out of 29 patients 3 received a surgical tracheostomy. The average duration of tracheostomy use was 8 days. Twenty patients were managed using a period of overnight tracheal intubation. Average duration of tracheal intubation was 1.2 days, with an average intensive care unit stay of 1.7 days. The average duration of hospital stay was 15.8 days for patients managed with overnight tracheal intubation and 30.1 days for patients who received a surgical tracheostomy. The return to theatre rate was 13.8% for reasons including flap failure and neck space infection. There were no airway issues reported in this series of patients.

CONCLUSIONS

Our findings suggest that overnight tracheal intubation can be a safe alternative to surgical tracheostomy in the majority of cases.

OP0109 EXPRESSION QUANTITATIVE TRAIT LOCI IN EARLY TREATMENT-NAÏVE RHEUMATOID ARTHRITIS

Background

To date more than 100 genetic loci have been associated with rheumatoid arthritis (RA), particularly in the human leukocyte antigen (HLA) region. Our understanding of the functional consequences of genetic variation in RA causality, however, is limited and it has been shown that a substantial portion of complex disease risk alleles modify gene expression in a cell-specific manner [1]. The Pathobiology of Early Arthritis Cohort (PEAC) is a longitudinal study looking at treatment-naiv̈e RA patients with genotyped data as well as both synovial and blood RNA-sequenced biopsies prior to treatment with disease modifying anti-rheumatic drugs (DMARDs).

Objectives

To explore expression quantitative trait loci (eQTL) in synovium and blood within PEAC and characterise the effects of genetic variation on gene expression measured by RNA-sequencing. A further goal was to investigate the role of these variants in RA disease severity and response variables.

Methods

Genotypes were generated by Illumina Human CoreExome-24 version 1-0 array in 118 RA patients. Single nucleotide polymorphisms (SNPs) in the HLA region were imputed using HLA-TAPAS. A candidate gene study was performed on variants within the HLA region using Plink v2.0. Synovial (n=85) and blood (n=51) RNA-sequenced samples then underwent cis-eQTL analysis (loci within ±5x105Mb of the variant) based on linear regression models with the matrixeQTL R package using PEER [2] and PCA eigenvectors as covariates. Differences in eQTL between tissues were determined using a linear interaction term.

Results

The candidate gene study determined several amino acids around HLA-DRB1 acting as markers for seropositivity, which replicated findings by Raychaudhuri et. al. [3]. Using eQTL analysis, around 33,000 synovial SNPs were found with genome-wide significance (p ≤ 5x10-8) and around 29,000 in blood. This corresponded to 279 unique significant genes in synovium and 417 in blood (Figure 1). There were 100 genes common to both synovium and blood, including PSORS1C3, HLA-DRB9 and ERAP2, which have known associations with autoimmune diseases and inflammatory arthritis. Notably, 92 genes showed significantly different patterns of QTL expression between synovial tissue and blood (p ≤ 5x10-8). eQTL data also confirmed the triad of genetic variants significantly driving tissue gene expression of HLA-DPB2, while both HLA-DPB2 SNPs and HLA-DPB2 RNA-sequencing synovial expression correlated highly with erythrocyte sedimentation rate (ESR).

Figure 1.

Manhattan plots for cis-expression quantitative trait loci (eQTL) analysis performed on 85 synovial samples (top) and 51 blood samples (middle). Tissue interaction eQTL (bottom) show significant differences between tissues (p ≤ 5x10-8).

Conclusion

The high significance of genes in the HLA region in both tissues is in-keeping with the strong association between HLA and susceptibility to RA, as well as other autoimmune diseases. Most notably variants linked to HLA-DPB2 synovial expression were found to be a marker for disease severity through ESR association. Additionally, the significant differences between eQTL in blood and synovium highlight the need to explore functional consequences of genetic associations in the diseased tissue directly.

References

[1]Thalayasingam et. al. (2018). CD4+ and B lymphocyte expression quantitative traits at rheumatoid arthritis risk loci in patients with untreated early arthritis: implications for causal gene identification. Arthritis & Rheumatology, 70(3), 361-370.

[2]Stegle et al. (2012). Using probabilistic estimation of expression residuals (PEER) to obtain increased power and interpretability of gene expression analyses. Nature protocols, 7(3), 500-507.

[3]Raychaudhuri et al. (2012). Five amino acids in three HLA proteins explain most of the association between MHC and seropositive rheumatoid arthritis. Nature genetics, 44(3), 291-296.

Disclosure of Interests

None declared

Health-related quality of life in maxillectomy patients undergoing dentoalveolar rehabilitation

OBJECTIVES

Surgical resection of the maxilla impairs aesthetics, speech, swallowing, and mastication. Maxillary reconstruction is increasingly performed with virtual surgical planning (VSP) to enhance functional dental rehabilitation with a conventional denture or osseointegrated implants. The aim of this study was to determine whether dental status and VSP is associated with health-related quality of life (HRQOL) and function in patients who have undergone maxillectomy.

MATERIALS AND METHODS

A cross-sectional study was conducted among patients who underwent free flap reconstruction or obturation of the maxilla between July 2009 and December 2020. The FACE-Q Head and Neck Cancer (FACE-Q) module, M.D. Anderson Dysphagia Inventory (MDADI), and Speech Handicap Index (SHI) were used to evaluate HRQOL.

RESULTS

Forty-three patients (response rate 59%) completed questionnaires and 48% underwent dental rehabilitation. In Okay Class II and III defects, adjusting for the effect of radiotherapy and time from surgery, there was a positive association between denture status and FACE-Q smiling (p = 0.020), eating (p = 0.012), smiling (p = 0.015), and MDADI global (p = 0.015), emotional (p = 0.027), functional (p = 0.028), and composite (p = 0.029) scores. VSP was associated with FACE-Q swallowing (p = 0.005), drooling (p = 0.030), eating (p = 0.008), smiling (p = 0.021), MDADI global (p = 0.017), emotional (p = 0.041), functional (p = 0.040), composite (p = 0.038), and SHI total scores (p = 0.042).

CONCLUSIONS

Dentoalveolar rehabilitation and VSP were associated with higher HRQOL scores relating to eating and drinking, smiling, and speaking.

The flashfm approach for fine-mapping multiple quantitative traits

Joint fine-mapping that leverages information between quantitative traits could improve accuracy and resolution over single-trait fine-mapping. Using summary statistics, flashfm (flexible and shared information fine-mapping) fine-maps signals for multiple traits, allowing for missing trait measurements and use of related individuals. In a Bayesian framework, prior model probabilities are formulated to favour model combinations that share causal variants to capitalise on information between traits. Simulation studies demonstrate that both approaches produce broadly equivalent results when traits have no shared causal variants. When traits share at least one causal variant, flashfm reduces the number of potential causal variants by 30% compared with single-trait fine-mapping. In a Ugandan cohort with 33 cardiometabolic traits, flashfm gave a 20% reduction in the total number of potential causal variants from single-trait fine-mapping. Here we show flashfm is computationally efficient and can easily be deployed across publicly available summary statistics for signals in up to six traits.

Developing a social prescribing research school using translational research: Learning from Wales

The Wales School for Social Prescribing Research (WSSPR) was launched in April 2020. Central to its functioning, WSSPR uses a translational research model (Cooksey, 2007; Weeks et al 2013) to describe, order and organise a multi-phase programme of applied research, development and evaluation. It promotes an equal and mutually supporting relationship between theory-building, knowledge acquisition and practice, without privileging any one activity. Within WSSPR sits the Wales Social Prescribing Research Network. The network has a membership of over 300 individuals interested in social prescribing research across Wales, this includes academics, social prescribers, policy makers, health and social care professionals and commissioners. The school is also linked to three communities of practice in the North, West & Mid, and South East of Wales, which collectively reach over 1000 social prescribing practitioners. Through the translational research model, issues and questions are raised by practice or members of the public through the network to WSSPR. These inform thinking and development of research projects and proposals. The network is then used to disseminate findings, receive feedback on findings and implement evidence-based changes in practice. This presentation will discuss the development of WSSPR and our networks & communities of practice using a translational model of research to develop programmes of research for Wales. It will discuss the challenges and provide step by step developmental guidance about setting up a research organisation for SP. It will demonstrate the impact of the social prescribing research and its contribution to the evidence base to date.

Seropositivity in blood donors and pregnant women during the first year of SARS-CoV-2 transmission in Stockholm, Sweden

BACKGROUND

In Sweden, social restrictions to contain SARS-CoV-2 have primarily relied upon voluntary adherence to a set of recommendations. Strict lockdowns have not been enforced, potentially affecting viral dissemination. To understand the levels of past SARS-CoV-2 infection in the Stockholm population before the start of mass vaccinations, healthy blood donors and pregnant women (n = 5,100) were sampled at random between 14 March 2020 and 28 February 2021.

METHODS

In this cross-sectional prospective study, otherwise-healthy blood donors (n = 2,600) and pregnant women (n = 2,500) were sampled for consecutive weeks (at four intervals) throughout the study period. Sera from all participants and a cohort of historical (negative) controls (n = 595) were screened for IgG responses against stabilized trimers of the SARS-CoV-2 spike (S) glycoprotein and the smaller receptor-binding domain (RBD). As a complement to standard analytical approaches, a probabilistic (cut-off independent) Bayesian framework that assigns likelihood of past infection was used to analyse data over time.

SETTING

Healthy participant samples were randomly selected from their respective pools through Karolinska University Hospital. The study was carried out in accordance with Swedish Ethical Review Authority: registration number 2020-01807.

PARTICIPANTS

No participants were symptomatic at sampling, and blood donors were all over the age of 18. No additional metadata were available from the participants.

RESULTS

Blood donors and pregnant women showed a similar seroprevalence. After a steep rise at the start of the pandemic, the seroprevalence trajectory increased steadily in approach to the winter second wave of infections, approaching 15% of all individuals surveyed by 13 December 2020. By the end of February 2021, 19% of the population tested seropositive. Notably, 96% of seropositive healthy donors screened (n = 56) developed neutralizing antibody responses at titres comparable to or higher than those observed in clinical trials of SARS-CoV-2 spike mRNA vaccination, supporting that mild infection engenders a competent B-cell response.

CONCLUSIONS

These data indicate that in the first year since the start of community transmission, seropositivity levels in metropolitan in Stockholm had reached approximately one in five persons, providing important baseline seroprevalence information prior to the start of vaccination.

Dentoalveolar outcomes in maxillary reconstruction: A retrospective review of 85 maxillectomy reconstructions

BACKGROUND

Although microvascular free flaps are often used to reconstruct maxillary defects, dentoalveolar rehabilitation is arguably less common despite its importance to midface function and aesthetics. The aim of this study is to review the contemporary management of maxillary defects in a single quaternary referral institution to identify factors that assist or impede dentoalveolar rehabilitation.

METHODS

A retrospective review of maxillary reconstructions performed between February 2017 and December 2020 was performed. Patient characteristics, defect classification, operative techniques, complications and dentoalveolar outcomes were recorded.

RESULTS

A total of 85 maxillary reconstructions were performed in 73 patients. Of the 64 patients where dental rehabilitation was required, 31 received a functional denture (48%) with 24 (38%) being implant-retained. Significant predictors of successful rehabilitation included the use of virtual surgical planning (VSP; 86% vs. 25%, p < 0.001), preoperative prosthodontic assessment (82% vs. 21%, p < 0.001), prefabrication (100% vs. 40%, p = 0.002) and use of the zygomatic implant perforator flap technique (100% vs. 39%, p = 0.001). Preoperative prosthodontic consultation was associated with 21-fold increase in the odds of rehabilitation (odds ratio 20.9, 95% confidence interval 6.54-66.66, p < 0.005).

CONCLUSION

Preoperative prosthodontic evaluation, VSP and reconstructive techniques developed to facilitate implant placement are associated with increased dental rehabilitation rates. Despite using an institutional algorithm, functional dentures are frequently prevented by factors including soft tissue constraints, disease recurrence and patient motivation.

The role of social prescribers in wales: a consensus methods study

Aims:

Social prescribing continues to grow and change across healthcare services in Wales; however, research of the day-to-day performance of social prescribers is limited. This study aimed to explore which roles are perceived to be the most important and frequently used by social prescribers in Wales and compare these results to reports in studies of services in other countries in order to support future role development and potential standardisation.

Methods:

This study used the Group Concept Mapping via the Concept Systems Global Max™ software to collect and analyse all data from both participants and literature.

Results:

There was a total of 101 statements generated (119 participants, 84 literature) ranging from generic interpersonal skills to specialised training (cognitive behavioural therapy). These statements were then sorted by conceptual similarity into seven clusters (Providing a Specialist Service, Working in a person-centred way, Skills, Connecting Clients with Community, Collaborative Working, Evaluating and postprogramme duties, and Networking/Community). Statements were rated based on their perceived importance and frequency, with the ‘Skills’ cluster having the highest overall average and ‘Providing a Specialist Service’ having the lowest.

Conclusions:

Reports indicate that in general there is variation in the roles performed by individual participants in Wales; however, greater variation was observed between participants and literature suggesting geographical divergence in practice. In the top 12 highest rated statements for both frequency and importance, individualistic traits such as empathy and ‘being a listener’ are favoured over specialised methods such as cognitive behavioural therapy and behaviour change taxonomy. Results suggest that local need plays a part in the choices and performance of social prescribers and as such should be considered in future standardisation.

Maxillofacial reconstruction with prefabricated prelaminated osseous free flaps

BACKGROUND

The prefabricated fibula flap is an advanced method of occlusal-based reconstruction that combines placement of osseointegrated dental implants with prelamination, using a split skin graft on the fibula, weeks prior to the definitive reconstruction. This approach is resource intensive but has several advantages including eliminating the delay from reconstruction to dental rehabilitation.

METHODS

A retrospective cohort study of all prefabricated fibula flaps used for mandible and maxillary reconstruction from 2012 to 2020 was performed. Outcome measures were implant survival, implant utilization and functional dental rehabilitation.

RESULTS

A total of 17 prefabricated fibula flaps were performed including two analogue and 15 digital plans. There were nine maxillary and eight mandibular reconstructions, of which 11 were primary and seven were secondary. There were no free flap failures. A total of 65 implants were placed (average 3.8, median 3 implants). There was one implant failure at 6 years giving a 1.5% failure rate. There was 91% implant utilization and 94% functional dental rehabilitation.

CONCLUSION

The prefabricated fibula flap provides outstanding dental rehabilitation in well-selected patients.

Occlusal-based planning for dental rehabilitation following segmental resection of the mandible and maxilla

Reconstruction of the maxilla and mandible incorporating a dental prosthesis supported by dental implants is a complex process but has tremendous benefit to patient rehabilitation following ablative procedures. This study presents a protocol that can be used to aid other institutions to provide the highest standard of reconstruction.

The Sydney Modified Alberta Reconstruction Technique (SM-ART) for dental rehabilitation following mandibulectomy or maxillectomy

The Sydney Modification of the Alberta Mandibular Reconstruction technique (SM-ART) is a hybrid of the Rohner method and the Alberta Reconstructive Technique (ART). SM-ART differs from ART in three ways, notably the use of custom plates, intraoral placement of implants via three-dimensionally printed guides and a skin graft buried deep into the skin paddle of the fibula flap in the first stage of the reconstruction.

Challenges and innovations in Primary Health Care in the Amazon: A Scoping Review

Background

The Amazon region crosses the territorial borders of nine countries with a vast complexity of ecological and social relations. Outside of large and medium cities, this region comprises a mosaic of ranches, villages, farms, isolated houses and small towns scattered over a vast territory, in large part accessed only by waterway. Working with health in this region requires specific strategies that respect the dynamics of this place. This research aimed to reveal the challenges and innovations of Primary Health Care (PHC) in places outside the largest cities in the Amazon.

Methods

The scoping review methodology was applied to peer-reviewed articles. Six databases were searched to identify scientific papers published in English, Spanish and Portuguese between January 2000 and November 2019. The analytical strategy was to combine descriptive statistics and qualitative content analysis to extract from each article all the content related to the research questions.

Results

This review included 26 papers. The most frequent challenges reported in the studies were related to the way of working (8), specific training for professionals (5), leadership and governance (4) and infrastructure improvement (2). A smaller number of studies were dedicated to innovative experiences, which approached training and methodologies for health agents recruited in the communities (4), technologies to the services (2) and a river unit as a model to work in Amazon(1).

Conclusions

The challenges presented in this review indicate the need to build services that are more sensitive to Amazonian locations and the need to train professionals for this region. Also, it revealed innovations with positive impacts which can be taken as key lessons regarding the functioning of PHC in the Amazon.

Key messages

This research fills a knowledge gap about PHC in the Amazon. The challenges and innovations presented in the review provide insights to assist PHC policy makers and managers with the design and delivery of health services in the Amazon.

Rapid Screening Assay for Beta-Lactam Antibiotics in Milk: Collaborative Study

A 15 min assay for beta-lactam antibiotics has been used by dairies for several years as a screening procedure for testing milk tankers before they unload. The test is based on a competition between 14C-penicillin and beta-lactam antibiotics in the milk samples for sites on a microbial cell wall that specifically binds beta-lactam. In a collaborative study, 11 laboratories correctly distinguished 10 coded zero penicillin G samples and 10 coded 0.01 IU/mL samples. The proposed test is qualitative, positive or negative, and can detect the presence of beta-lactam antibiotics at the 0.01 IU/mL level. The control point for determining positive or negative samples is more than 3 standard deviations from the mean of 0.01 IU/mL. The method has been adopted official first action.

Using consensus methods to develop a Social Prescribing Learning Needs Framework for practitioners in Wales

Aims:

Social prescribing is being widely implemented in Wales, but there is no consensus on the necessary learning, training and education needs for people delivering social prescribing. The purpose of the study was to develop an education and training needs conceptual framework for social prescribers in Wales, which could be used by commissioners and providers for the development of social prescribing curricula.

Methods:

This study used two consensus methods. First, Group Concept Mapping using Concept Systems Global MaxTM software which identified the important and available learning needs of 18 ( n = 18) geographically spread social prescribing practitioners. Second, a world café style workshop asked 85 ( n = 85) social prescribers to identify when training and support would be most appropriate and valuable in developing their role and skills.

Results:

A Social Prescribing Learning Needs Framework was developed identifying important learning needs and their availability across a timeline from induction onwards. This was conceptualised from a group concept mapping cluster map and go-zone report. The map comprises five clusters of statements (compassion, interpersonal relationships, socioeconomic disadvantage, networking and monitoring data) from the original 120 statements of learning needs identified by participants. The Go-Zone report displayed how each learning need was rated by participants on scales of importance and availability. A large number of training needs (45%) that were identified as important, are not currently available to social prescribers. All training needs were placed within the first year of the social prescriber working timeline, with 39% placed in an induction period.

Conclusion:

The use of two different consensus methods enabled social prescribers geographically spread across Wales to engage with the study. The Social Prescribing Learning Needs Framework will be used to inform the commissioning and decommissioning of training for people delivering social prescribing in Wales.

QIM19-146: A Multidisciplinary Approach to Conquer Central-Line Associated Blood Stream Infections: Establishing the Continuum of Prevention

Background: Central line associated blood stream infection (CLABSI) rates have been above the benchmark for our academic medical center that includes a comprehensive cancer center. In response, a 20% CLABSI reduction rate was set by the hospital Chief Medical and Associate Chief Nursing Officers. A multidisciplinary group convened to standardize central line insertion and maintenance practices. Product review showed 20 different central line insertion kits and 6 different dressing kits throughout the system. Hospital central line policy focused solely on nursing practice and there was not a policy including provider practice regarding central line insertion. A gap analysis determined dressing and insertion site integrity was compromised in 53% of our patients, including visible blood under 38% of the dressings, with oncology patients having some of our highest rates of bleeding. Objective: The purpose of this quality improvement project was to collaborate amongst disciplines to review practice, products, and policy for central line insertion and maintenance. We aimed to systematically improve practice across the central line continuum of prevention. Methods: A multidisciplinary team evaluated and defined current and best practice for policy and product changes. Implementation of best practice checklists included a team checklist to be used during insertion of every central line in the intensive care units and checklists that detailed practice steps in accordance with the updated central line policy. Central line dressing change prototypes were designed, products were compared, and approval for a standardized kit to support practice occurred. A new antimicrobial and hemostatic dressing was selected for line care to improve site integrity. The number of central line insertion kits was reduce by half and dressing kits were reduced to just one standard kit for the hospital system. Results: CLABSI rates have decreased from 7.43 cases/month to 3.6 cases/month following. Trends post-product rollout and repeat gap analysis data will be included at time of presentation. Conclusion: Reduction of CLABSI requires a multidisciplinary approach focusing simultaneously on best practices for central line insertion and maintenance. Best evidence for provider and nursing practice needs to be bundled in a comprehensive policy with checklist and products to support the standardization. Clinician evaluation and input on choosing products is critical to positive patient outcomes.

Amplitude Analysis of the Decay B[over ¯]^{0}→K_{S}^{0}π^{+}π^{-} and First Observation of the CP Asymmetry in B[over ¯]^{0}→K^{*}(892)^{-}π^{+}

The time-integrated untagged Dalitz plot of the three-body hadronic charmless decay B[over ¯]^{0}→K_{S}^{0}π^{+}π^{-} is studied using a pp collision data sample recorded with the LHCb detector, corresponding to an integrated luminosity of 3.0  fb^{-1}. The decay amplitude is described with an isobar model. Relative contributions of the isobar amplitudes to the B[over ¯]^{0}→K_{S}^{0}π^{+}π^{-} decay branching fraction and CP asymmetries of the flavor-specific amplitudes are measured. The CP asymmetry between the conjugate B[over ¯]^{0}→K^{*}(892)^{-}π^{+} and B^{0}→K^{*}(892)^{+}π^{-} decay rates is determined to be -0.308±0.062.

Measurement of the Ratio of the B^{0}→D^{*-}τ^{+}ν_{τ} and B^{0}→D^{*-}μ^{+}ν_{μ} Branching Fractions Using Three-Prong τ-Lepton Decays

The ratio of branching fractions R(D^{*-})≡B(B^{0}→D^{*-}τ^{+}ν_{τ})/B(B^{0}→D^{*-}μ^{+}ν_{μ}) is measured using a data sample of proton-proton collisions collected with the LHCb detector at center-of-mass energies of 7 and 8 TeV, corresponding to an integrated luminosity of 3  fb^{-1}. For the first time, R(D^{*-}) is determined using the τ-lepton decays with three charged pions in the final state. The B^{0}→D^{*-}τ^{+}ν_{τ} yield is normalized to that of the B^{0}→D^{*-}π^{+}π^{-}π^{+} mode, providing a measurement of B(B^{0}→D^{*-}τ^{+}ν_{τ})/B(B^{0}→D^{*-}π^{+}π^{-}π^{+})=1.97±0.13±0.18, where the first uncertainty is statistical and the second systematic. The value of B(B^{0}→D^{*-}τ^{+}ν_{τ})=(1.42±0.094±0.129±0.054)% is obtained, where the third uncertainty is due to the limited knowledge of the branching fraction of the normalization mode. Using the well-measured branching fraction of the B^{0}→D^{*-}μ^{+}ν_{μ} decay, a value of R(D^{*-})=0.291±0.019±0.026±0.013 is established, where the third uncertainty is due to the limited knowledge of the branching fractions of the normalization and B^{0}→D^{*-}μ^{+}ν_{μ} modes. This measurement is in agreement with the standard model prediction and with previous results.

Measurement of the Ratio of Branching Fractions B(B_{c}^{+}→J/ψτ^{+}ν_{τ})/B(B_{c}^{+}→J/ψμ^{+}ν_{μ})

A measurement is reported of the ratio of branching fractions R(J/ψ)=B(B_{c}^{+}→J/ψτ^{+}ν_{τ})/B(B_{c}^{+}→J/ψμ^{+}ν_{μ}), where the τ^{+} lepton is identified in the decay mode τ^{+}→μ^{+}ν_{μ}ν[over ¯]_{τ}. This analysis uses a sample of proton-proton collision data corresponding to 3.0  fb^{-1} of integrated luminosity recorded with the LHCb experiment at center-of-mass energies of 7 and 8 TeV. A signal is found for the decay B_{c}^{+}→J/ψτ^{+}ν_{τ} at a significance of 3 standard deviations corrected for systematic uncertainty, and the ratio of the branching fractions is measured to be R(J/ψ)=0.71±0.17(stat)±0.18(syst). This result lies within 2 standard deviations above the range of central values currently predicted by the standard model.

Search for Dark Photons Produced in 13 TeV pp Collisions

Searches are performed for both promptlike and long-lived dark photons, A^{'}, produced in proton-proton collisions at a center-of-mass energy of 13 TeV, using A^{'}→μ^{+}μ^{-} decays and a data sample corresponding to an integrated luminosity of 1.6  fb^{-1} collected with the LHCb detector. The promptlike A^{'} search covers the mass range from near the dimuon threshold up to 70 GeV, while the long-lived A^{'} search is restricted to the low-mass region 214<m(A^{'})<350  MeV. No evidence for a signal is found, and 90% confidence level exclusion limits are placed on the γ-A^{'} kinetic-mixing strength. The constraints placed on promptlike dark photons are the most stringent to date for the mass range 10.6<m(A^{'})<70  GeV, and are comparable to the best existing limits for m(A^{'})<0.5  GeV. The search for long-lived dark photons is the first to achieve sensitivity using a displaced-vertex signature.

First Observation of the Rare Purely Baryonic Decay B^{0}→pp[over ¯]

The first observation of the decay of a B^{0} meson to a purely baryonic final state, B^{0}→pp[over ¯], is reported. The proton-proton collision data sample used was collected with the LHCb experiment at center-of-mass energies of 7 and 8 TeV and corresponds to an integrated luminosity of 3.0  fb^{-1}. The branching fraction is determined to be B(B^{0}→pp[over ¯])=(1.25±0.27±0.18)×10^{-8}, where the first uncertainty is statistical and the second systematic. The decay mode B^{0}→pp[over ¯] is the rarest decay of the B^{0} meson observed to date. The decay B_{s}^{0}→pp[over ¯] is also investigated. No signal is seen and the upper limit B(B_{s}^{0}→pp[over ¯])<1.5×10^{-8} at 90% confidence level is set on the branching fraction.

χ_{c1} and χ_{c2} Resonance Parameters with the Decays χ_{c1,c2}→J/ψμ^{+}μ^{-}

The decays χ_{c1}→J/ψμ^{+}μ^{-} and χ_{c2}→J/ψμ^{+}μ^{-} are observed and used to study the resonance parameters of the χ_{c1} and χ_{c2} mesons. The masses of these states are measured to be m(χ_{c1})=3510.71±0.04(stat)±0.09(syst)  MeV and m(χ_{c2})=3556.10±0.06(stat)±0.11(syst)  MeV, where the knowledge of the momentum scale for charged particles dominates the systematic uncertainty. The momentum-scale uncertainties largely cancel in the mass difference m(χ_{c2})-m(χ_{c1})=45.39±0.07(stat)±0.03(syst)  MeV. The natural width of the χ_{c2} meson is measured to be Γ(χ_{c2})=2.10±0.20(stat)±0.02(syst)  MeV. These results are in good agreement with and have comparable precision to the current world averages.

Updated search for long-lived particles decaying to jet pairs

A search is presented for long-lived particles with a mass between 25 and 50 GeV / c 2 and a lifetime between 2 and 500 ps, using proton-proton collision data corresponding to an integrated luminosity of 2.0 fb - 1 , collected by the LHCb detector at centre-of-mass energies of 7 and 8 TeV. The particles are assumed to be pair-produced in the decay of a 125 GeV / c 2 Standard-Model-like Higgs boson. The experimental signature is a single long-lived particle, identified by a displaced vertex with two associated jets. No excess above background is observed and limits are set on the production cross-section as a function of the mass and lifetime of the long-lived particle.

Neonicotinoid pesticide limits improvement in buzz pollination by bumblebees

Neonicotinoid pesticides have been linked to global declines of beneficial insects such as bumblebees. Exposure to trace levels of these chemicals causes sub-lethal effects, such as reduced learning and foraging efficiency. Complex behaviours may be particularly vulnerable to the neurotoxic effects of neonicotinoids. Such behaviours may include buzz pollination (sonication), in which pollinators, usually bees, use innate and learned behaviours to generate high-frequency vibrations to release pollen from flowers with specialised anther morphologies. This study assesses the effect of field-realistic, chronic exposure to the widely-used neonicotinoid thiamethoxam on the development of sonication buzz characteristics over time, as well as the collection of pollen from buzz-pollinated flowers. We found that the pollen collection of exposed bees improved less with increasing experience than that of unexposed bees, with exposed bees collecting between 47% and 56% less pollen by the end of 10 trials. We also found evidence of two distinct strategies for maximising pollen collection: (1) extensions to the duration of individual buzzes and (2) extensions of the overall time spent buzzing. We find new complexities in buzz pollination, and conclude that the impacts of field-realistic exposure to a neonicotinoid pesticide may seriously compromise this important ecosystem service.

Observation of D^{0} Meson Decays to π^{+}π^{-}μ^{+}μ^{-} and K^{+}K^{-}μ^{+}μ^{-} Final States

The first observation of the D^{0}→π^{+}π^{-}μ^{+}μ^{-} and D^{0}→K^{+}K^{-}μ^{+}μ^{-} decays is reported using a sample of proton-proton collisions collected by LHCb at a center-of-mass energy of 8 TeV, and corresponding to 2  fb^{-1} of integrated luminosity. The corresponding branching fractions are measured using as normalization the decay D^{0}→K^{-}π^{+}[μ^{+}μ^{-}]_{ρ^{0}/ω}, where the two muons are consistent with coming from the decay of a ρ^{0} or ω meson. The results are B(D^{0}→π^{+}π^{-}μ^{+}μ^{-})=(9.64±0.48±0.51±0.97)×10^{-7} and B(D^{0}→K^{+}K^{-}μ^{+}μ^{-})=(1.54±0.27±0.09±0.16)×10^{-7}, where the uncertainties are statistical, systematic, and due to the limited knowledge of the normalization branching fraction. The dependence of the branching fraction on the dimuon mass is also investigated.

Search for Baryon-Number Violating Ξ_{b}^{0} Oscillations

A search for baryon-number violating Ξ_{b}^{0} oscillations is performed with a sample of pp collision data recorded by the LHCb experiment, corresponding to an integrated luminosity of 3  fb^{-1}. The baryon number at the moment of production is identified by requiring that the Ξ_{b}^{0} come from the decay of a resonance Ξ_{b}^{*-}→Ξ_{b}^{0}π^{-} or Ξ_{b}^{'-}→Ξ_{b}^{0}π^{-}, and the baryon number at the moment of decay is identified from the final state using the decays Ξ_{b}^{0}→Ξ_{c}^{+}π^{-},Ξ_{c}^{+}→pK^{-}π^{+}. No evidence of baryon-number violation is found, and an upper limit at the 95% confidence level is set on the oscillation rate of ω<0.08  ps^{-1}, where ω is the associated angular frequency.

Improved limit on the branching fraction of the rare decay K S 0 → μ + μ -

A search for the decay K S 0 → μ + μ - is performed, based on a data sample of proton-proton collisions corresponding to an integrated luminosity of 3 fb - 1 , collected by the LHCb experiment at centre-of-mass energies of 7 and 8 TeV . The observed yield is consistent with the background-only hypothesis, yielding a limit on the branching fraction of B ( K S 0 → μ + μ - ) < 0.8 ( 1.0 ) × 10 - 9 at 90 % ( 95 % ) confidence level. This result improves the previous upper limit on the branching fraction by an order of magnitude.

Observation of the Doubly Charmed Baryon Ξ_{cc}^{++}

A highly significant structure is observed in the Λ_{c}^{+}K^{-}π^{+}π^{+} mass spectrum, where the Λ_{c}^{+} baryon is reconstructed in the decay mode pK^{-}π^{+}. The structure is consistent with originating from a weakly decaying particle, identified as the doubly charmed baryon Ξ_{cc}^{++}. The difference between the masses of the Ξ_{cc}^{++} and Λ_{c}^{+} states is measured to be 1334.94±0.72(stat.)±0.27(syst.)  MeV/c^{2}, and the Ξ_{cc}^{++} mass is then determined to be 3621.40±0.72(stat.)±0.27(syst.)±0.14(Λ_{c}^{+})  MeV/c^{2}, where the last uncertainty is due to the limited knowledge of the Λ_{c}^{+} mass. The state is observed in a sample of proton-proton collision data collected by the LHCb experiment at a center-of-mass energy of 13 TeV, corresponding to an integrated luminosity of 1.7  fb^{-1}, and confirmed in an additional sample of data collected at 8 TeV.

Study of charmonium production in b -hadron decays and first evidence for the decay B s 0 → ϕ ϕ ϕ

Using decays to ϕ -meson pairs, the inclusive production of charmonium states in b -hadron decays is studied with pp collision data corresponding to an integrated luminosity of 3.0 fb - 1 , collected by the LHCb experiment at centre-of-mass energies of 7 and 8 TeV. Denoting by B C ≡ B ( b → C X ) × B ( C → ϕ ϕ ) the inclusive branching fraction of a b hadron to a charmonium state C that decays into a pair of ϕ mesons, ratios R C 2 C 1 ≡ B C 1 / B C 2 are determined as R η c ( 1 S ) χ c 0 = 0.147 ± 0.023 ± 0.011 , R η c ( 1 S ) χ c 1 = 0.073 ± 0.016 ± 0.006 , R η c ( 1 S ) χ c 2 = 0.081 ± 0.013 ± 0.005 , R χ c 0 χ c 1 = 0.50 ± 0.11 ± 0.01 , R χ c 0 χ c 2 = 0.56 ± 0.10 ± 0.01 and R η c ( 1 S ) η c ( 2 S ) = 0.040 ± 0.011 ± 0.004 . Here and below the first uncertainties are statistical and the second systematic. Upper limits at 90% confidence level for the inclusive production of X(3872), X(3915) and χ c 2 ( 2 P ) states are obtained as R χ c 1 X ( 3872 ) < 0.34 , R χ c 0 X ( 3915 ) < 0.12 and R χ c 2 χ c 2 ( 2 P ) < 0.16 . Differential cross-sections as a function of transverse momentum are measured for the η c ( 1 S ) and χ c states. The branching fraction of the decay B s 0 → ϕ ϕ ϕ is measured for the first time, B ( B s 0 → ϕ ϕ ϕ ) = ( 2.15 ± 0.54 ± 0.28 ± 0 . 21 B ) × 10 - 6 . Here the third uncertainty is due to the branching fraction of the decay B s 0 → ϕ ϕ , which is used for normalization. No evidence for intermediate resonances is seen. A preferentially transverse ϕ polarization is observed. The measurements allow the determination of the ratio of the branching fractions for the η c ( 1 S ) decays to ϕ ϕ and p p ¯ as B ( η c ( 1 S ) → ϕ ϕ ) / B ( η c ( 1 S ) → p p ¯ ) = 1.79 ± 0.14 ± 0.32 .

Measurement of B_{s}^{0} and D_{s}^{-} Meson Lifetimes

We report on a measurement of the flavor-specific B_{s}^{0} lifetime and of the D_{s}^{-} lifetime using proton-proton collisions at center-of-mass energies of 7 and 8 TeV, collected by the LHCb experiment and corresponding to 3.0  fb^{-1} of integrated luminosity. Approximately 407 000 B_{s}^{0}→D_{s}^{(*)-}μ^{+}ν_{μ} decays are partially reconstructed in the K^{+}K^{-}π^{-}μ^{+} final state. The B_{s}^{0} and D_{s}^{-} natural widths are determined using, as a reference, kinematically similar B^{0}→D^{(*)-}μ^{+}ν_{μ} decays reconstructed in the same final state. The resulting differences between widths of B_{s}^{0} and B^{0} mesons and of D_{s}^{-} and D^{-} mesons are Δ_{Γ}(B)=-0.0115±0.0053(stat)±0.0041(syst)  ps^{-1} and Δ_{Γ}(D)=1.0131±0.0117(stat)±0.0065(syst)  ps^{-1}, respectively. Combined with the known B^{0} and D^{-} lifetimes, these yield the flavor-specific B_{s}^{0} lifetime, τ_{B_{s}^{0}}^{fs}=1.547±0.013(stat)±0.010(syst)±0.004(τ_{B})  ps and the D_{s}^{-} lifetime, τ_{D_{s}^{-}}=0.5064±0.0030(stat)±0.0017(syst)±0.0017(τ_{D})  ps. The last uncertainties originate from the limited knowledge of the B^{0} and D^{-} lifetimes. The results improve upon current determinations.

Observation of the Decays Λ_{b}^{0}→χ_{c1}pK^{-} and Λ_{b}^{0}→χ_{c2}pK^{-}

The first observation of the decays Λ_{b}^{0}→χ_{c1}pK^{-} and Λ_{b}^{0}→χ_{c2}pK^{-} is reported using a data sample corresponding to an integrated luminosity of 3.0  fb^{-1}, collected by the LHCb experiment in pp collisions at center-of-mass energies of 7 and 8 TeV. The following ratios of branching fractions are measured: B(Λ_{b}^{0}→χ_{c1}pK^{-})/B(Λ_{b}^{0}→J/ψpK^{-})=0.242±0.014±0.013±0.009,B(Λ_{b}^{0}→χ_{c2}pK^{-})/B(Λ_{b}^{0}→J/ψpK^{-})=0.248±0.020±0.014±0.009,B(Λ_{b}^{0}→χ_{c2}pK^{-})/B(Λ_{b}^{0}→χ_{c1}pK^{-})=1.02±0.10±0.02±0.05,where the first uncertainty is statistical, the second systematic, and the third due to the uncertainty on the branching fractions of the χ_{c1}→J/ψγ and χ_{c2}→J/ψγ decays. Using both decay modes, the mass of the Λ_{b}^{0} baryon is also measured to be m_{Λ_{b}^{0}}=5619.44±0.28±0.26  MeV/c^{2}, where the first and second uncertainties are statistical and systematic, respectively.

First Observation of a Baryonic B_{s}^{0} Decay

We report the first observation of a baryonic B_{s}^{0} decay, B_{s}^{0}→pΛ[over ¯]K^{-}, using proton-proton collision data recorded by the LHCb experiment at center-of-mass energies of 7 and 8 TeV, corresponding to an integrated luminosity of 3.0  fb^{-1}. The branching fraction is measured to be B(B_{s}^{0}→pΛ[over ¯]K^{-})+B(B_{s}^{0}→p[over ¯]ΛK^{+})=[5.46±0.61±0.57±0.50(B)±0.32(f_{s}/f_{d})]×10^{-6}, where the first uncertainty is statistical and the second systematic, the third uncertainty accounts for the experimental uncertainty on the branching fraction of the B^{0}→pΛ[over ¯]π^{-} decay used for normalization, and the fourth uncertainty relates to the knowledge of the ratio of b-quark hadronization probabilities f_{s}/f_{d}.

Measurement of the CP Violation Parameter A_{Γ} in D^{0}→K^{+}K^{-} and D^{0}→π^{+}π^{-} Decays

Asymmetries in the time-dependent rates of D^{0}→K^{+}K^{-} and D^{0}→π^{+}π^{-} decays are measured in a pp collision data sample collected with the LHCb detector during LHC Run 1, corresponding to an integrated luminosity of 3  fb^{-1}. The asymmetries in effective decay widths between D^{0} and D[over ¯]^{0} decays, sensitive to indirect CP violation, are measured to be A_{Γ}(K^{+}K^{-})=(-0.30±0.32±0.10)×10^{-3} and A_{Γ}(π^{+}π^{-})=(0.46±0.58±0.12)×10^{-3}, where the first uncertainty is statistical and the second systematic. These measurements show no evidence for CP violation and improve on the precision of the previous best measurements by nearly a factor of two.

Search for the Decays B_{s}^{0}→τ^{+}τ^{-} and B^{0}→τ^{+}τ^{-}

A search for the rare decays B_{s}^{0}→τ^{+}τ^{-} and B^{0}→τ^{+}τ^{-} is performed using proton-proton collision data collected with the LHCb detector. The data sample corresponds to an integrated luminosity of 3  fb^{-1} collected in 2011 and 2012. The τ leptons are reconstructed through the decay τ^{-}→π^{-}π^{+}π^{-}ν_{τ}. Assuming no contribution from B^{0}→τ^{+}τ^{-} decays, an upper limit is set on the branching fraction B(B_{s}^{0}→τ^{+}τ^{-})<6.8×10^{-3} at the 95% confidence level. If instead no contribution from B_{s}^{0}→τ^{+}τ^{-} decays is assumed, the limit is B(B^{0}→τ^{+}τ^{-})<2.1×10^{-3} at the 95% confidence level. These results correspond to the first direct limit on B(B_{s}^{0}→τ^{+}τ^{-}) and the world's best limit on B(B^{0}→τ^{+}τ^{-}).

Biologic therapies for refractory juvenile dermatomyositis: five years of experience of the Childhood Arthritis and Rheumatology Research Alliance in North America

BACKGROUND

The prognosis of children with juvenile dermatomyositis (JDM) has improved remarkably since the 1960's with the use of corticosteroid and immunosuppressive therapy. Yet there remain a minority of children who have refractory disease. Since 2003 the sporadic use of biologics (genetically-engineered proteins that usually are derived from human genes) for inflammatory myositis has been reported. In 2011-2016 we investigated our collective experience of biologics in JDM through the Childhood Arthritis and Rheumatology Research Alliance (CARRA).

METHODS

The JDM biologic study group developed a survey on the CARRA member experience using biologics for Juvenile DM utilizing Delphi consensus methods in 2011-2012. The survey was completed online by the CARRA members interested in JDM in 2012. A second survey was similarly developed that provided more opportunity to describe their experiences with biologics in JDM in detail and was completed by CARRA members in Feb 2013. During three CARRA meetings in 2013-2015, nominal group techniques were used for achieving consensus on the current choices of biologic drugs. A final survey was performed at the 2016 CARRA meeting.

RESULTS

One hundred and five of a potential 231 pediatric rheumatologists (42%) responded to the first survey in 2012. Thirty-five of 90 had never used a biologic for Juvenile DM at that time. Fifty-five of 91 (denominators vary) had used biologics for JDM in their practice with 32%, 5%, and 4% using rituximab, etanercept, and infliximab, respectively, and 17% having used more than one of the three drugs. Ten percent used a biologic as monotherapy, 19% a biologic in combination with methotrexate (mtx), 52% a biologic in combination with mtx and corticosteroids, 42% a combination of a biologic, mtx, corticosteroids (steroids), and an immunosuppressive drug, and 43% a combination of a biologic, IVIG and mtx. The results of the second survey supported these findings in considerably more detail with multiple combinations of drugs used with biologics and supported the use of rituximab, abatacept, anti-TNFα drugs, and tocilizumab in that order. One hundred percent recommended that CARRA continue studying biologics for JDM. The CARRA meeting survey in 2016 again supported the study and use of these four biologic drug groups.

CONCLUSIONS

Our CARRA JDM biologic work group developed and performed three surveys demonstrating that pediatric rheumatologists in North America have been using multiple biologics for refractory JDM in numerous scenarios from 2011 to 2016. These survey results and our consensus meetings determined our choice of four biologic therapies (rituximab, abatacept, tocilizumab and anti-TNFα drugs) to consider for refractory JDM treatment when indicated and to evaluate for comparative effectiveness and safety in the future. Significance and Innovations This is the first report that provides a substantial clinical experience of a large group of pediatric rheumatologists with biologics for refractory JDM over five years. This experience with biologic therapies for refractory JDM may aid pediatric rheumatologists in the current treatment of these children and form a basis for further clinical research into the comparative effectiveness and safety of biologics for refractory JDM.

Study of J/ψ Production in Jets

The production of J/ψ mesons in jets is studied in the forward region of proton-proton collisions using data collected with the LHCb detector at a center-of-mass energy of 13 TeV. The fraction of the jet transverse momentum carried by the J/ψ meson, z(J/ψ)≡p_{T}(J/ψ)/p_{T}(jet), is measured using jets with p_{T}(jet)>20  GeV in the pseudorapidity range 2.5<η(jet)<4.0. The observed z(J/ψ) distribution for J/ψ mesons produced in b-hadron decays is consistent with expectations. However, the results for prompt J/ψ production do not agree with predictions based on fixed-order nonrelativistic QCD. This is the first measurement of the p_{T} fraction carried by prompt J/ψ mesons in jets at any experiment.