Clinical and health care utilization variables can predict 90-day hospital re-admission in adults with Crohn's disease for point of care risk evaluation

BACKGROUND

Hospital re-admission for persons with Crohn's disease (CD) is a significant contributor to morbidity and healthcare costs. We derived prediction models of risk of 90-day re-hospitalization among persons with CD that could be applied at hospital discharge to target outpatient interventions mitigating this risk.

METHODS

We performed a retrospective study in persons with CD admitted between 2009 and 2016 for an acute CD-related indication. Demographic, clinical, and health services predictor variables were ascertained through chart review and linkage to administrative health databases. We derived and internally validated a multivariable logistic regression model of 90-day CD-related re-hospitalization. We selected the optimal probability cut-point to maximize Youden's index.

RESULTS

There were 524 CD hospitalizations and 57 (10.9%) CD re-hospitalizations within 90 days of discharge. Our final model included hospitalization within the prior year (adjusted odds ratio [aOR] 3.27, 95% confidence interval [CI] 1.76-6.08), gastroenterologist consultation within the prior year (aOR 0.185, 95% CI 0.0950-0.360), intra-abdominal surgery during index hospitalization (aOR 0.216, 95% CI 0.0500-0.934), and new diagnosis of CD during index hospitalization (aOR 0.327, 95% CI 0.0950-1.13). The model demonstrated good discrimination (optimism-corrected c-statistic value 0.726) and excellent calibration (Hosmer-Lemeshow goodness-of-fit p-value 0.990). The optimal model probability cut point allowed for a sensitivity of 71.9% and specificity of 70.9% for identifying 90-day re-hospitalization, at a false positivity rate of 29.1% and false negativity rate of 28.1%.

CONCLUSIONS

Demographic, clinical, and health services variables can help discriminate persons with CD at risk of early re-hospitalization, which could permit targeted post-discharge intervention.

A reverse translational approach reveals the protective roles of Mangifera indica in inflammatory bowel disease

Inflammatory bowel diseases (IBDs) are chronic intestinal disorders often characterized by a dysregulation of T cells, specifically T helper (Th) 1, 17 and T regulatory (Treg) repertoire. Increasing evidence demonstrates that dietary polyphenols from Mangifera indica L. extract (MIE, commonly known as mango) mitigate intestinal inflammation and splenic Th17/Treg ratio. In this study, we aimed to dissect the immunomodulatory and anti-inflammatory properties of MIE using a reverse translational approach, by initially using blood from an adult IBD inception cohort and then investigating the mechanism of action in a preclinical model of T cell-driven colitis. Of clinical relevance, MIE modulates TNF-α and IL-17 levels in LPS spiked sera from IBD patients as an ex vivo model of intestinal barrier breakdown. Preclinically, therapeutic administration of MIE significantly reduced colitis severity, pathogenic T-cell intestinal infiltrate and intestinal pro-inflammatory mediators (IL-6, IL-17A, TNF-α, IL-2, IL-22). Moreover, MIE reversed colitis-induced gut permeability and restored tight junction functionality and intestinal metabolites. Mechanistic insights revealed MIE had direct effects on blood vascular endothelial cells, blocking TNF-α/IFN-γ-induced up-regulation of COX-2 and the DP2 receptors. Collectively, we demonstrate the therapeutic potential of MIE to reverse the immunological perturbance during the onset of colitis and dampen the systemic inflammatory response, paving the way for its clinical use as nutraceutical and/or functional food.

New biologic (Ab-IPL-IL-17) for IL-17-mediated diseases: identification of the bioactive sequence (nIL-17) for IL-17A/F function

OBJECTIVES

Interleukin (IL) 17s cytokines are key drivers of inflammation that are functionally dysregulated in several human immune-mediated inflammatory diseases (IMIDs), such as rheumatoid arthritis (RA), psoriasis and inflammatory bowel disease (IBD). Targeting these cytokines has some therapeutic benefits, but issues associated with low therapeutic efficacy and immunogenicity for subgroups of patients or IMIDs reduce their clinical use. Therefore, there is an urgent need to improve the coverage and efficacy of antibodies targeting IL-17A and/or IL-17F and IL-17A/F heterodimer.

METHODS AND RESULTS

Here, we initially identified a bioactive 20 amino acid IL-17A/F-derived peptide (nIL-17) that mimics the pro-inflammatory actions of the full-length proteins. Subsequently, we generated a novel anti-IL-17 neutralising monoclonal antibody (Ab-IPL-IL-17) capable of effectively reversing the pro-inflammatory, pro-migratory actions of both nIL-17 and IL-17A/F. Importantly, we demonstrated that Ab-IPL-IL-17 has less off-target effects than the current gold-standard biologic, secukinumab. Finally, we compared the therapeutic efficacy of Ab-IPL-IL-17 with reference anti-IL-17 antibodies in preclinical murine models and samples from patients with RA and IBD. We found that Ab-IPL-IL-17 could effectively reduce clinical signs of arthritis and neutralise elevated IL-17 levels in IBD patient serum.

CONCLUSIONS

Collectively, our preclinical and in vitro clinical evidence indicates high efficacy and therapeutic potency of Ab-IPL-IL-17, supporting the rationale for large-scale clinical evaluation of Ab-IPL-IL-17 in patients with IMIDs.

Aging modulates homeostatic leukocyte trafficking to the peritoneal cavity in a sex-specific manner

Aging is associated with exacerbated systemic inflammation (inflammaging) and the progressive loss of immune system function (immunosenescence). Leukocyte migration is necessary for effective immunity; however, dysregulated trafficking of leukocytes into tissue contributes to inflammaging and the development of age-related inflammatory diseases. Aging modulates leukocyte trafficking under inflammatory conditions; however, whether aging modulates leukocyte trafficking under homeostatic conditions remains to be elucidated. Although immune responses are evidently sexually dimorphic, limited studies have investigated the effect of sex on age-related changes to leukocyte trafficking processes. Here, we investigated age-related and sex-specific changes to the leukocyte populations within the peritoneal cavity of young (3-mo), middle-aged (18-mo) and old (21-mo) male and female wild-type mice in the steady state. We found an age-related increase in the number of leukocytes within the peritoneal cavity of female mice, predominantly B cells, which may reflect increased trafficking through this tissue with age. This was accompanied by an increased inflammatory environment within the aged cavity, including increased levels of chemoattractants, including B cell chemoattractants CXCL13 and CCL21, soluble adhesion molecules, and proinflammatory cytokines, which was more pronounced in aged female mice. Intravital microscopy techniques revealed altered vascular structure and increased vascular permeability within the peritoneal membrane of aged female mice, which may support increased leukocyte trafficking to the cavity with age. Together, these data indicate that aging affects homeostatic leukocyte trafficking processes in a sex-specific fashion.

PEPITEM modulates leukocyte trafficking to reduce obesity-induced inflammation

Dysregulation of leukocyte trafficking, lipid metabolism, and other metabolic processes are the hallmarks that underpin and drive pathology in obesity. Current clinical management targets alternations in lifestyle choices (e.g. exercise, weight loss) to limit the impact of the disease. Crucially, re-gaining control over the pathogenic cellular and molecular processes may offer an alternative, complementary strategy for obese patients. Here we investigate the impact of the immunopeptide, PEPITEM, on pancreas homeostasis and leukocyte trafficking in mice on high-fed obesogenic diet (HFD). Both prophylactic and therapeutic treatment with PEPITEM alleviated the effects of HFD on the pancreas, reducing pancreatic beta cell size. Moreover, PEPITEM treatment also limited T-cell trafficking (CD4+ T-cells and KLRG1+ CD3+ T-cells) to obese visceral, but not subcutaneous, adipose tissue. Similarly, PEPITEM treatment reduced macrophage numbers within the peritoneal cavity of mice on HFD diet at both 6 and 12 weeks. By contrast, PEPITEM therapy elevated numbers of T and B cells were observed in the secondary lymphoid tissues (e.g. spleen and inguinal lymph node) when compared to the untreated HFD controls. Collectively our data highlights the potential for PEPITEM as a novel therapy to combat the systemic low-grade inflammation experienced in obesity and minimize the impact of obesity on pancreatic homeostasis. Thus, offering an alternative strategy to reduce the risk of developing obesity-related co-morbidities, such as type 2 diabetes mellitus, in individuals at high risk and struggling to control their weight through lifestyle modifications.

A166 RISK STRATIFICATION OF EARLY RE-HOSPITALIZATION IN PERSONS WITH INFLAMMATORY BOWEL DISEASES USING MULTIVARIABLE MODELS

Background

Hospitalization for persons with inflammatory bowel disease (IBD), including Crohn’s disease (CD) and ulcerative colitis (UC), is a significant contributor to morbidity and health care costs in Canada. Recognition of individuals at high risk of re-hospitalization could help inform targeted outpatient interventions that mitigate this risk.

Purpose

The aim of our study is to derive prediction models of risk of early (90-day) re-hospitalization among persons with IBD.

Method

We conducted a retrospective cohort study of all adult persons with IBD admitted to The Ottawa Hospital, Canada, for an acute IBD-related indication between April 2009 - March 2016. Demographic, clinical, and health services variables were obtained through chart review. Persons were linked to population-based health administrative datasets to identify historical and future IBD-related hospitalizations across the greater Ottawa region. Multivariable logistic regression models of 90-day re-hospitalization in persons with CD and UC were derived, and candidate predictors that demonstrated an independent association with the outcome at a p-value of 0.1 were retained. Bootstrap internal validation (200 iterations) was performed on the final models. Model performance and calibration were evaluated using the optimism-corrected c-statistic value and Hosmer-Lemeshow goodness of fit test, respectively. Adjusted odds ratios are reported with 95% confidence intervals (CI). Optimal probability cut points for re-hospitalization were selected to optimize sensitivity, specificity, and the J (Youden’s) index.

Result(s)

There were 524 CD and 248 UC hospitalizations during the study period. Of these, 57 (10.9%) CD and 27 (10.9%) UC hospitalizations were associated with re-hospitalization within 90 days of discharge. Forty-two candidate predictors were tested among CD hospitalizations, and 35 were tested among UC hospitalizations. Four variables were retained in each of the final models. Model performance and calibration for each variable are described in Table 1. The optimal range of probability cut points allowed for a sensitivity/positive predictive value (PPV)/false positive rate (FPR) of 0.72/0.23/0.29 (maximum J-index of 0.43) in the model for CD, and 0.78/0.33/0.19 (maximum J-index of 0.59) in the model for UC, respectively.

Image

Conclusion(s)

Demographic, clinical, and health services variables at the time of discharge have the potential to help identify persons with IBD at risk of early re-hospitalization, thereby permitting targeted outpatient intervention. Application of the models to our reference cohorts would earmark 1/3 or less of patients for early post-discharge intervention, with the potential to benefit more than 70% of patients destined for early re-hospitalization. Although the PPVs of our models were low, the models incorrectly predicted early re-hospitalization in less than 30% of patients. We are in process of externally validating these models in other jurisdictions across Ontario to test their generalizability.

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None

Disclosure of Interest

None Declared

A220 ONTARIO POPULATION TRENDS IN INTESTINAL AND EXTRA-INTESTINAL CANCERS OVER 25 YEARS AMONG PERSONS WITH INFLAMMATORY BOWEL DISEASES AND MATCHED CONTROLS

NOT PUBLISHED AT AUTHOR’S REQUEST

S100A8/A9 drives the formation of procoagulant platelets through GPIbα

S100A8/A9, also known as "calprotectin" or "MRP8/14," is an alarmin primarily secreted by activated myeloid cells with antimicrobial, proinflammatory, and prothrombotic properties. Increased plasma levels of S100A8/A9 in thrombo-inflammatory diseases are associated with thrombotic complications. We assessed the presence of S100A8/A9 in the plasma and lung autopsies from patients with COVID-19 and investigated the molecular mechanism by which S100A8/A9 affects platelet function and thrombosis. S100A8/A9 plasma levels were increased in patients with COVID-19 and sustained high levels during hospitalization correlated with poor outcomes. Heterodimeric S100A8/A9 was mainly detected in neutrophils and deposited on the vessel wall in COVID-19 lung autopsies. Immobilization of S100A8/A9 with collagen accelerated the formation of a fibrin-rich network after perfusion of recalcified blood at venous shear. In vitro, platelets adhered and partially spread on S100A8/A9, leading to the formation of distinct populations of either P-selectin or phosphatidylserine (PS)-positive platelets. By using washed platelets, soluble S100A8/A9 induced PS exposure but failed to induce platelet aggregation, despite GPIIb/IIIa activation and alpha-granule secretion. We identified GPIbα as the receptor for S100A8/A9 on platelets inducing the formation of procoagulant platelets with a supporting role for CD36. The effect of S100A8/A9 on platelets was abolished by recombinant GPIbα ectodomain, platelets from a patient with Bernard-Soulier syndrome with GPIb-IX-V deficiency, and platelets from mice deficient in the extracellular domain of GPIbα. We identified the S100A8/A9-GPIbα axis as a novel targetable prothrombotic pathway inducing procoagulant platelets and fibrin formation, in particular in diseases associated with high levels of S100A8/A9, such as COVID-19.

Galectin-9 supports primary T cell transendothelial migration in a glycan and integrin dependent manner

Adaptive immunity relies on the efficient recruitment of T cells from the blood into peripheral tissues. However, the current understanding of factor(s) coordinating these events is incomplete. Previous studies on galectin-9 (Gal-9), have proposed a functionally significant role for this lectin in mediating leukocyte adhesion and transmigration. However, very little is known about its function in T cell migration. Here, we have investigated the role of the Gal-9 on the migration behaviour of both human primary CD4⁺ and CD8⁺ T cells. Our data indicate that Gal-9 supports both CD4⁺ and CD8⁺ T cell adhesion and transmigration in a glycan dependent manner, inducing L-selectin shedding and upregulation of LFA-1 and CXCR4 expression. Additionally, when immobilized, Gal-9 promoted capture and firm adhesion of T cells under flow, in a glycan and integrin-dependent manner. Using an in vivo model, dorsal air pouch, we found that Gal-9 deficient mice display impaired leukocyte trafficking, with a reduction in pro-inflammatory cytokines/chemokines generated locally. Furthermore, we also demonstrate that Gal-9 inhibits the chemotactic function of CXCL12 through direct binding. In conclusion, our study characterises, for the first time, the capture, adhesion, and migration behaviour of CD4⁺ and CD8⁺ T cells to immobilised /endothelial presented Gal-9, under static and physiological flow conditions. We also demonstrate the differential binding characteristics of Gal-9 to T cell subtypes, which could be of potential therapeutic significance, particularly in the treatment of inflammatory-based diseases, given Gal-9 ability to promote apoptosis in pathogenic T cell subsets.

POS1550-HPR DRIVE-THROUGH PHLEBOTOMY – DOES IT WORK FOR cDMARDs MONITORING?

Background

Centralised phlebotomy services have been an integral part of providing blood monitoring facility for people with chronic diseases prescribed vital therapies. However the patient experience is not always optimal due to the issues of congestion, parking, long waiting times and have been accentuated during COVID-19 pandemic with the need for minimising physical contact. Expert panels have advocated for the creation of innovative approaches to provide safe patient care while maintaining precautions against COVID-19 spread. Several groups have published the concept and experience of using a drive-through clinic for anticoagulation monitoring and management. There is limited data on how this model of care can impact other clinical services such as rheumatology where patient groups are more vulnerable.

Objectives

In response to the growing pressure on phlebotomy service at our institution enhanced by COVID-19 pandemic, our rheumatology service implemented a drive-through phlebotomy clinic to provide the option for patients and families to stay in their vehicles whilst having venepuncture. The objectives were to evaluate the feasibility and patient experience of the service.

Methods

At our large university teaching hospital, we set up a drive-through phlebotomy service provided by a senior health care assistant supervised by the lead nurse. It was located near the hospital entrance where vehicles could park for a few minutes without disrupting traffic flow. Patients were identified from the departmental database and were offered the facility via telephone. Eligibility was assessed using a standardised proforma focusing on logistics such as ability to drive and access to a mobile phone. Appointments were scheduled in advance with patients choosing this care option. On the day, patients were screened for COVID-19–related symptoms before their appointment and were encouraged to stay in their vehicles wearing a mask before being approached by the HCA. At the end of clinic, all samples were submitted to the central laboratory.

All the data was prospectively collated with patients’ consent and anonymised for analysis. In addition to demographics, diagnosis and drug record, duration of visit and patient feedback was collected.

Results

112 patients were offered the service during a 12-week pilot. Mean age of the participants was 49.5 yrs (19-91) with 73 (65%) women. 74 (65%) were of Caucasian and 28 (25%) of Asian origin. 94 (84%) had inflammatory arthritides and all were prescribed DMARDs and/or bone active agents.

69 (61%) had blood samples taken using this service. Most common reason to decline was an already arranged appointment with standard phlebotomy (n=14, 12.5%). Six (5%) could not be bled due to difficult venepuncture. Mean duration of appointment was 12.5 mins (5-60). 68 (60%) provided feedback with 61 (90%) rating 5/5 and 60 (89%) rating it better than standard phlebotomy. All would like to have the option for future and 67 (98%) were highly likely or likely to recommend the service to family and relatives.

Conclusion

To our knowledge, this is the first study to demonstrate the utility of drive-through phlebotomy for people with rheumatic diseases prescribed DMARDs. Excellent feedback of the participants confirms the need and desire for such innovation in health care. Prior publications have shown the benefits of such clinics in anticoagulation services. Arguably, it’s more prudent to have this facility for those where there is no alternative such as point-of-care or home INR monitoring. In post COVID-19 services reconfiguration with telemedicine and innovative models of care, this allowed flexibility for our department to develop and establish an alternative process. The availability of drive-through appointments and the close physical proximity to the clinic made it an appealing option for a vulnerable group of patients evidenced by their outstanding experience and feedback. Overall, an HCA-delivered, nurse-supervised drive-through pathway is highly effective, safe and provides an innovative solution to strained phlebotomy services.

Disclosure of Interests

None declared

A159 OPIOID USE IS DECLINING AMONG PEOPLE WITH INFLAMMATORY BOWEL DISEASE: A POPULATION-BASED STUDY

Background

Patients with inflammatory bowel disease (IBD) are more likely to use opioids than those without IBD and are more susceptible to the negative consequences of opioid use, including increased risk of death.

Aims

Examine trends in the use of opioids among people with and without IBD, where opioids were prescribed, and who prescribed them.

Methods

We identified Ontarians with IBD (7/2012–3/2017) from population-based health administrative data using validated algorithms. We matched each patient with IBD on age and sex to 5 people without IBD. We calculated age- and sex-standardized quarterly rates of patients taking opioids, characterized as any, chronic (>90 days), or acute (≤90 days) among people with and without IBD. Among people with IBD, we identified the location of the last healthcare interaction prior to filling the prescription (hospital, emergency department [ED], outpatient clinic), presuming this was where the opioid was prescribed. Opioids prescribed after outpatient visits were stratified by specialty (gastroenterologist, family physician/internist, surgeon, other). Average quarterly percentage change was calculated using Poisson regression, adjusting for age, sex, income, and rural/urban household.

Results

Of 92,233 IBD patients (mean 47 y at study entry, 45% male, 50% Crohn’s), 56% had at least 1 opioid prescription during the study period. Opioid use was more common among people with IBD (any: IRR 2.11, 95% CI 2.08–2.14; chronic: IRR 2.61, 95% CI 2.54–2.69; acute: IRR 1.82, 95% CI 1.79–1.94), Figure A. Among IBD patients, any opioid use decreased by 0.5% (95%CI 0.4–0.5) per quarter, from 13.4% (95%CI 13.1–13.6) to 12.7% (95%CI 12.5–13.0). Chronic opioid use decreased by 0.3% (95%CI 0.2–0.4) per quarter while acute opioid use among IBD patients decreased by 0.6% (95% CI 0.5–0.7) per quarter. Most opioids were prescribed after an outpatient visit (70.2%), most often (82.7%) by a family physician or internist. Total outpatient prescriptions declined by 1.9% (95%CI 1.7–2.0) per quarter, from 5.8% (95%CI 5.6–5.9) to 3.8% (95%CI 3.7–3.9). Relative quarterly decreases were similar across all specialties, Figure B.

Conclusions

Opioid use remains common among IBD patients but has decreased since 2012. The prescriptions most often originated after outpatient visits to family physicians and internists rather than gastroenterologists or surgeons.

Trends in (A) the acute and chronic opioid use among those with and without IBD and (B) the specialist prescribing opioids to IBD patients when the most recent healthcare contact was an outpatient visit.

Funding Agencies

American College of Gastroenterology

A162 CHRONIC OPIOID THERAPY IS ASSOCIATED WITH INCREASED HEALTH SERVICES UTILIZATION AND DIRECT HEALTHCARE COSTS: A POPULATION-BASED STUDY

Background

Opioid use is more common among people living with Inflammatory bowel disease (IBD).

Aims

Investigate the associations between receiving chronic opioid therapy and health services utilization and direct healthcare costs among IBD patients receiving chronic opioid therapy.

Methods

We identified prevalent cases of IBD in Ontario (7/2012–3/2017) from population-based health administrative data using previously validated algorithms. Patients with ongoing opioid use for >90 days (chronic opioid recipients) were matched based on age, sex, IBD type, and disease duration with up to 5 IBD patients with no period of chronic opioid use. For the year after becoming a chronic opioid recipient (i.e., from the 91^st day of chronic opioid therapy), we determined: 1) the mean (SD) number of IBD-specific, IBD-related, and all-cause outpatient visits, emergency department (ED) visits, and hospitalizations; and 2) total, hospitalization, ED, and outpatient healthcare costs. IBD-specific visits had a diagnostic code for Crohn’s disease or ulcerative colitis; IBD-related visits additionally included diagnostic codes for signs, symptoms, and extra-intestinal manifestations of IBD. Patients were censored at the time of a new cancer diagnosis or upon initiation of palliative care. We used Poisson models to compare the number of healthcare encounters in chronic opioid recipients and patients with no period of chronic opioid therapy then used generalized linear models with a gamma distribution and log-link to compare direct healthcare costs in the two groups. Regression models accounted for matching and were adjusted for income, rural/urban household, and comorbidities (resource intensity using the John Hopkins ACG Index).

Results

We identified 9913 IBD patients with at least one period of chronic opioid therapy matched to 44,274 without chronic opioid therapy (mean 43 y at chronic opioid use, 43% male, 58% Crohn’s). Patients receiving chronic opioid therapy had significantly more health care encounters (Figure A). Annual per capita total health care cost among chronic opioid recipients was $13,452 (SD 33,777) compared to $5140 (SD 28,999) among patients with no chronic opioid therapy (Figure B). After adjustment, healthcare costs were approximately double in chronic opioid recipients and was consistent for all cost types (overall, hospitalization, ED, and outpatient).

Conclusions

IBD patients who were chronic opioid users had significantly more health services utilization and direct healthcare costs compared to patients without periods of chronic opioid use. These associations persisted after adjusting for the resource intensity of any co-occurring conditions.

Health services utilization (A) and direct healthcare costs (B) among people with inflammatory bowel disease (IBD) who are chronic opioid users compared to those without a period of chronic opioid use.

Funding Agencies

American College of Gastroenterology

POS1488-HPR CAN A SPECIALIST NURSE LEAD A COMPREHENSIVE OSTEOPOROSIS SERVICE WITH REMOTE SUPERVISION – AN INNOVATIVE CONCEPT

Background:

Specialist services traditionally rely on a consultant to lead a multidisciplinary team and provide patient facing activities. However, demand outstrips the limited expertise available and therefore significant delays occur in treatment pathways. There is an urgent need to expand the skill set of the employed workforce and think ‘outside the box’. A service run by clinical nurse specialists (CNS) can be an effective solution. CNS are already an integral part of multidisciplinary teams caring for a diverse range of patients including those with chronic conditions such as osteoporosis.

Objectives:

We designed an innovative osteoporosis service with patients consulting only a metabolic bone CNS with a consultant rheumatologist providing remote oversight. The aim of the project was to improve the efficiency of the service by eliminating consultant appointments and reducing unnecessary hospital visits while continuing to deliver a high-quality and safe service.

Methods:

A new pathway was implemented where a consultant rheumatologist and a CNS virtually triaged post menopausal women over the age of 65 into the service. A dedicated proforma provided the template for the CNS to undertake new patient telephone consultation. Relevant investigations were requested during the telephone clinic and treatment related information was despatched to help with shared decision making. All patients were then reviewed in a Rheumatologist-CNS virtual MDT. An appropriate parenteral treatment option was agreed and confirmed to each individual. The CNS worked through a safety checklist and provided further advice and support to the patient as necessary. Using the database, we compared the timelines for the patient journey to the conventional pathway, obtained the number of consultant follow-up appointments saved by implementing this service, and calculated total savings.

Results:

In the pilot phase, 116 patients were triaged into the new service. The patient cohort was a combination of new referrals and patients taken from the consultants’ waiting lists. The mean age of the participants was 78 years (65-93). The median time: from referral to virtual triage was 20 days (0-308); from triage to new patient CNS telephone consultation was 20 days (0-137); and from virtual MDT to treatment authorisation was zero days (0-331 days). 45 patients had anabolic therapy commenced via home care. The remainder had anti resorptive therapy. No patient requested face-to-face review. Only one patient fed back that they would’ve preferred to see the consultant once. 116 new patient consultant appointments were saved and the median delay in treatment commencement was reduced from 84 to 38 days.

Conclusion:

To our knowledge, this is the first successful example of an innovative service wholly provided by CNS for commencing parenteral anti-osteoporotic therapy with only remote consultant supervision. Our service redesign has significantly improved the efficiency of the parenteral osteoporosis pathway with reduction in treatment delay and a more streamlined patient journey. A nurse-delivered osteoporosis treatment pathway is highly effective, safe and provides an innovative solution to address thinly stretched health care resources for people with chronic conditions.

Disclosure of Interests:

None declared

POS1478-HPR NURSE LED REMOTE MANAGEMENT OF OSTEOPOROSIS – DO PATIENTS APPROVE?

Background:

Specialist services are heavily reliant on consultant delivered models however lack of sufficient consultant appointments pose a significant operational challenge. Clinical nurse specialists (CNSs) are highly trained and can fill this gap whilst maintaining a high standard of care.

Objectives:

We designed an innovative proof-of-concept osteoporosis service with patients only consulting a metabolic bone CNS and a consultant providing remote oversight. The aim of the project was to improve the efficiency of the service by eliminating consultant appointments and reducing unnecessary hospital visits whilst continuing to deliver high-quality care.

Methods:

A new pathway was implemented where a consultant rheumatologist and a CNS virtually triaged women over the age of 65 into the service. A dedicated proforma provided the template for the CNS to undertake new patient telephone consultation. Relevant investigations were requested during the telephone clinic and treatment related information was despatched to help with shared decision making. All patients were then reviewed in a consultant-CNS virtual MDT. Appropriate parenteral treatment option was agreed and confirmed to each individual. The CNS worked through a safety checklist and provided further advice and support to the patient as necessary. We surveyed 100 consecutive patients to gain their feedback regarding the service using a ten-item questionnaire employing binary and Likert scale options.

Results:

The questionnaire was posted to 100 patients. Mean age of participants was 77.2 years (65-92). 75 returned the survey. 67 (89%) were happy with the waiting time and seventy (93%) found thirty-minute appointment acceptable. 66 (88%) were happy with the phone consultation and agreed that the care plan was adequately explained. 73 (97%) were happy for the CNS review in future and would recommend the service. 67 (89%) were satisfied with the overall service. Though most (95%) were able to take the call maintaining privacy, eleven (15%) participants would’ve found physical appointment more convenient. When asked which medium they would prefer for future reviews, only fifty (66%) patients would keep telephone as their choice. Sixteen (21%) would prefer face to face consultation, seven (9%) a combination of the two and only two would choose online option.

Conclusion:

To our knowledge, this is the first successful example of an innovative service wholly provided by CNSs. Most patients were satisfied with this model of care and would highly recommend it. They were happy to be reviewed by CNS in the future. However a significant minority did not like the remote element and a higher proportion would choose physical review in future if offered. Interestingly, telephone consultation still scored substantially higher than online platform despite being physically visible in the latter. This is intriguing as most remote services strive for online consultations assuming its preference to phone. Our study suggests against this notion certainly in older patient group. Overall, a nurse-delivered osteoporosis treatment pathway is highly effective, safe and provides an innovative solution though remote consultations may not be the optimal delivery model.

Disclosure of Interests:

None declared

SAT0648-HPR CAN A SPECIALIST NURSE REPLACE A CONSULTANT - AN INNOVATIVE MODEL FOR OSTEOPOROSIS CARE

Background:

Specialist services are heavily reliant on a consultant reviewing a patient and discussing management options. However this can significantly delay treatment pathway owing to lack of sufficient consultant appointments. Clinical nurse specialists (CNSs) are an integral part of a multidisciplinary team employed to provide effective care for the diverse needs of patients with chronic conditions such as osteoporosis.

Objectives:

We designed an innovative proof-of-concept osteoporosis service with patients only consulting a metabolic bone CNS and a consultant providing remote oversight. The aim of the project was to improve the efficiency of the service by eliminating consultant appointments and reducing unnecessary hospital visits whilst continuing to deliver a high-quality and safe service.

Methods:

A new pathway was implemented where a consultant rheumatologist and a CNS virtually triaged post menopausal women over the age of 65 into the service. A dedicated proforma provided the template for the CNS to undertake new patient telephone consultation. Relevant investigations were requested during the telephone clinic and treatment related information was despatched to help with shared decision making. All patients were then reviewed in a consultant-CNS virtual MDT. Appropriate parenteral treatment option was agreed and confirmed to each individual. The CNS worked through a safety checklist and provided further advice and support to the patient as necessary. Using the database, we compared the timelines for patient journey to conventional pathway, obtained the number of consultant follow-up appointments saved by implementing this service and calculated total savings.

Results:

In the proof-of-concept phase, 60 patients were triaged into the new service. It was a combination of 25 new referrals and 35 patients pulled from the consultants’ waiting list. Mean age of participants was 77.2 years (65-92). Referral to virtual triage took median 20 days (0-62). Median time for triage to new patient CNS telephone consultation was 18 days (6-87). Time to virtual MDT for treatment authorisation was median zero days (0-76 days). 19 patients had anabolic therapy commenced via home care. Remaining had anti resorptive therapy. No patient requested face-to-face review. Only one patient fed back that they would’ve preferred to see the consultant once. Sixty new patient consultant appointments were saved and median delay in treatment commencement was reduced from 84 to 38 days.

Conclusion:

To our knowledge, this is the first successful example of an innovative service wholly provided by CNSs for commencing parenteral anti-osteoporotic therapy with only remote consultant supervision. Our service redesign has significantly improved the efficiency of the parenteral osteoporosis pathway with reduction in treatment delay and a more streamlined patient journey. A nurse-delivered osteoporosis treatment pathway is highly effective, safe and provides an innovative solution to thinly stretched health care needs of people with chronic conditions.

Disclosure of Interests:

Julie Begum: None declared, Joanne Fourmy: None declared, Muhammad Khurram Nisar Grant/research support from: Muhammad Nisar undertakes clinical trials and received support (including attendance at conferences, speaker fees and honoraria) from Roche, Chugai, MSD, Abbvie, Pfizer, BMS, Celgene, Novartis and UCB

, Consultant of: Muhammad Nisar undertakes clinical trials and received support (including attendance at conferences, speaker fees and honoraria) from Roche, Chugai, MSD, Abbvie, Pfizer, BMS, Celgene, Novartis and UCB

, Speakers bureau: Muhammad Nisar undertakes clinical trials and received support (including attendance at conferences, speaker fees and honoraria) from Roche, Chugai, MSD, Abbvie, Pfizer, BMS, Celgene, Novartis and UCB

FRI0615-HPR CAN DEDICATED COMMUNITY HEALTH HUBS IMPROVE PHYSICAL ACTIVITY IN A MULTI-ETHNIC RHEUMATOLOGY PRACTICE?

Background:

Self care is an important management strategy for people with inflammatory arthritis (IA). Focused education should enable people to manage their life with IA and optimise their health and well-being. Several studies have shown positive effects of dedicated health programs on a range of patient reported outcomes such as self-efficacy, pain, fatigue, quality of life and overall well-being. However these benefits are only achievable and long lasting if people are provided with professional support to stay motivated and make appropriate adjustments to obtain better health.

Objectives:

The objective of our intervention was to assess the outcomes of a dedicated health education program delivered in a diverse community setting represented by minorities with poor educational and socio-economic background.

Methods:

We partnered with our local authority to establish a dedicated rheumatology community health hub for our patients with long term rheumatic conditions. Both clinical and paramedical staff in rheumatology clinics advertised the service and those who consented were referred. They were offered a 1:1 assessment with a health and well-being practitioner who would refer onwards based on the needs of the patient. In this pilot study we analysed the outcomes achieved at one year.

Results:

187 patients were referred to the service. 158 had IA and 29 had osteoporosis. 57 (30%) were White, 86 (46%) Asian, 26 (14%) Afro-Caribbean and 18 (10%) of other ethnicity. Mean age was 64 years (range 36-95). Interventions included weight management (10%), general health check (4%), dedicated exercise program (30%), physical activities (46%) and talking therapies (8%) and smoking cessation (2%). 100% responded to the contact and signed up for the intervention. 80% completed a minimum of 12 week intervention. 89% continued to attend physical activity at least once a week long term. Only five service users dropped out for varying reasons.

Conclusion:

Physical activity programs can be successful in a diverse community setting with patients from low socio-economic and educational classes. There is a need to engage these patients and offer professional support which can produce carry-over effects on physical outcomes and enhance patients’ long-term adherence to such programmes. Our study demonstrates that patient activation for self management and improved physical activity can be attained irrespective of patients’ backgrounds.

Disclosure of Interests:

Julie Begum: None declared, Muhammad Khurram Nisar Grant/research support from: Muhammad Nisar undertakes clinical trials and received support (including attendance at conferences, speaker fees and honoraria) from Roche, Chugai, MSD, Abbvie, Pfizer, BMS, Celgene, Novartis and UCB, Consultant of: Muhammad Nisar undertakes clinical trials and received support (including attendance at conferences, speaker fees and honoraria) from Roche, Chugai, MSD, Abbvie, Pfizer, BMS, Celgene, Novartis and UCB, Speakers bureau: Muhammad Nisar undertakes clinical trials and received support (including attendance at conferences, speaker fees and honoraria) from Roche, Chugai, MSD, Abbvie, Pfizer, BMS, Celgene, Novartis and UCB

AB1183 TERIPARATIDE SWITCH TO BIOSIMILAR - IS IT COST EFFECTIVE?

Background:

Teriparatide is an effective treatment option for osteoporosis however NICE restricts its use to patients with high disease burden. This was based on cost effectiveness evaluation of the originator (Forsteo®) and would be different for recently introduced generic preparation.

Objectives:

We wished to evaluate the current prescribing behaviour prior to a potential switch to generic version and associated cost savings.

Methods:

All patients prescribed Teriparatide since the commencement of specialist osteoporosis service in Aug 2014 at our University teaching hospital covering 350,000 population were included. Data was extracted from electronic database with full access to demographics, population characteristics, disease parameters and medication history.

Results:

113 patients were prescribed Teriparatide over five years. Mean age of participants was 76 yrs (53-96). They had on average three comorbidities (0-8) with most common being hypertension (n=44, 38.9%) and inflammatory arthritis (n=21, 18.5%). Sixteen (14.1%) individuals had concurrent corticosteroids. Median number of fractures prior to therapy were four (0-12). Prior treatments included oral therapy (n= 90,79.6%), IV zoledronate (n=22, 19.4%) and denosumab (n=19, 16.8%). 66 (58.4%) of patients only had one prior bone active medication. Mean duration of prior therapy was 62.4 months (9-192 months). 17 (15.0%) patients had chronic kidney disease with lowest eGFR of 38. 41 (36.2%) had Vit D level between 40-75 nmol/L. Median T score was -3.8 (-2.1 - -6.0) which improved to -3.4 (-2.9 - -3.9) after two years.

Conclusion:

Our real-world study shows that teriparatide is used predominantly in complex, multi-morbid older individuals with several prior fractures. Despite that teriparatide remains effective for a wide range of individuals including those with inflammatory arthritis and/or concurrent steroid use. Neither moderate CKD nor mild Vit D insufficiency seems to impact its efficacy. This is in line with recent meta-analysis of real life teriparatide use in complex osteoporosis with multimorbidity. Our study should enhance clinicians’ confidence in its prescribing. It’s notable that the use is higher than current estimates based on NICE cost effectiveness analysis for eligibility of teriparatide. Instead of annual predicted use of 4.8/100,000 population, it was prescribed to 6.4/100,000. This could potentially have a cost impact however the introduction of a generic version would mitigate against it. We calculated our savings to be over £125,000 if all patients were switched. These savings at national level would hopefully improve access to a wider patient cohort and perhaps allow earlier use in the treatment paradigm.

Disclosure of Interests:

Tahreem Akram: None declared, Maham Siddique: None declared, Hafiz A. Javed: None declared, Julie Begum: None declared, Joanne Fourmy: None declared, Muhammad Khurram Nisar Grant/research support from: Muhammad Nisar undertakes clinical trials and received support (including attendance at conferences, speaker fees and honoraria) from Roche, Chugai, MSD, Abbvie, Pfizer, BMS, Celgene, Novartis and UCB

, Consultant of: Muhammad Nisar undertakes clinical trials and received support (including attendance at conferences, speaker fees and honoraria) from Roche, Chugai, MSD, Abbvie, Pfizer, BMS, Celgene, Novartis and UCB

, Speakers bureau: Muhammad Nisar undertakes clinical trials and received support (including attendance at conferences, speaker fees and honoraria) from Roche, Chugai, MSD, Abbvie, Pfizer, BMS, Celgene, Novartis and UCB

THU0552 SWITCH TO BIOSIMILAR ADALIMUMAB - IS IT COST EFFECTIVE?

Background:

Since the introduction of anti-TNF biosimilars in routine clinical practice, there has been a drive to implement the switch program for all biosimilars at the point of availability. First adalimumab biosimilar was granted marketing authorisation by the EMA in March 2017. Our Trust was aligned to NHS England strategy which required adoption of biosimilar within three months for new patients and one year for switchers. This could help deliver significant savings to the NHS whilst achieving similar clinical outcomes.

Objectives:

We report our early experience of introducing adalimumab biosimilar (SB5).

Methods:

A list of all patients prescribed adlimumab was extracted through our database. A ‘switch’ letter was drafted and sent to all patients including Imraldi information sheet. Patients were given the opportunity to contact nurse helpline for information or if disease control worsened/adverse effects developed. We reviewed all relevant records and collected data on any adverse events and disease outcome on either side of the switch. Patients were reviewed as originally planned by their respective clinicians.

Results:

198 patients were identified established on adalimumab. All had switched by October 2019 to Imraldi. Mean age of switchers was 48 (range 16-83 years). Gender distribution was equal (99 each). 35 (17%) were Asian, two Afro-Caribbean, four other and the remaining 157 (80%) were White Caucasian. 54 (27%) had RA, 81 (41%) PsA, 57 (29%) AS and six had JIA. Coprescribed DMARDs included methotrexate (n=53, 27%), sulfasalazine (n=15, 7.5%), hydroxychloroquine (n=14, 7%) and leflunomide in two individuals. 83 (42%) participants were prescribed adalimumab monotherapy.

Prior to switch, median DAS28 for RA group was 2.28 (0.57 – 6.29). Median BASDAI and spinal VAS for AS cohort was 3.3 (0.8 – 8.8) and 3.0 (0 – 9) respectively. Tender and swollen joint components for PsARC were median three (0-8 tender, 0-6 swollen) in PsA group. Only 30% of the patients had been reviewed face-to-face following the switch. Their respective median disease activity indices were not significantly different from pre-switch assessments. Fifteen (7.5%) patients switched back to the originator for following reasons; injection site reaction (n=7), loss of disease control (n=7) and inability to use the new device (n=1).

Conclusion:

Our experience of switching adalimumab patients has been reasonably successful. All were happy to switch after receiving a letter and having the opportunity to contact if necessary. Substantial annual cost savings of over £300,000 have been projected for this financial year. At group level there were no major differences in disease outcomes and 90% reported no issues. However, just under 10% of those reviewed have decided to return to the originator within three months of switch with loss of efficacy and thereby confidence in the drug. We support the routine switching from originator to biosimilar adalimumab however close monitoring is required certainly in the first few weeks of dose administration.

Disclosure of Interests:

Julie Begum: None declared, Muhammad Khurram Nisar Grant/research support from: Muhammad Nisar undertakes clinical trials and received support (including attendance at conferences, speaker fees and honoraria) from Roche, Chugai, MSD, Abbvie, Pfizer, BMS, Celgene, Novartis and UCB

, Consultant of: Muhammad Nisar undertakes clinical trials and received support (including attendance at conferences, speaker fees and honoraria) from Roche, Chugai, MSD, Abbvie, Pfizer, BMS, Celgene, Novartis and UCB

, Speakers bureau: Muhammad Nisar undertakes clinical trials and received support (including attendance at conferences, speaker fees and honoraria) from Roche, Chugai, MSD, Abbvie, Pfizer, BMS, Celgene, Novartis and UCB

AB1357-HPR DESIGNING THE ROYAL COLLEGE OF NURSING COMPETENCY FRAMEWORK FOR RHEUMATOLOGY NURSES

Background:

The 1st Edition of the RCN Competency Framework for Rheumatology Nurse Specialists (RNS) will be published in March 2020. The role of the RNS is complex, and can include caring for children and young people. The importance of RNS’s was highlighted by the National Rheumatoid Arthritis Society (NRAS 2017). The British Society for Rheumatology (BSR) outlined the need for education, training supervision and work force development. Education for RNS isn’t currently centralized but is key to improving skills and developing workforce for the future. RNS are in short supply resulting in problems of access to services and delays in care (BSR 2019). In all 4 UK nations the titles of RNS and proficiency vary greatly (Titrate trial 2019) This is likely to have an impact on patient experience and outcomes. The European League Against Rheumatism (EULAR) developed recommendations for the role of the RNS which were recently updated (Beech et al, 2019). This framework maps all of these requirements.

Objectives:

This work supports the development of roles, improve access for patients and reduce. This document will act as a foundation for building sustainability and a more robust education and role development strategy. This work will strengthen rheumatology nursing and support all 4 UK nation’s issues regarding recruitment, retention, sustainability, succession planning and benchmarking. Dissemination is key and we will work hard with stakeholders to ensure centralization of a nationally adopted framework. This abstract submission will increase dissemination opportunities.

Methods:

Online data sources were searched for the most relevant and current evidence. Where research evidence wasn’t available, existing and new knowledge was utilised from a consensus of clinical expert and patient opinions, several rounds of discussions took place virtually and face to face. RCN Rheumatology Nurse Forum Workshop attendees in June 2019 also answered a questionnaire to elicit views and demographic information regarding roles.

Results:

The questionnaire results demonstrated 100% (n37) agreement with the development of the framework and that only 2 respondents had completed a competency process. 60% were RNS. Of these 52% (n13) were band 6, 47% (n9) were band 7, and 1% were band 8 consultant nurses. The questionnaire highlighted the need to develop the framework. Results were fed back to the working party to inform the domains to be included.

Conclusion:

Document will be at BSR 2020 having successfully submitted a session proposal and abstract. Evaluation will begin later in the year 6 to 12 months from launch. We will measure impact using a variety of methods including membership Facebook pages and the questionnaire at point of download request. We will measure where and how the competency is being used and adoption of the framework throughout the UK.

References:

[1]Beech B, Primdahl J, van Tubergen A, et al., (2019) 2019 update of the EULAR recommendations for the role of the nurse in the management of chronic inflammatory arthritis. Ann Rheum Dis.http://dx.doi.org/10.1136/annrheumdis-2019-215458 (accessed 13 December 2019). Benner, P (1984) From novice to expert, excellence

[2]British Society of Rheumatology (2019) State of Play, London: BSR. Available at: www. rheumatology.org.uk/Portals/0/Documents/ Policy/BSR_State_Of_Play_Scotland2018. pdf?ver=2019-03-11-094117-440 (accessed 13 December 2019).

[3]Martin N, Ibrahim F, Tom B, et al., (2017) Does intensive management improve remission rates in patients with intermediate rheumatoid arthritis? (the TITRATE trial): study protocol for a randomized controlled trial. Trials. 2017;18:591. doi.org/10.1186/s13063-017-2330-8.

Disclosure of Interests:

Polly Livermore: None declared, Diana Finney Speakers bureau: Nordic

Abbvie, Julie Begum: None declared, Ruth Wyllie: None declared, Trish Cornell Employee of: Consultant Nurse for Abbvie, Helen Smith: None declared, Lisa Howie: None declared, Louise Parker: None declared

Distinct fibroblast subsets drive inflammation and damage in arthritis

The identification of lymphocyte subsets with non-overlapping effector functions has been pivotal to the development of targeted therapies in immune-mediated inflammatory diseases (IMIDs)1,2. However, it remains unclear whether fibroblast subclasses with non-overlapping functions also exist and are responsible for the wide variety of tissue-driven processes observed in IMIDs, such as inflammation and damage3-5. Here we identify and describe the biology of distinct subsets of fibroblasts responsible for mediating either inflammation or tissue damage in arthritis. We show that deletion of fibroblast activation protein-α (FAPα)+ fibroblasts suppressed both inflammation and bone erosions in mouse models of resolving and persistent arthritis. Single-cell transcriptional analysis identified two distinct fibroblast subsets within the FAPα+ population: FAPα+THY1+ immune effector fibroblasts located in the synovial sub-lining, and FAPα+THY1- destructive fibroblasts restricted to the synovial lining layer. When adoptively transferred into the joint, FAPα+THY1- fibroblasts selectively mediate bone and cartilage damage with little effect on inflammation, whereas transfer of FAPα+ THY1+ fibroblasts resulted in a more severe and persistent inflammatory arthritis, with minimal effect on bone and cartilage. Our findings describing anatomically discrete, functionally distinct fibroblast subsets with non-overlapping functions have important implications for cell-based therapies aimed at modulating inflammation and tissue damage.

Dynamics of antibiotic resistance with special reference to Shiga toxin-producing Escherichia coli infections

The discovery of antibiotics was paralleled by the evolution of antibiotic resistance which is probably the best example of contemporary evolution in action. The selection pressure, imposed by indiscriminate use of antibiotics, has changed the scale, mode and tempo of antibiotic resistance evolution. The presence of multidrug resistance, wide range of adaptability features and the infectivity make antibiotic resistance of Shiga toxin-producing Escherichia coli (STEC) more dangerous. The characterization, prevalence and the virulence factors of STEC have been profusely reported, whereas, the antibiotic resistance has been largely ignored because the antibiotic use in STEC infections is controversial. Thus, the current review has focussed on the source, evolution, persistence, mechanism, dissemination and control of antibiotic resistance viz-a-viz the STEC infections. The resistance development occurs by the inactivation of antibiotics, regulating the membrane permeability, modification of natural antibiotic targets or the use of efflux pumps against antibiotics. And, the dissemination of resistance genes occurs vertically by DNA replication and horizontally by conjugation, transduction and transformation. The prevention of development and dissemination of antibiotic resistance needs international public health bodies to rationalize the antibiotic use, prevent the flux of antibiotics into the environment, develop the rapid diagnostics tests, undertake proper surveillance of antibiotic resistance, promote the research on antibiotic resistance prevention, promote the research and development of novel alternative antibiotics, and encourage the widespread social awareness campaigns against the inappropriate antibiotic usage.

External Diameter of Vermiform Appendix in Bangladeshi People of Different Age & Sex

This cross sectional descriptive study was performed on 70 postmortem vermiform appendix (male 34 and female 36) to find out the external diameter of vermiform appendix of Bangladeshi people in different age and sex. The specimens were collected from autopsy laboratory of the Department of Forensic Medicine, Mymensingh Medical College, Mymensingh, Bangladesh from October 2016 to March 2017 by purposive sampling technique. The collected samples were divided into four age groups. They were Group A (upto 20 years), Group B (21 to 40 years), Group C (41 to 60 years) and Group D (above 60 years). Dissection was performed according to standard autopsy techniques. The vermiform appendix was collected and preserved in 10% formol-saline solution. The external diameter of vermiform appendix was measured with the help of digital slide calipers. Three measurements were taken at its base, middle and near the tip (1cm away from the tip) and expressed in mm. The data were analyzed by using student unpaired 't' test and compaired with the findings of other national and international studies and standard text books. It was observed that external diameter of vermiform appendix gradually decreased as age advanced. The mean±SD external diameter of vermiform appendix at base was 6.50±0.82 mm, 6.22±0.60 mm, 6.00±0.51 mm and 5.51±0.57 mm in Group A, B, C & D respectively. The mean±SD external diameter of vermiform appendix at middle was 6.09±0.89 mm, 5.67±0.65 mm, 5.38±0.59 mm and 4.95±0.76 mm in Group A, B, C and D respectively. The mean±SD external diameter of vermiform appendix near the tip (1 cm away from the tip) was 5.73±0.88 mm, 5.21±0.72 mm, 4.81±0.74 mm and 4.34±0.74 mm in Group A, B, C and D respectively. Statistical analysis shows that the mean differences of external diameter of vermiform appendix at its base between Group A&D, B&D were statistically moderately significant at p<0.01 level. Between Group C&D was statistically significant at p<0.05 level and between Group A&B, B&C, A&C were statistically non significant at p = or >0.05 level. Mean differences of external diameter of vermiform appendix at its middle between Group A&D, B&D were statistically moderately significant at p<0.01 level. Between Group A&C was statistically significant at p<0.05 level and between Group A&B, B&C, C&D were statistically non significant at p = or >0.05 level. Mean differences of external diameter of vermiform appendix near its tip (1 cm away from the tip) between Group A&D was statistically highly significant at p<0.001 and mean differences between Group B&D, A&C were statistically moderately significant at p<0.01 level. Between Group A&B was statistically significant at p<0.05 level and between Group B&C, C&D were statistically non significant at p = or >0.05 level. Mean external diameter of vermiform appendix in male was higher than that of female in all age group at its base, middle and near the tip (1cm away from the tip) but mean difference between sexes in the different study groups was statistically non significant at p = or >0.05 level. The present study will help to increase the information pool on the external diameter of vermiform appendix of Bangladeshi people.

Cyclin D mediates tolerance of genome-doubling in cancers with functional p53

Background

Aneuploidy and chromosomal instability (CIN) are common features of human malignancy that fuel genetic heterogeneity. Although tolerance to tetraploidization, an intermediate state that further exacerbates CIN, is frequently mediated by TP53 dysfunction, we find that some genome-doubled tumours retain wild-type TP53. We sought to understand how tetraploid cells with a functional p53/p21-axis tolerate genome-doubling events.

Methods

We performed quantitative proteomics in a diploid/tetraploid pair within a system of multiple independently derived TP53 wild-type tetraploid clones arising spontaneously from a diploid progenitor. We characterized adapted and acute tetraploidization in a variety of flow cytometry and biochemical assays and tested our findings against human tumours through bioinformatics analysis of the TCGA dataset.

Results

Cyclin D1 was found to be specifically overexpressed in early but not late passage tetraploid clones, and this overexpression was sufficient to promote tolerance to spontaneous and pharmacologically induced tetraploidy. We provide evidence that this role extends to D-type cyclins and their overexpression confers specific proliferative advantage to tetraploid cells. We demonstrate that tetraploid clones exhibit elevated levels of functional p53 and p21 but override the p53/p21 checkpoint by elevated expression of cyclin D1, via a stoichiometry-dependent and CDK activity-independent mechanism. Tetraploid cells do not exhibit increased sensitivity to abemaciclib, suggesting that cyclin D-overexpressing tumours might not be specifically amenable to treatment with CDK4/6 inhibitors.

Conclusions

Our study suggests that D-type cyclin overexpression is an acute event, permissive for rapid adaptation to a genome-doubled state in TP53 wild-type tumours and that its overexpression is dispensable in later stages of tumour progression.

Anti-inflammatory effect of dikaempferol rhamnopyranoside, a diflavonoid from Eugenia jambolana Lam. Leaves

Traditionally, the Indian Blackberry or locally called Jamun, Eugenia jambolana Lam. (Syn.: Syzygium cumini), is well known for its pharmacological potential, particularly anti-inflammatory. Here, we studied kaempferol-7-O-α-L-rhamnopyranoside]-4'-O-4'- [kaempferol-7-O-α-L-rhamnopyranoside (EJ-01) isolated from the E. jambolana leaves for possible anti-inflammatory activity. EJ-01 (3, 10 and 30 mg/kg, p.o.) was assessed for anti-inflammatory activity using carrageenan-induced paw edema model in mice by determining edema volume, myeloperoxidase (MPO), nitrite plus nitrate (NOx) and cytokine levels in paw edema tissue. EJ-01 significantly attenuated the edema, MPO levels, tumor necrosis factor-alpha (TNF-α) and interleukin-1beta (IL-1β) levels in the edema of paw at the 5th hour after carrageenan injection at all doses. EJ-01 (30 mg/kg) decreased the nitric oxide (NO) levels of the edema of paw at the 5th hour after carrageenan injection. The anti-inflammatory mechanisms of EJ-01 might be related to the decrease in the level of edema paw by reduced activities of NO and MPO. It probably exerts anti-inflammatory effects through the suppression of TNF-α and IL-1β. Therefore, we conclude that EJ-01 could be positively exploited for itspotential benefits against inflammatory diseases and support the pharmacological basis of E. jambolana as traditional herbal medicine for the treatment of inflammatory diseases.

Neu-Laxova syndrome: a case report

Neu-Laxova syndrome (NLS) is a rare lethal syndrome found in both consanguinous and non-consanguinous couple. This is characterized by terrible face with unusual craniofacial appearance with exophthalmos, spectrum of central nervous system malformation, like microcaphaly, hypoplastic cerebellum, cleft lip/palate, ichthyosis and oedema. The diagnosis is made on the basis of clinical parameter. We report a 4 hour old male term newborn with IUGR of Neu-Laxova syndrome presented with anencephaly, rudimentary cerebellum, exophthalmos of right eye, bilateral cleft lip and palate and cryptorchidism. Anencephaly and cryptorchidism are two recently reported findings of NLS. We are presenting this case in addition from Bangladesh to lend further support to those two new findings as component of Neu-Laxova syndrome. Outcome of this syndrome is not good. Most of the patients are died of infection within hours to days.

Histomorphological study of lymphoid follicle of vermiform appendix

The study was done to find out the number of lymphoid follicle of vermiform appendix in Bangladeshi people and to increase the knowledge regarding variational anatomy in our population. Total 40 fresh appendixes were collected for histological study of different age and sex during postmortem examination in the autopsy laboratory of Forensic department of Mymensingh Medical College. This cross sectional descriptive study was done by convenient sampling technique. For convenience of differentiating the number of lymphoid follicle of vermiform appendix in relation to age and sex, findings were classified in four groups, up to 20 years, 21 to 35 years, 36 to 55 years and 56 to 70 years. In the present study the number of lymphoid follicle were highest in group A, mean were (5.40+/-1.30) and lowest in group D where mean were (1.05+/-0.35). In male mean were 3.16 and in female mean were 2.86. Diameter of the lymphoid follicle in group A was highest (40.14+/-2.66) and lowest in group D (0.24+/-1.35). Number of germinal centre are highest in group B (2.20 +/- 0.45) and lowest in group D (0.00 +/- 0.00).

Neonatal tetanus in rural Bangladesh: risk factors and toxoid efficacy

OBJECTIVES

Tetanus continues to be a leading cause of neonatal death in Bangladesh as in other developing countries, yet little is known about risk factors or the efficacy of tetanus toxoid in this setting.

METHODS

In May 1990, mothers of 6148 infants born alive between March 15, 1989, and March 14, 1990, in 30 rural unions of Rajshahi Division in Bangladesh were interviewed. Three surviving controls for each neonatal tetanus death were matched for sex, residence, and date of birth.

RESULTS

Of 330 neonatal deaths, 112 met the case definition for tetanus. Risk was increased with a history of neonatal tetanus in a previous child, application of coconut oil to the vagina, and use of multiple ties on the umbilical cord. Risk was reduced by the birth attendant washing hands and using a cleaned cord-cutting tool. Risk was not reduced by a maternal history of two doses of tetanus toxoid (TT2), although estimated efficacy of TT2 was 45% (95% confidence interval = 16% to 64%). Subsequent to the survey, a reference laboratory reported to potency in three consecutive lots of tetanus vaccine from the production laboratory in Bangladesh.

CONCLUSIONS

These findings identify high-risk mothers, stress the importance of washing hands and cleaning the cord-cutting tool, and demand improved quality control of tetanus vaccine production.

High vaginal swab(HVS), routine microscopy and culture sensitivity in diabetic and non diabetic, a comparative retrospective study of five years

Diabetic women are significantly more prone to develop vaginitis (both bacterial and fungal) than non diabetic. Among the positive cases predominant bacterial isolate being E. Coli. All fungus positive culture yielded the growth of candida species. Direct wet film preparation of the fungus positive cases revealed only 30% were positive for fungus, thus if candida vaginitis is suspected, the diagnosis cannot be ruled out on the basis of negative direct preparation. More over, diabetics should be advised maintain proper glycaemic control and personal hygiene to get rid of this distressing problem.

A study on the prevalence of tuberculosis in a rural community of Bangladesh

The population of two villages of Chagalnaiya Upazila was selected for a study on the prevalence of pulmonary tuberculosis through a two stage screening process. Initial screening was conducted on 3406 persons which is 78% of the total population (3920) of the two villages. The initial screening revealed 182 persons with the history of cough lasting 4 weeks or more, chest pain, continuous fever and haemoptysis. Sputum examinations for Acid Fast Bacilli (AFB) of tuberculosis detected 21 sputum positive cases giving a prevalence rate of 6.2 (per 1000 population) higher than the estimated national average of 5.0 per 1000. Most of the cases were not receiving treatment. Some social and environmental factors of suspected and detected cases were also studied.

Assessment of a mobile training programme on nutrition for Bangladesh rural development board (BRDB) women's programme in Bangladesh

About half of the total population of the country are women and without their active participation no development programme can be achieved. This study involved a total number of 690 trainees from 23 upazilas of different districts in Bangladesh. The results obtained from both pre and post tests were compared and analyzed to find out the impact of the mobile training programme on nutrition. The mean age of the trainees was 29.54. The mean number of children per trainee was 3.73 and the mean income was close to Taka 1048.26. Analysis of the results regarding knowledge of the training about nutrition at pre and post training stages reveal that at post training stage they were more aware of the importance of nutrition. The difference in knowledge level at pre and post training stages was statistically significant (P less than .001).