POS0744 SYSTEMIC LUPUS ERYTHEMATOSUS WITH ACTIVE MUSCULOSKELETAL SYMPTOMS: PATIENT REPORTED SYMPTOM IMPACT, TREATMENT PATTERNS AND SATISFACTION WITH CURRENT THERAPY OPTIONS

Background

Musculoskeletal (MSK) symptoms affect 50-95% of patients with SLE over their disease course negatively impacting functioning, and quality of life (QoL).1 In SLE-UPDATE, a US, cross-sectional, non-interventional online survey of adults with SLE, over half of the participants reported active MSK symptoms, including pain or swelling in the joints (53%) and stiffness (57%).2 The present study evaluated the sub-group of participants with ‘currently active’ MSK symptoms.

Objectives

To describe the self-reported disease burden, treatment patterns, and satisfaction with therapies in patients with SLE, comparing those with versus without active MSK symptoms.

Methods

This secondary analysis of SLE-UPDATE survey data stratified participants into active or non-active MSK group. Participants currently experiencing pain or swelling and/or stiffness in their joints and had a Joint Pain NRS > 4 were in the “active MSK group”. All remaining participants were in the “non-active MSK group”. Analysis comprised descriptive statistics, mean (standard deviation [SD]) for continuous variables, and frequency (percentage [%]) for categorical variables. Two-sample t-test to compare mean scores and chi-squared testing to compare proportions were used.

Results

Of the survey participants, 285 were in the active MSK group and 215 in the non-active MSK group. The active MSK group was older (44.3 vs. 40.2 years, <0.001) and had a longer time since diagnosis (12.6 vs. 9.2 years, <0.001). More people in the MSK group had fibromyalgia (FM) (45 vs 12%, <0.0001), worse pain, fatigue, and QoL (Table 1) suggestive of Type 2 non-inflammatory SLE symptoms. Fewer in the MSK group were employed full-time (36.5 vs. 62.8%) and more were on permanent disability (27.0 vs. 6.5%). More participants in the active MSK group negatively assessed their general health (fair or poor) over the last month (53.4 vs. 20.4%). The active MSK group self-reported more “flares” over the prior 3 months; with 44.9 vs 41.9% reporting 1-3 flares, 15.1 vs 5.1% reporting 4-6 flares, and 8.1 vs 2.3% reporting > 7 flares.

Table 1.

Patient Reported Outcomes

Active MSKNon-Active MSKFMNon-FMFMNon-FMN=129N=156N=26N=189Worst Pain NRS, Mean (SD)6.5 (1.7)*4.8 (2.6)6.9 (1.6)*6.2 (1.8)4.0 (2.2)4.9 (2.6)~Worst Joint Pain NRS, Mean (SD)6.7 (1.7)*4.5 (2.6)7.1 (1.6)*6.5 (1.6)3.5 (2.0)4.6 (2.6)*FACIT Fatigue Score, Mean (SD)19.1 (10.8)*28.1 (11.6)15.4 (9.5)*22.1 (10.9)25.7 (13.8)28.4 (11.3)~LupusPRO HRQoL Score (SD)48.9 (20.2)*64.1 (23.0)45.5 (18.1)*51.7 (21.4)63.0 (23.9)64.3 (22.9)~

NRS: 0 (none)-10 (worst imaginable); FACIT Fatigue: 0-52, higher= less fatigue; LupusPRO: 0-100, higher= better QoL; *p < 0.05; ~ Not significant

The active MSK group used more anti-malarials (50.9 vs. 30.7%), immunosuppressants (37.2 vs. 26.5%), including methotrexate (12.6 vs 3.3%), narcotic analgesics (18.6 vs. 10.2%), and topicals for joint pain (30.5 vs. 10.2%). Interestingly, treatment goals of greatest importance in both groups were reduction in fatigue and pain, but pain reduction had higher importance in active MSK group (rated very important by 26.7 vs. 18.1%). Lower proportions in the active MSK group were satisfied with steroids (58.0 vs. 77.8% <0.01), immunosuppressants (65.1 vs. 80.7% <0.05), methotrexate (47.2 vs. 85.7% =0.061), and belimumab (80 vs. 95.5%=0.102).

Conclusion

Reduction of pain and fatigue was the main treatment goal of patients with SLE whether they had active or non-active MSK symptoms. Patients with active MSK symptoms had higher pain and fatigue, lower QoL, and less satisfaction with current therapies compared to SLE patients without active MSK symptoms, driven only in part by co-morbid FM. Findings from these analyses suggest there are unmet needs to better understand MSK manifestations, their overlap with Type 2 SLE symptoms, align patient/physician priorities, and improve therapies for MSK symptoms for patients with SLE.

References

[1]Mahmoud K. Curr Opin Rheumatol 2017;29:486-492

[2]Birt J. Rheum Ther 2021;8:1189-1205

Acknowledgements

The authors would like to thank the Lupus Foundation of America for their support with the design of the survey.

Disclosure of Interests

Diane L Kamen: None declared, Julie Birt Shareholder of: Shareholder of Eli Lilly & Company, Employee of: Employee of Eli Lilly & Company, Monica Hadi Grant/research support from: Evidera received funding to conduct this research, Elizabeth Gibbons Grant/research support from: Evidera received funding to conduct this research, Don Bushnell Grant/research support from: Evidera has received funding for the conduct of this research, Ren Yu Grant/research support from: Evidera has received funding to conduct this research, Laure Delbecque Shareholder of: Shareholder of Eli Lilly, Employee of: Employee of Eli Lilly, Kirstin Griffing Shareholder of: Eli Lilly & Company shareholder, Employee of: Eli Lilly & Company paid employee, Anca Askanase Grant/research support from: Investigator for GSK, AZ, Pfizer, Idorsia, Eli Lilly

Role of zeolite content in Ni-Mo/β-USY zeolite catalyst on hydrocracking of n-hexadecane and vacuum gas oil in a batch reactor and a fixed-bed reactor

In this paper, different materials that involved amorphous silica–alumina and hydrothermally synthesized beta zeolite and treated Y zeolite (USY) were introduced as parts of the hydrocracking catalyst supports. The prepared supports were used for preparation of Ni-Mo/silica alumina–zeolite catalysts by wetness impregnation method. The prepared catalysts were characterized by BET, temperature programmed desorption (TPD), temperature programmed reduction (TPR), and field emission – scanning electron microscopy (FE–SEM) methods. Effect of zeolite type and content on hydrocracking of n-hexadecane and vacuum gas oil in a batch and a fixed-bed reactor was investigated. Also, the content of coke formed after reaction was measured by thermal gravimetric methods (TGA). Hydrocracking was done at 400 °C and 55 bar. The hydrocracking of vacuum gas oil results showed that in the Ni-Mo/10B-30USY catalyst containing higher USY zeolite with high total acidity, selectivity to middle distillate was higher than the other (90%). Moreover, the Ni-Mo/10B-30USY catalyst in hydrocracking of n-hexadecane had a higher yield (82%) and was more selective to heavier products (C9–C12). The findings indicated that in the Ni-Mo/10B-30USY catalyst, coke content was more than the other due to high acidity.

Determination of parasitic burden in the brain tissue of infected mice in acute toxoplasmosis after treatment by fluconazole combined with sulfadiazine and pyrimethamine

BACKGROUND/AIMS

One of the opportunistic pathogens which cause serious problems in the human immune system is Toxoplasma gondii, with toxoplasma encephalitis (TE) seen in patients affected by it. The treatment of these patients is limited, and if not treated on time, death will be possible.

METHODS

In this study, the effects of the treatment with different doses of fluconazole (FLZ) in combination with the current treatment of acute toxoplasmosis on reducing the mortality rate and the parasitic load in the murine model in vivo were studied. The mice were treated with different doses of fluconazole alone, sulfadiazine, and pyrimethamine plus fluconazole. A day after the end of the treatment and 1 day before death, the mice's brains were collected, and after DNA extraction and molecular tests, the parasite burden was detected.

RESULTS

This study showed that a 10-day treatment with 20 mg/kg of fluconazole combined with sulfadiazine and pyrimethamine 1.40 mg/kg per day affected acute toxoplasmosis and reduced the parasitic load significantly in brain tissues and also increased the survival rate of all mice in this group until the last day of the study, in contrast to other treatment groups. These results also indicate the positive effects of combined therapy on Toxoplasma gondii and the prevention of relapse.

CONCLUSIONS

Reducing the parasitic burden and increasing the survival rate were more effective against acute toxoplasmosis in the combined treatment of different doses of fluconazole with current treatments than current treatments without fluconazole. In other words, combination therapy with fluconazole plus pyrimethamine reduced the parasitic burden in the brain significantly, so it could be a replacement therapy in patients with intolerance sulfadiazine.

THU0253 FATIGUE AND PAIN REMAIN PROMINENT AND IMPACTFUL IN PATIENTS WITH SYSTEMIC LUPUS ERYTHEMATOSUS (SLE): A CROSS-SECTIONAL SURVEY OF SLE PATIENTS IN THE UNITED STATES

Background:

Systemic lupus erythematosus (SLE) is a chronic autoimmune inflammatory condition impacting multiple organ systems.1,2SLE affects approximately 1.5 million Americans, disproportionately females of reproductive age, and is more prevalent in non-Caucasian populations.3Fatigue and pain are some of the most prominent symptoms of SLE, contributing to the heavy disease burden and disruption to daily life.4This study aimed to further understand the burden of SLE. Lilly worked with the Lupus Foundation of America (LFA) and Evidera to develop the SLE-UPDATE (Understanding Preferences, Disease Activity and Treatment Expectations) survey.

Objectives:

To understand the patient-perceived symptom burden of SLE, in particular pain and fatigue, within the current landscape of therapeutic options. This study also focused on current treatment patterns in SLE patients.

Methods:

This was a cross-sectional, non-interventional, online survey study conducted in partnership with the LFA. English-speaking United States patients aged ≥18 years with a self-reported diagnosis of SLE completed the survey following online screening and informed consent. Descriptive data are presented by means (standard deviation [SD]) for continuous measures, and frequency (n, %) for dichotomous measures. Demographic, clinical, and patient-reported outcomes were collected including the FACIT-Fatigue (range 0-52, higher scores indicate less fatigue), Pain Numerical Rating Scale (NRS) (0 [none] to 10 [worst imaginable]), Worst Joint Pain NRS (0 [none] to 10 [worst imaginable]), and the LupusPRO, a validated, lupus-specific quality of life (QoL) instrument (range 0-100, higher scores indicate better QoL).

Results:

A total of 500 patients with SLE completed the survey. Patients were predominantly female (75%), white/Caucasian (76%), with a mean age of 42.6 years and mean disease duration of 11.1 years.

Most patients with SLE rated their overall condition as either good (38%) or fair (31%), with 8% rating poor and 7% excellent. Current non-biologic prescription medication use included: antimalarials 42%, corticosteroids 33%, immunosuppressants 33%, nonsteroidal anti-inflammatory drugs (NSAID) 32%, other analgesics 15% and 10% were using tofacitinib. Biologic therapies were being used by only 19%, including intravenous (IV) Benlysta (37%),subcutaneous(SC) Benlysta (25%), rituximab (17%), and 22% were using other biologics. Fatigue was the most commonly reported symptom (69%), with 40% of patients ranking fatigue as their most bothersome SLE symptom. Forty eight percent of patients with current fatigue rated the severity as moderate and 33% as severe. The mean (SD) FACIT-Fatigue score was 22.9 (12.0). The next most commonly reported symptoms were joint stiffness (57%), sleep problems (55%), joint pain/swelling (53%), and muscle pain (52%). Sixty percent of patients reported experiencing pain all or most of the time over the past seven days. A total of 30% of patients with current joint pain/swelling rated it as severe, and 24% of patients with current joint stiffness rated it as severe. The mean scores for Worst pain NRS and Worst Joint Pain NRS were both 5.8 out of 10.

The LupusPRO domains indicated by respondents as the most impacted by SLE were Emotional Health, Pain/Vitality, and Lupus Medications.

Conclusion:

Fatigue, followed by pain and joint stiffness, were the most common patient-reported symptoms contributing to the overall SLE disease burden. Further research could highlight the efforts required to address the inadequacies in treatment and management of pain and fatigue in this patient population.

Disclosure of Interests:

Julie Birt Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company, Monica Hadi: None declared, Nashmel Sargalo: None declared, Ella Brookes: None declared, Paul Swinburn: None declared, Leslie Hanrahan: None declared, Karin Tse: None declared, Natalia Bello Vega Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company, Kirstin Griffing Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company, Maria Silk Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company, Laure Delbecque Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company, Diane L Kamen Consultant of: Consulted on SLE survey development for Lilly and consulted on SLE trial protocol development for EMD Serono in 2019

A utility valuation study assessing the impact of postprandial glucose control on quality of life of individuals with type 1 or type 2 diabetes

Background

Consideration of health-related quality of life (HRQOL) in diabetes has been associated with long-term and short-term complications such as hypoglycaemia, but not with short-term glucose control. This study aimed to collect health utilities related to different degrees of poorly controlled postprandial glucose (PPG) and its impact on HRQOL in the UK and in Sweden.

Methods

Three health state descriptions were developed based on literature reviews and interviews with people with diabetes and healthcare professionals, characterising mild, moderate and severe impact of postprandial hyperglycaemic symptoms on HRQOL. Time Trade-Off (TTO) interviews with a 10-year trade-off period were conducted with samples of the UK general public and of Swedish people with diabetes. Mean TTO-derived health state values were expressed on a scale from 0 (death) to 1 (full health).

Results

One hundred fifty participants from the general population were interviewed in the UK (57% female, mean age 35 years) and 150 participants with diabetes in Sweden (64% female, mean age 51 years, 42% type 1 and 58% type 2 diabetes). The mean TTO-derived health state values were for the UK and Swedish participants: mild impact of poorly PPG control (0.89/0.76); moderate (0.75/0.71); severe (0.56/0.58).

Conclusions

Glucose lowering treatments associated with improved control over PPG levels could have important benefits to people with type 1 and type 2 diabetes since findings suggest that increasing severity in postprandial hyperglycaemic symptoms is perceived as having significant negative impact on HRQOL of individuals with type 1 or type 2 diabetes.

Staff and relatives' perspectives on the aggressive behaviour of older people with dementia in residential care: a qualitative study

Staff and relative perspectives on patient aggression in dementia care units are seriously under researched in the U.K. Any work that has been conducted has relied upon quantitative studies. Qualitative research on aggression management in older peoples services are rare. In-depth views that can offer insights into causation and management strategies are therefore under represented in the literature. In order to investigate this issue further we interviewed a number of nursing staff and relatives in four U.K. care homes in the North West of England. Using a combined approach of one-to-one interviews (for staff) and focus groups (for relatives) we explored their views as to the reasons for and ways of responding to aggressive behaviour. This was part of a larger study reported upon elsewhere. Using thematic analysis we found similar results from both staff and relatives and as such their views were categorized into two broad areas: causation and management. In regards to causation we noted three sub-themes; internal, external and interpersonal factors which are further subdivided in the paper and for management two broad categories: the compassionate approach and 'don't go in strong'. The results indicated that staff in the participating units embraced a person-centred approach to aggression management. They predominantly respond to aggressive incidents with interpersonal strategies, such as distraction as opposed to medication or restraint. Overall they adopt a person centre approach to patient care. Relatives were clear in their perceptions of aggression as an interpersonal challenge, which is compounded or mediated by the illness of dementia. Consequently they were positive in their views of staff using non-coercive interventions. While the results of this and our earlier study are promising suggesting a less invasive approach to this aspect of dementia care, given the limitations of a small sample, more research of a similar nature is warranted. Findings from multidimensional studies can then provide a sounder basis for health and social care education, and person centred informed practice to reduce the incidence of aggression through preventative strategies.

Compliance and use of the World Health Organization checklist in UK operating theatres

Background

The World Health Organization (WHO) Surgical Safety Checklist is reported to reduce surgical morbidity and mortality, and is mandatory in the UK National Health Service. Hospital audit data show high compliance rates, but direct observation suggests that actual performance may be suboptimal.

Methods

For each observed operation, WHO time-out and sign-out attempts were recorded, and the quality of the time-out was evaluated using three measures: all information points communicated, all personnel present and active participation.

Results

Observation of WHO checklist performance was conducted for 294 operations, in five hospitals and four surgical specialties. Time-out was attempted in 257 operations (87·4 per cent) and sign-out in 26 (8·8 per cent). Within time-out, all information was communicated in 141 (54·9 per cent), the whole team was present in 199 (77·4 per cent) and active participation was observed in 187 (72·8 per cent) operations. Surgical specialty did not affect time-out or sign-out attempt frequency (P = 0·453). Time-out attempt frequency (range 42–100 per cent) as well as all information communicated (15–83 per cent), all team present (35–90 per cent) and active participation (15–93 per cent) varied between hospitals (P &lt; 0·001 for all).

Conclusion

Meaningful compliance with the WHO Surgical Safety Checklist is much lower than indicated by administrative data. Sign-out compliance is generally poor, suggesting incompatibility with normal theatre work practices. There is variation between hospitals, but consistency across studied specialties, suggesting a need to address organizational culture issues.

Not the typical Tornwaldt's cyst this time? A nasopharyngeal cyst associated with canalis basilaris medianus

We report a patient with a cystic structure in the nasopharynx mimicking a Tornwaldt's cyst, which was felt to represent a different entity owing to the lack of the distinct features of a typical Tornwaldt's cyst. It was associated with a bony cleft in the basiocciput that was considered to be a canalis basilaris medianus (CBM), thought to represent an embryological vestige of the cephalic end of the notochord along its course within the basiocciput.

A survey of staff attitudes and responses to people with dementia who are aggressive in residential care settings

Aggression is reportedly common among older people with dementia in residential care. The attitudes of staff in care homes and strategies they use are under researched. Theoretical models that may be used to both understand and respond to such behaviour exist. They are the standard and person-centred paradigms. The aim of this study was to explore the views of nursing staff about aggressive behaviour in people with dementia and strategies used in practice. A survey of the attitudes of staff in six dementia care units using the Management of Aggression in People with Dementia Attitude Questionnaire was conducted including an audit of aggressive incidents using the Staff Observation Aggression Scale-Revised over a 3-month period. Staff expressed views reflective of a person-centred as opposed to standard paradigm. They viewed aggressive behaviour by people with dementia as deriving from the environment, situation or interactions with others. Participants strongly supported interpersonal means of responding to aggression, the moderate use of medication, and were largely opposed to physical restraint. Aggressive incidents were managed using less intrusive strategies such as distraction and de-escalation. Responses to aggressive behaviour, while pragmatic, were largely underpinned by a person-centred ethic as reflected in the attitudes expressed by staff.

Has fine-needle aspiration biopsy changed thyroid practice?

OBJECTIVE

To assess the influence of fine-needle aspiration (FNA) biopsy on the management of nodular thyroid disease.

METHODS

We retrospectively evaluated the effect of the availability of FNA biopsy on thyroid surgical practice at our institution by comparing the data for two study periods--1975-1976 (before the introduction of FNA) and 1985-1986 (5 years after its introduction).

RESULTS

The study inclusion criteria were fulfilled by 1,451 patients. In 1975-1976, 938 patients had thyroid operations at our institution. FNA biopsy was introduced into our practice in 1980. In 1985-1986, 513 patients underwent a thyroid surgical procedure. Before the FNA era, the frequency of carcinoma in patients selected for thyroidectomy was 18%, whereas after FNA became available, it increased to 25% (P< 0.0001). When patients were selected for surgical treatment because of either "suspicious" or malignant cytologic results, the yield of carcinoma increased to 40%.

CONCLUSION

These data suggest that FNA biopsy has improved selectivity for operation in patients with nodular thyroid disease and has reduced the number of patients who undergo thyroidectomy for benign disease. The result is an increasing yield of malignant lesions found at surgical intervention. FNA biopsy has had a substantial cost-saving effect on thyroid practice.

Y receptor-mediated induction of CD63 transcripts, a tetraspanin determined to be necessary for differentiation of the intestinal epithelial cell line, hBRIE 380i cells

Peptide YY (PYY) and neuropeptide Y (NPY) are peptides that coordinate intestinal activities in response to luminal and neuronal signals. In this study, using the rat hybrid small intestinal epithelial cell line, hBRIE 380i cells, we demonstrated that PYY- and NPY-induced rearrangement of actin filaments may be in part through a Y1alpha and/or a nonneuronal Y2 receptor, which were cloned from both the intestinal mucosa and the hBRIE 380i cells. A number of PYY/NPY-responsive genes were also identified by subtractive hybridization of the hBRIE 380i cells in the presence or absence of a 6-h treatment with PYY. Several of these genes coded for proteins associated with the cell cytoskeleton or extracellular matrix. One of these proteins was the transmembrane-4 superfamily protein CD63, previously shown to associate with beta(1)-integrin and implicated in cell adhesion. CD63 immunoreactivity, using antibody to the extracellular domain, was highest in the differentiated cell clusters of the hBRIE 380i cells. The hBRIE 380i cells transfected with antisense CD63 cDNA lost these differentiated clusters. These studies suggest a new role for NPY and PYY in modulating differentiation through cytoskeletal associated proteins.

[Cerebral miliary granulomatosis with Histoplasma capsulatum in an HIV seronegative patient]

A 51 year old patient who worked in Africa for eight years, presented twelve years later a progressive ataxia associated with headaches. Neuroimaging studies done after a partial complex seizure demonstrated multiple supra and sub-tentorial cortical ring enhancing lesions. Histoplasma capsulatum histoplasmosis was found on histological examination of brain biopsy and confirmed by isolation of the fungus. Medical treatment with intravenous amphotericin B followed by oral itraconazole (400 mg per day) improved both clinical and radiological status. This observation of cerebral histoplasmosis is rather unusual for a seronegative HIV patient in a non endemic area.

Molybdate binding by ModA, the periplasmic component of the Escherichia coli mod molybdate transport system

ModA, the periplasmic-binding protein of the Escherichia coli mod transport system was overexpressed and purified. Binding of molybdate and tungstate to ModA was found to modify the UV absorption and fluorescence emission spectra of the protein. Titration of these changes showed that ModA binds molybdate and tungstate in a 1:1 molar ratio. ModA showed an intrinsic fluorescence emission spectrum attributable to its three tryptophanyl residues. Molybdate binding caused a conformational change in the protein characterized by: (i) a shift of tryptophanyl groups to a more hydrophobic environment; (ii) a quenching (at pH 5.0) or enhancement (at pH 7.8) of fluorescence; and (iii) a higher availability of tryptophanyl groups to the polar quencher acrylamide. The tight binding of molybdate did not allow an accurate estimation of the binding constants by these indirect methods. An isotopic binding method with 99MoO42- was used for accurate determination of KD (20 nM) and stoichiometry (1:1 molar ratio). ModA bound tungstate with approximately the same affinity, but did not bind sulfate or phosphate. These KDs are 150- to 250-fold lower than those previously reported, and compatible with the high molybdate transport affinity of the mod system. The affinity of ModA for molybdate was also determined in vivo and found to be similar to that determined in vitro.

Effect of albumin on net copper accumulation by fibroblasts and hepatocytes

The liver accumulates copper rapidly and preferentially from plasma. The effects of albumin on net copper accumulation by fibroblasts and hepatocytes were compared to determine whether preferential uptake involves hepatocyte-specific sequestering of copper. Although albumin inhibits the initial rates (30 s) of copper transport by fibroblasts and hepatocytes similarly, the effects of albumin on net copper accumulation (4 h) by these cell types were strikingly different. Fibroblasts accumulate only approximately 15% as much copper when equimolar albumin is present as from albumin-free media; hepatocytes accumulate about the same amount of copper with or without extracellular albumin present. Copper efflux data show that the special capacity of hepatocytes to accumulate copper in the presence of extracellular albumin is due to greater copper retention by hepatocytes than fibroblasts. The ability of hepatocytes to accumulate copper does not seem to be due to albumin-receptor-mediated uptake, since albumin was not co-transported with copper. The data are consistent with an equilibrium model of copper accumulation in which intracellular and extracellular copper are in equilibrium with intracellular and extracellular ligands. A high-affinity, copper-binding fraction that was previously identified in cytosols from hepatocytes was low or absent in fibroblasts. This may contain a liver-specific protein(s) that helps hepatocytes sequester and retain copper from albumin or serum-containing media. Irrespective of the exact species involved, the data are consistent with rapid, preferential copper uptake by the liver being due in part to a liver-specific, intracellular copper-binding protein(s) with a high binding affinity for copper.