Reversal of Cerebral Arteriopathy Post-Hematopoietic Stem Cell Transplant for Sickle Cell Disease

Sickle cell disease (SCD) is a chronic hematologic disorder which causes progressive cerebral arteriopathy beginning in childhood. As a result, arterial ischemic stroke is a major cause of morbidity and mortality in SCD, and SCD is a leading cause of childhood stroke worldwide. Allogenic hematopoietic stem cell transplant (HSCT) may be curative for individuals with SCD. Long-term outcomes and effects are currently being studied. In this report, we describe a child with SCD who presented with arterial ischemic stroke at 6 years of age and was found to have a severe form of cerebral large vessel arteriopathy by catheter-directed angiography. The patient initially underwent revascularization surgery by indirect superficial temporal artery to middle cerebral artery bypass, and 1 year later, he underwent curative HSCT. Approximately 3 years after HSCT, repeat catheter-directed angiography revealed a striking reversal of cerebral large vessel arteriopathy. This article reveals a previously unrecognized and potentially beneficial effect of HSCT that may ameliorate cerebral large vessel arteriopathy and improve cerebrovascular health for children with SCD.

ICOS and OX40 tandem co-stimulation enhances CAR T-cell cytotoxicity and promotes T-cell persistence phenotype

Chimeric Antigen Receptor (CAR) T-cell therapies have emerged as an effective and potentially curative immunotherapy for patients with relapsed or refractory malignancies. Treatment with CD19 CAR T-cells has shown unprecedented results in hematological malignancies, including heavily refractory leukemia, lymphoma, and myeloma cases. Despite these encouraging results, CAR T-cell therapy faces limitations, including the lack of long-term responses in nearly 50-70% of the treated patients and low efficacy in solid tumors. Among other reasons, these restrictions are related to the lack of targetable tumor-associated antigens, limitations on the CAR design and interactions with the tumor microenvironment (TME), as well as short-term CAR T-cell persistence. Because of these reasons, we developed and tested a chimeric antigen receptor (CAR) construct with an anti-ROR1 single-chain variable-fragment cassette connected to CD3ζ by second and third-generation intracellular signaling domains including 4-1BB, CD28/4-1BB, ICOS/4-1BB or ICOS/OX40. We observed that after several successive tumor-cell in vitro challenges, ROR1.ICOS.OX40ζ continued to proliferate, produce pro-inflammatory cytokines, and induce cytotoxicity against ROR1+ cell lines in vitro with enhanced potency. Additionally, in vivo ROR1.ICOS.OX40ζ T-cells showed anti-lymphoma activity, a long-lasting central memory phenotype, improved overall survival, and evidence of long-term CAR T-cell persistence. We conclude that anti-ROR1 CAR T-cells that are activated by ICOS.OX40 tandem co-stimulation show in vitro and in vivo enhanced targeted cytotoxicity associated with a phenotype that promotes T-cell persistence.

Investigating racial disparities in quality-of-life years after pediatric hematopoietic stem cell transplant

BACKGROUND

While racial disparities in the clinical outcomes of hematopoietic stem cell transplant (HSCT) patients have been explored, racial disparities in quality of life (QoL) during the re-adjustment phase after transplant are yet to be investigated in pediatric patients. The objective of this study was to examine the role of patient race in QoL at least 2 years after pediatric HSCT.

PROCEDURE

We conducted a retrospective chart review of patients under 21 years of age at diagnosis who received an allogeneic transplant at our institution between January 2007 and December 2017. Patient QoL was assessed using the Pediatric Quality-of-Life Inventory Generic Score Scales (PedsQL TM 4.0) at least 2 years post transplant. Patient demographic, treatment, and transplant outcome data were obtained for subsequent analysis, where patient race was categorized as either Black, White, Hispanic, or Native American.

RESULTS

Data were collected on 86 pediatric patients who underwent HSCT. Forty patients (46.5%) were non-Hispanic White, 29 (33.7%) Hispanic, 10 (11.6%) Black, and seven (8.1%) Native American. Where preliminary analyses indicated a difference in QoL by patient race, there were no significant differences in physical, emotional, social, and school functioning by patient race after adjusting for transplant characteristics (age at transplant, sex, diagnosis, donor type, and conditioning regimen) and determinants of socioeconomic status (insurance type, estimated household income).

CONCLUSIONS

Pediatric patients had comparable QoL, regardless of race, at a median of 3 years after HSCT in our study cohort.

Efficacy of Azacitidine and Prophylactic Donor Lymphocyte Infusion after HSCT in Pediatric Patients with Acute Myelogenous Leukemia: A Retrospective Pre-Post Study

Pediatric patients with acute myeloid leukemia (AML) who undergo allogeneic hematopoietic stem cell transplantation (HSCT) continue to have high rates of relapse. In 2018, Phoenix Children's Hospital started using post-HSCT maintenance therapy in patients with AML in attempt to decrease the number of relapses after HSCT. This therapy consisted of the hypomethylating agent azacitidine (AZA; 6 cycles starting on day +60) and prophylactic donor lymphocyte infusion (DLI; 3 escalating doses beginning after day +120). We aimed to compare 2-year leukemia-free survival (LFS) post-HSCT between patients with AML who received post-HSCT maintenance therapy with AZA and prophylactic DLI and historical control patients who did not receive post-HSCT therapy. This retrospective pre-post study was conducted at Phoenix Children's Hospital and included patients with AML who underwent HSCT between January 1, 2008, and May 31, 2022. We compared LFS, overall survival (OS), and immune reconstitution patterns post-HSCT between patients with AML who received post-HSCT maintenance therapy with AZA and prophylactic DLI (postintervention group) and historical control patients who did not receive this post-HSCT maintenance therapy (preintervention group). Sixty-three patients were evaluable. After excluding 7 patients who died or relapsed prior to day +60, 56 patients remained, including 39 in the preintervention group and 17 in the postintervention group. The median age at transplantation was 9.1 years in the preintervention group and 11 years in the postintervention group (P = .33). The 2-year LFS was 61.5% in the preintervention group, compared to 88.2% in the postintervention group (P = .06). The 2-year OS was 69.2% in the preintervention group and 88.2% in the postintervention group (P = .15). The rates of CD3⁺CD4⁺ T cell and CD19⁺ B cell recovery were faster in the preintervention group compared to the postintervention group (P = .004 and .0006, respectively). In this limited retrospective study, post-HSCT maintenance therapy using AZA and prophylactic DLI was well tolerated; however, its efficacy is yet to be fully determined.

Measuring the principal Hugoniot of inertial-confinement-fusion-relevant TMPTA plastic foams

Wetted-foam layers are of significant interest for inertial-confinement-fusion capsules, due to the control they provide over the convergence ratio of the implosion and the opportunity this affords to minimize hydrodynamic instability growth. However, the equation of state for fusion-relevant foams are not well characterized, and many simulations rely on modeling such foams as a homogeneous medium with the foam average density. To address this issue, an experiment was performed using the VULCAN Nd:glass laser at the Central Laser Facility. The aim was to measure the principal Hugoniot of TMPTA plastic foams at 260mg/cm^{3}, corresponding to the density of liquid DT-wetted-foam layers, and their "hydrodynamic equivalent" capsules. A VISAR was used to obtain the shock velocity of both the foam and an α-quartz reference layer, while streaked optical pyrometry provided the temperature of the shocked material. The measurements confirm that, for the 20-120 GPa pressure range accessed, this material can indeed be well described using the equation of state of the homogeneous medium at the foam density.

Real-world effectiveness and rheumatologist satisfaction with secukinumab in the treatment of patients with axial spondyloarthritis

OBJECTIVES

To assess the effectiveness of secukinumab in patients with axSpA treated in routine clinical settings in 5 European countries.

METHODS

Retrospective analysis of a cross-sectional survey to assess real-world effectiveness of secukinumab in the management of axSpA and rheumatologist satisfaction with treatment in France, Germany, Italy, Spain and the UK from March to December 2018. Outcomes collected included patient demographics, clinical characteristics and rheumatologist- and patient-reported satisfaction with secukinumab treatment.

RESULTS

Five hundred thirty-five patients receiving secukinumab for more than 4 months were assessed, 359 of whom were diagnosed with AS and 178 with nr-axSpA. Rheumatologist assessment of disease status at treatment initiation indicated that 39 (7.3%) had stable/improving disease. Secukinumab treatment for 4 months or longer resulted in 515 (95.9%) patients judged as stable/improving. Treatment was associated with benefits from initiation to assessment in terms of BASDAI (6.2 vs 2.8), 44-joint count score (9.7 vs 6.6), rheumatologist global VAS score (56.9 vs 23.0) and patient global VAS scores (64.4 vs 25.5). These benefits for key clinical outcomes were sustained for periods of 12 months or longer. Patient-reported outcomes on health status using EQ-5D, global functioning using the ASAS health index and overall work impairment via WPAI were sustained over the treatment period, while patient and rheumatologist satisfaction with secukinumab treatment remained very high at 80.2 and 91.2%, respectively.

CONCLUSION

Consistent benefits across multiple clinical and patient-reported outcomes were seen with secukinumab treatment in patients with AS and nr-axSpA treated in routine clinical settings across five European countries. Key Points • In routine clinical settings across five European countries, secukinumab treatment resulted in improvements in a wide range of clinical outcomes including physician-reported disease severity, disease status, pain, BASDAI, 44-joint count score and global VAS scores. • Key clinical and patient reported outcomes were sustained for a 12-month period or longer with secukinumab treatment. • Rheumatologist- and patient-reported treatment satisfaction was high with secukinumab.

Selective Ion Acceleration by Intense Radiation Pressure

We report on the selective acceleration of carbon ions during the interaction of ultrashort, circularly polarized and contrast-enhanced laser pulses, at a peak intensity of 5.5×10^{20}  W/cm^{2}, with ultrathin carbon foils. Under optimized conditions, energies per nucleon of the bulk carbon ions reached significantly higher values than the energies of contaminant protons (33  MeV/nucleon vs 18 MeV), unlike what is typically observed in laser-foil acceleration experiments. Experimental data, and supporting simulations, emphasize different dominant acceleration mechanisms for the two ion species and highlight an (intensity dependent) optimum thickness for radiation pressure acceleration; it is suggested that the preceding laser energy reaching the target before the main pulse arrives plays a key role in a preferential acceleration of the heavier ion species.

POS0104 ESSDAI AND ITS ASSOCIATION WITH PATIENT OUTCOMES IN SJÖGREN’S SYNDROME: A REAL-WORLD SURVEY IN THE US

Background:

The EULAR Sjögren’s syndrome disease activity index (ESSDAI) is considered the gold standard for measuring Sjögren’s syndrome disease activity in clinical trials, but there is limited evidence of its application in the real-world.

Objectives:

To describe the distribution of ESSDAI scores in the real-world and it’s association with patient outcomes.

Methods:

Data were drawn from the Adelphi Primary Sjögren’s syndrome (pSS) Disease Specific Programme™, a real-world point-in-time survey of rheumatologists and their consulting pSS patients in the United States. Proxy ESSDAI scores were calculated for each patient by assigning a score to the rheumatologists’ perception of “not present”, “mild”, “moderate” or “severe” for each of the twelve domains of the ESSDAI. ESSDAI scores were then grouped according to the definitions of mild (ESSDAI 0-4), moderate (ESSDAI 5-13) and severe (ESSDAI ≥14). Rheumatologists provided data about patient demographics and clinical characteristics. Patients self-completed patient reported outcome (PRO) tools including the EuroQol 5-dimension 5-level utility score (EQ-5D), Work Productivity and Activity Impairment questionnaire (WPAI) and The Functional Assessment of Chronic Illness Therapy – Fatigue (FACIT-F). Differences in clinical characteristics and patient-reported outcomes were examined according to ESSDAI severity score. Spearman’s Rho association was used to assess the correlation of ESSDAI severity with PROs.

Results:

Rheumatologists (n=84) provided data for 511 pSS patients, mean age 53.3 years, 88.5% female, 79.8% white/Caucasian and mean time since diagnoses 4.6 years. Of the 511 patients, 44.2% were considered to be mild, 30.9% moderate and 24.9% severe in terms of their calculated ESSDAI score. Demographic characteristics of the three ESSDAI groups were similar, Table 1. Patients with severe ESSDAI scores have been diagnosed with pSS for longer than those with mild or moderate ESSDAI scores.

Increasing ESSDAI severity was associated with worse EQ-5D utility scores (rho=-0.346, p<0.0001), worse FACIT-F scores (rho=-0.277, p<0.0001) and worse overall work impairment (rho=0.462, p<0.0001).

Table 1.

Demographic characteristics of pSS patients in the US, by ESSDAI severity

Total(n=511)Mild ESSDAI(n=226)Moderate ESSDAI(n=158)Severe ESSDAI(n=127)Patient age, mean (SD) years53.3 (14.2)52.6 (15.0)53.6 (14.0)54.2 (12.9)% (n) female88.5 (452)89.4 (226)88.6 (158)86.6 (127)Ethnicity, % (n)White/Caucasian79.8 (408)86.3 (195)74.7 (118)74.8 (95)African-American9.2 (47)6.2 (14)10.1 (16)13.4 (17)Hispanic/Latino6.1 (31)5.3 (12)8.2 (13)4.7 (6)Other4.9 (25)2.2 (5)7.0 (11)7.1 (9)Time since diagnosis, mean (SD) years [n]4.6 (5.4) [379]4.0 (4.9) [162]4.9 (5.6) [118]5.1 (5.8) [99]Insurance type, % (n)Commercial (including employer provided)59.9 (306)62.4 (141)56.3 (89)59.8 (76)Medicare20.5 (105)18.1 (41)23.4 (37)21.3 (27)Health insurance exchange plan9.6 (49)10.2 (23)10.1 (16)7.9 (10)Other9.6 (49)8.8 (20)9.5 (15)11.0 (14)None- (2)- (1)- (1)- (0)Employment status, % (n)Working full or part time58.9 (301)61.9 (140)53.2 (84)60.6 (77)Long-term sick/unemployed/retired24.5 (125)20.8 (47)27.2 (43)27.6 (35)Homemaker12.7 (65)10.2 (23)17.1 (27)11.8 (15)Other/unknown3.9 (20)7.1 (16)2.5 (4)- (0)Smoking status, % (n) current smoker6.8 (35)3.5 (8)5.7 (9)14.2 (18)

Conclusion:

A worsening severity on the ESSDAI scale is associated with worse outcomes for patients in the real-world. Treating systemic disease beyond symptomatic treatments is important to improve patient outcomes.

Disclosure of Interests:

Briana Ndife Shareholder of: Novartis Pharmaceuticals Corp, Employee of: Novartis Pharmaceuticals Corp, Ben Hoskin: None declared, Nicola Booth: None declared

AB0548 EFFECTIVENESS OF IXEKIZUMAB IN PATIENTS WITH PSORIATIC ARTHRITIS: RESULTS FROM A REAL-WORLD EUROPEAN SURVEY

Background:

Limited real world (RW) data are available for IL-17A blocker ixekizumab (Ixe), approved for psoriatic arthritis (PsA) in EU Feb 2018.

Objectives:

Describe RW outcomes for PsA patients (pts) receiving Ixe.

Methods:

Cross-sectional, observational study of PsA pts treated with Ixe in the 2020 Adelphi PsA Plus Program (FR, DE, ES & UK). Rheumatologists recruited the first 6 consecutive consulting Ixe pts and provided demographics, PsA manifestations, clinical measures (66 swollen joint count (SJC), 68 tender joint count (TJC), psoriasis area and severity index [PASI], body surface area [BSA] affected by psoriasis [PsO]), rheumatologist-recorded pt measures (skin/joint pain & fatigue [0-10 numeric rating scales (NRS)], health assessment questionnaire [HAQ-DI]) & prescribed dose. All outcomes recorded for pts with scores available at Ixe initiation (II) & at last assessment (LA).

Results:

124 rheumatologists provided data for 698 Ixe pts, mean age 49 years (19-79), 48% female, mean BMI 27 (18-44), 56% dermatologist co-managed and mean time diagnosed 6 years (0-35). At Ixe initiation, 78% of pts with known BSA had concomitant mod-sev-PsO defined as BSA≥10% (mean 19.8, n=428) and mean PASI 26.3 (n=164). The predominant PsA phenotype was polyarthritic in 49% (n=345), mono/oligoarthritic in 30% (n=208), axial in 12% (n=81) and enthesitic in 8% (n=55). Previous treatment before Ixe included ≥1 conventional synthetic DMARD (csDMARD) for 71% of pts. Of bio-experienced pts (57%), 40% had received ≥2 biologics. Mean Ixe treatment duration (n=698) 39.4 weeks (wks, 0-170), of which 575 (82%) had received >12 wks of Ixe. 71% of pts received label recommended dose (80mg every 4wks). 52% pts received csDMARD in combination with Ixe. In the RW, Ixe improved TJC, SJC, joint pain, BSA, fatigue and HAQ-DI, Table 1.

Table 1.

Outcomes for pts receiving Ixe >12weeks (n=575)

OverallBSA ≥10% at Ixe initiationMod-sev-PsO physician judgementPredominant mono/oligo arthritisPredominant polyarthritisWith csDMARDWithout csDMARDBSA, n35627025498184188168mean [SD]Ixe initiation (II)19.8 [14.8]24.7 [13.5]23.1 [13.6]17.4 [15.0]20.9 [15.0]21.8 [15.0]17.4 [14.2]Last Assessment (LA)6.6 [7.5]9.3 [8.7]7.9 [7.9]5.0 [6.0]7.6 [8.4]7.3 [7.9]5.9 [7.1]Mean weeks on Ixe43414150414146TJC*, n125728639725669mean [SD, %<5]II12.2 [10.6, 29]14.4 [11.3, 18]12.9 [11.1, 21]6.4 [8.2, 59]15.4 [10.8, 12]13.0 [9.9, 25]11.5 [11.1, 32]LA4.1 [6.4, 77]5.2 [7.7, 71]3.6 [6.3, 80]1.1 [1.4, 97]6.2 [7.7, 64]3.4 [3.9, 73]4.6 [7.8, 80]SJC*, n1458210244846085mean [SD, %<5]II14.8 [13.5, 33]18.8 [14.4, 22]16.3 [13.8, 26]7.2 [8.5, 68]18.2 [13.6, 12]14.5 [12.0, 37]15.1 [14.8, 31]LA4.8 [8.7, 79]7.0 [10.7, 66]5.1 [9.3, 75]0.9 [1.9, 95]6.6 [9.0, 68]3.1 [7.8, 90]5.9 [9.1, 71]Joint pain (NRS 0-10), n575270349166291294281mean [SD]II6.6 [1.7]6.7 [1.7]6.7 [1.7]6.2 [1.8]7.0 [1.5]6.6 [1.7]6.6 [1.6]LA2.7 [1.9]3.0 [2.1]2.8 [2.0]2.1 [1.6]3.0 [2.1]2.8 [1.9]2.5 [1.9]Fatigue (NRS 0-10), n575270349166291294281mean [SD]II5.4 [2.5]5.8 [2.4]5.7 [2.5]4.7 [2.5]5.7 [2.4]5.7 [2.4]5.1 [2.5]LA2.6 [2.1]2.7 [2.1]2.7 [2.2]2.0 [1.9]2.9 [2.2]2.7 [2.1]2.6 [2.1]HAQ DI, n59414210283128mean [SD, %<0.5]II1.8 [0.7, 5]1.9 [0.6, 0]1.8 [0.7, 2]1.9 [0.7, 10]1.8 [0.8, 7]1.9 [0.6, 3]1.7 [0.8, 7]LA0.8 [0.6, 41]0.8 [0.6, 32]0.8 [0.7, 45]0.7 [0.7, 60]0.7 [0.6, 36]0.7 [0.5, 32]0.7 [0.8, 50]

*Additional analysis for pts whose fatigue/joint pain rating improved (from ≥4 at Ixe initiation to ≤3 at LA), their mean TJC was 2.7 & SJC 4.3 at LA for fatigue, TJC 1.7 & SJC 2.7 at LA for joint pain.

When BSA was not recorded, physician judgement of PsO severity was used. No imputation of missing data.

Conclusion:

We report RW outcome data amongst pts treated with Ixe including mono/oligo arthritis and a limited sample of enthesitis and dactylitis pts. Our results are consistent with clinical trial populations across disease domains, including an improvement in joint pain.

Disclosure of Interests:

William Tillett Speakers bureau: AbbVie, Amgen, Celgene, Lilly, Janssen, Novartis, Pfizer Inc. and UCB, Consultant of: AbbVie, Amgen, Celgene, Lilly, Janssen, Novartis, MSD, Pfizer Inc. and UCB, Grant/research support from: AbbVie, Celgene, Eli Lilly & company, Janssen and UCB, Victoria Navarro-Compán Speakers bureau: AbbVie, BMS, Janssen, Eli Lilly & Co, MSD, Novartis, Pfizer, Roche and UCB, Consultant of: AbbVie, BMS, Janssen, Eli Lilly & Co, MSD, Novartis, Pfizer, Roche and UCB, Grant/research support from: AbbVie, BMS, Janssen, Eli Lilly & Co, MSD, Novartis, Pfizer, Roche and UCB, Nicola Booth: None declared., Thorsten Holzkaemper Shareholder of: Eli Lilly & Company, Employee of: Eli Lilly & Company, Julie Hill Shareholder of: Eli Lilly & Company, Employee of: Eli Lilly & Company, Ennio Lubrano Speakers bureau: Alfa-Sigma, Abbvie, Galapagos, Janssen Cilag, Lilly., Consultant of: Alfa-Sigma, Abbvie, Galapagos, Janssen Cilag, Lilly., Tamas Truer Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company.

Immune effector cell therapies in oncology: A systematic analysis and forecast from ClinicalTrials.gov

e14516

Background: IEC are arguably the most promising therapy in oncology, and FDA approvals for CAR T cells are a testament to their real potential. This has led to a great growth of clinical trials (CT), making the evaluation of their associated data increasingly challenging. To facilitate this process, we performed a systematic review of ClinicalTrials.gov focused on IEC therapies in oncology. We performed an analysis of the CT data and forecast trends for 2025. Methods: CT registries were retrieved from ClinicalTrials.gov with a systematic search query. We included CT registered between 1993-2020, which used IEC-based therapies in oncology. Statistical analysis using descriptive and inferential methods allowed us to identify trends and establish forecasts. Results: We identified 938 registrations of IEC-CTs in oncology, and 51% of those were active. The most common IEC type was CAR T (51%), followed by NK (15%), TCR T (8%), TIL (8%), and CIK (3%). 69% of IEC-CTs were aimed at a specific target vs. 31% that lack that specificity. The number of annual CAR T-CTs continue to increase, and we forecast 320 registrations during 2025. Since 2018, the number of CTs using unmodified T cells and TIL has increased (largely due to metastatic melanoma studies). NK cells CTs represent 8% of all registrations, and by 2025 we anticipate that >150 NK-based CTs will be registered per year, a number similar to CAR T-CTs registered during 2020. IEC-CTs based on allogeneic sources represent 18% of all registrations and are expected to grow 2.5 fold in the next 5 years. In solid tumors, the most common IEC-CTs are based on Non-CAR studies, while in hem-malignancies 76% of CTs are CAR T. Only one solid tumor, CAR T-CT, has reached phase 2/3, while 7 CIK-CTs were used to target various organ tumors. Conclusions: IEC-CTs continue to grow exponentially and represent an active field of clinical research in oncology. Allogeneic and NK-CTs increase rapidly and are among the most promising IEC-CTs. A rising proportion of CTs in solid tumors are using CIK and TIL rather than CAR T-cells, which are more popular for treating hem-malignancies. This is a direct reflection of the challenges associated with CAR T infiltration and persistence in solid tumors. Our analyses indicate that annual IEC-CTs registrations will double by 2025. We anticipate the increase in cellular therapy options will demand an organized response, including adequate logistical planning and policy implementation in response to the landscape changes in clinical oncology during the upcoming years.[Table: see text]

Estimates of Caffeine Use Disorder, Caffeine Withdrawal, Harm and Help-seeking in New Zealand: A cross-sectional survey

BACKGROUND

Caffeine Use Disorder (CUD) is not yet formally recognized in the DSM-5, but emerging evidence suggests CUD could impact up to one in five people. The primary aim of this study was to estimate levels of caffeine consumption and its associations with CUD and withdrawal, taking socio-demographic characteristics (age, gender, ethnicity, income) into account. Secondary aims were to measure caffeine-related harm and treatment preferences.

METHODS

We administered an online cross-sectional survey via Facebook to a convenience sample of 2379 adults in New Zealand. Caffeine consumption was assessed across six products: coffee, tea, energy drinks, cola, alcohol mixed with caffeine, and other products (e.g., caffeine pills, sports supplements).

RESULTS

20% of participants met proposed criteria for CUD, with 30% meeting DSM-5 criteria for caffeine withdrawal. Moderate (200-400 mg per day) and high consumption (>400 mg per day) was associated with a three-fold increase in the odds of CUD and a two-fold increase in the odds of withdrawal. Women and current smokers were at higher risk of CUD and withdrawal even at moderate consumption levels. Nearly 85% of respondents experienced at least one caffeine-related harm in the past 12-months. The number of harms increased with level of caffeine consumption. Nearly 50% indicated a self-help treatment for caffeine reduction would be of interest.

CONCLUSIONS

High rates of CUD and caffeine withdrawal amongst moderate caffeine users, women and smokers suggests caffeine consumption guidelines may need refinement. Caffeine-related harm that is not clinically meaningful may still be of concern to individuals and warrants further investigation.

AB0648 COMPARING SYMPTOMS, TREATMENT PATTERNS, AND QUALITY OF LIFE OF ANKYLOSING SPONDYLITIS PATIENTS AND NON-RADIOGRAPHIC AXIAL SPONDYLOARTHRITIS IN JAPAN

Background:

Axial spondyloarthritis (axSpA) is a chronic inflammatory disease of the axial skeleton associated with impaired health-related quality of life (QoL) and disability.

Objectives:

To better understand the symptoms, clinical characteristics, treatment patterns, and quality of life (QoL), of non-radiographic axial spondyloarthritis (nr-axSpA) patients and how they compare to ankylosing spondylitis (AS) patients in Japan.

Methods:

Data from a cross-sectional survey conducted with physician (rheumatologists, orthopedic surgeon, and internal medicine) and their consulting patients in Japan were analyzed. Data were collected from Jun-Aug 2018 via physician-completed patient record forms and patient self-completed forms. Patients who had physician confirmed diagnoses of AS and nr-axSpA were eligible to participate. Demographics, disease status (improving, stable, unstable, deteriorating), symptoms, and medication use were reported by the physician, while work disability and QoL measures were reported by the patient using validated questionnaires. QoL and treatment patterns of nr-axSpA and AS patients were compared using parametric tests and non-parametric tests where appropriate.

Results:

Data from 41 physician, 72 AS patients, and 91 nr-axSpA patients were included in this analysis. A higher proportion of AS patients were male (70.8% vs. 58.2%; p=0.1040), yet this was not statistically significant. AS patients had a similar mean age (55.0 vs. 55.1; p=0.9762) compared to nr-axSpA patients. The majority of AS and nr-axSpA patients (61.1% vs. 62.9%; p=0.872) were not receiving a biologic. On average, AS and nr-axSpA patients reported similar rates of symptoms (Table 1). Patient reported outcomes such as the Assessment of SpondyloArthritis international Society Health Index (ASAS HI;6.0 vs. 6.4; p=0.6103), Patient Global Assessment (18.7 vs 22.7; p=0.4239), and the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI; 3.1 vs. 3.4; p=0.3453) were similar between AS and nr-axSpA patients. AS patients reported a lower EQ-5D VAS (62.6 vs. 71.3; p=0.0237) when compared to nr-axSpA patients.

Table 1.

Characteristics of AS and nr-axSpA Patients in Japan

ASN=72Nr-axSpAN=91p-valueMean age, (SD)55.0 (17.5)55.1 (16.5)0.9762Gender, males; n (%)51 (70.8%)53 (58.2%)0.1040BMI, mean (SD)23.4 (3.5)22.7 (3.1)0.1890Joint Inflammation or Stiffness; n (%)25 (34.7%)32 (35.2%)1.0000Inflammatory Back Pain; n(%)25 (34.7%)34 (37.4%)0.7456HLA-B27 positive; n (%)7 (9.7%)4 (4.4%)0.2169Alternating Buttock Pain; n (%)6 (8.3%)5 (5.5%)0.5390Dactylitis; n (%)5 (6.9%)6 (6.6%)1.0000Enthesitis; n (%)5 (6.9%)9 (9.9%)0.5825Tendonitis; n (%)0 (0.0%)2 (2.2%)0.5037Synovitis; n (%)3 (4.2%)4 (4.4%)1.0000Arthritis; n (%)15 (20.8%)26 (28.6%)0.2806Osteoporosis; n (%)8 (11.1%)13 (14.3%)0.6412Physician’s Global VAS, mean (SD)12.1 (11.2)22.6 (11.0)0.0100Patient Global VAS, mean (SD)18.7 (18.5)22.7 (11.7)0.4239EQ-5D VAS, mean (SD)62.6 (25.0)71.3 (20.2)0.0237BASDAI, mean (SD)3.1 (1.8)3.4 (2.6)0.3453ASAS HI, mean (SD)6.0 (4.3)6.4 (5.1)0.6103

Conclusion:

Nr-axSpA and AS being part of the same disease spectrum (i.e. axial spondyloarthritis) share the same clinical features. The burden of the disease, as assessed by QoL measurements, is also similar in AS and nr-axSpA patients.

Figure 1.

Medication Use among AS and nr-axSpA Patients in Japan

Disclosure of Interests:

Tetsuya Tomita Consultant of: Eli Lilly and Company, Toshihiko Aranishi Employee of: Eli Lilly Japan, Kohei Hagimori Employee of: Eli Lilly Japan, Ko Nakajo Employee of: Eli Lilly Japan, Nicola Booth Consultant of: Janssen, Elizabeth Holdsworth Employee of: Adelphi Real World, Theresa Hunter Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company

FRI0358 USAGE OF C-REACTIVE PROTEIN TESTING IN THE DIAGNOSIS AND MONITORING OF PSORIATIC ARTHRITIS (PSA): RESULTS FROM A REAL-WORLD SURVEY IN THE US AND EUROPE

Background:

C-reactive protein (CRP) is an important non-specific marker of both acute and chronic inflammation and can be elevated in patients with PsA. The role of CRP in the management of PsA is unclear.

Objectives:

To describe how CRP testing is implemented in real-world clinical practice for disease management of PsA.

Methods:

A cross-sectional study among patients with PsA recruited by rheumatologists and dermatologists was conducted in France, Germany, Italy, Spain, UK and US. Data were collected from Jun-Aug 2018 via physician-completed patient record forms. Use of CRP testing was obtained by asking the physician to state (yes/no) whether CRP was used to aid PsA diagnosis, confirm the patient’s PsA and to monitor the patient’s PsA. Where physicians stated use of CRP testing, they were then asked to provide the number of CRP tests conducted in the last 12 months.

Results:

Data were collected for 2270 patients with PsA (595 US, 1675 EU5). In EU5, 78.7% of patients had CRP conducted to aid diagnosis (vs 43.4% in US) and 72.0% had CRP conducted to monitor their condition (vs 34.6% in US). Patients seen by rheumatologists (vs dermatologists) were at least 50% more likely to have CRP used for monitoring purposes, this difference being most pronounced in the US. In EU5, CRP was conducted a mean [SD] of 2.7 [1.7] times in the last 12 months, versus 2.0 [1.4] in the US. Country level usage of CRP testing is shown in Table 2.

Table 2.

Purpose and frequency of CRP testing

CRP conducted…EU5 (n=1675)France (n=277)Germany (n=360)Italy (n=360)Spain (n=369)UK(n=309)US(n=595)To aid diagnosis, n (%)1319 (78.7)233 (84.1)282 (78.3)283 (78.6)315 (85.4)206 (66.7)258 (43.4)To confirm PsA, n (%)692 (41.3)83 (30.0)156 (43.3)151 (41.9)179 (48.5)123 (39.8)110 (18.5)To monitor PsA, n (%) [n]1190 (72.0)[1652]209 (75.7) [276]261 (74.1) [352]256 (72.9) [351]283 (77.1) [367]181 (59.2) [306]203 (34.6) [586]Patients with ≥1 CRP in last 12 months, n (%)1355 (80.9)238 (85.9)291 (80.8)304 (84.4)319 (86.4)203 (65.7)255 (42.9)Number conducted in last 12months, mean [SD]2.7 [1.7]3.1 [2.5]2.4 [1.7]2.5 [1.3]2.6 [1.2]2.9 [2.0]2.0 [1.4]Table 1.

Patient demographic and clinical characteristics

Overall (n=2270)EU5(n=1675)US(n=595)Patient seen by rheumatologist, n (%)1130 (49.8)834 (49.8)296 (49.7)Age, mean [SD]46.6 [13.3]48.1 [13.1]50.0 [13.5]Female, n (%)1047 (46.1)774 (46.2)273 (45.9)BMI, mean [SD]26.8 [4.7]26.3 [4.3]28.1 [5.5]Caucasian, n (%)2051 (90.4)1551 (92.6)500 (84.0)Current smoker, n (%)403 (20.3)352 (24.3)51 (9.5)Employment, n (%)-Working full-time1271 (58.2)894 (55.6)377 (65.3)Current disease severity, n (%)-Mild1702 (75.0)1253 (74.8)449 (75.5)-Moderate/Severe568 (25.0)422 (25.2)146 (24.5)Current treatment, n (%)-Receiving bDMARD*1231 (54.2)910 (54.3)321 (53.9)-Receiving tsDMARD*251 (11.1)121 (7.2)130 (21.8)-Receiving csDMARD*835 (36.8)698 (41.7)137 (23.0)-Receiving opioid55 (2.4)29 (1.7)26 (4.4)Total number of HCP visits in last 12months, mean [SD]6.5 [5.8]7.0 [6.3]5.0 [3.6]

*bDMARD: biologic DMARD, tsDMARD: targeted synthetic DMARD, csDMARD: conventional synthetic DMARD

Conclusion:

The majority (80.9%) of patients with PsA in EU5 had at least one CRP test in the last 12 months, versus 42.9% in the US. CRP is more commonly used for diagnosis and monitoring of PsA in Europe compared to the US and is more commonly ordered by rheumatologists than dermatologists.

Disclosure of Interests:

Alexis Ogdie Grant/research support from: Pfizer to Penn, Novartis to Penn, Amgen to Forward/NDB, Consultant of: Abbvie, Amgen, Bristol-Myers Squibb, Celgene, Corrona, Janssen, Eli Lilly, Novartis, Pfizer, William Tillett Grant/research support from: AbbVie, Celgene, Eli Lilly, Janssen, Novartis, Pfizer Inc, UCB, Consultant of: AbbVie, Amgen, Celgene, Lilly, Janssen, Novartis, MSD, Pfizer Inc, UCB, Speakers bureau: AbbVie, Amgen, Celgene, Lilly, Janssen, Novartis, Pfizer Inc, UCB, Lihi Eder Grant/research support from: Abbvie, Lily, Janssen, Amgen, Novartis, Consultant of: Janssen, Speakers bureau: Abbvie, Lily, Janssen, Amgen, Novartis, Nicola Booth Consultant of: Janssen, Sara Bruce Wirta Employee of: Janssen-Cilag Sweden AB, Oliver Howell Employee of: Janssen, Agata Schubert Employee of: Janssen-Cilag, Steve Peterson Employee of: Janssen Research & Development, LLC, Soumya D Chakravarty Shareholder of: Johnson & Johnson, Employee of: Janssen Scientific Affairs, LLC, Laura C Coates: None declared

AB0755 REAL WORLD EFFECTIVENESS OF SECUKINUMAB IN PSORIATIC ARTHRITIS: FINDINGS FROM A RECENT CROSS SECTIONAL SURVEY OF RHEUMATOLOGISTS AND PATIENTS IN EUROPE

Background:

Secukinumab has demonstrated significant and sustained reduction of disease activity and improvement in physical functioning and quality of life in PsA pts in RCTs.1

Objectives:

This study assessed effectiveness of secukinumab in PsA in a real-world setting.

Methods:

This was a cross-sectional survey of rheumatologists, dermatologists and pts in France, Germany, Italy, Spain, and UK. Data were collected online from June-Dec 2018 via physician-completed patient record forms. Pts receiving any treatment for PsA were included in survey (n=1675). Pts receiving secukinumab >4 months were included in this analysis. Pts reported quality of life, work, and disability measures at their current consultation. Physicians reported patient demographic and disease characteristics, concomitant and previous treatments, and time since diagnosis. Physicians also reported overall, skin and joint disease severity, pain (1-10 scale), BSA psoriasis involvement, global VAS score, PASI score, SJC, and TJC for 2 time points: initiation of treatment and at the time of data collection (current consultation). Data were analysed descriptively. The data analysed here is representative of pts that are currently receiving secukinumab and does not assess pts that have discontinued treatment.

Results:

572 PsA pts were receiving secukinumab >4 months at their current consultation. Patient mean age was 47.9 yrs, with 43% female, 59% working full time, and a mean BMI of 26.6. On average, pts were diagnosed with PsA 5.6 years before the current consultation, had received secukinumab for 11.0 months, and for 59% of pts secukinumab was their 1st advanced therapy (bDMARDs or tsDMARDs), 24% their 2nd and 16% their 3rd or more. 25% of pts were also receiving a csDMARD concurrently. Pts reported a mean EQ5D utility score of 0.83, mean WPAI overall work impairment of 24.3%, mean HAQ-DI score as 0.6, and mean PsAID12 score as 2.6 at current consultation. Proportion of pts with moderate and severe overall disease severity, and skin and joint severity decreased at current consultation vs at the initiation treatment (Table 1). Between initiation of treatment and current consultation, pts achieved a significant reduction in disease activity scores, pain score, global VAS scores, BSA, PASI score as well as a greater proportion of pts achieving a BSA < 3%, a PASI score < 3 (Table 2).

Conclusion:

This multinational study demonstrated secukinumab effectiveness in routine care in PsA pts, with significant improvements across all outcomes.

References:

[1]Mease et al. RMD Open. 2018; 4(2): e000723

Table 1.

Disease severity at initiation of secukinumab and at current consultation

At initiation of secukinumab (n=572)At current consultation (n=572)Overall disease severity, n (%)Mild32 (5.6)432 (75.5)Moderate316 (55.2)131 (22.9)Severe218 (38.1)9 (1.6)Don’t know6 (1.0)-Skin severity, n (%)Mild93 (16.3)478 (83.6)Moderate287 (51.2)82 (14.3)Severe154 (26.9)12 (2.1)Don’t know38 (6.6-Joint severity, n (%)Mild50 (8.7)444 (77.6)Moderate329 (57.5)118 (20.6)Severe181 (31.6)10 (1.7)Don’t know12 (2.1)-Table 2.

Physician reported outcomes at initiation of secukinumab and at current consultation, mean (SD)

At initiation of secukinumab (n=572)At current consultation (n=572)BSAa19.2 (15.3)4.6 (8.7)BSA < 3%, n (%)28 (8.2)213 (62.5)PASI score (0-72)a17.2 (11.5)4.2 (8)PASI score < 3, n (%)11 (7.1)99 (64.3)DAS28 scorea5.2 (1.5)*2.8 (1.3)TJC (0-68)a12.1 (9.9)2.5 (3.6)SJC (0-66)a10.0 (9.5)2.9 (7.5)Pain score (1-10)6.3 (2.0)2.6 (1.6)Physician global VAS score (1-100)a59.4 (24.2)23.3 (22.2)Patient global VAS score (1-100)a56.7 (30.4)23.4 (18.3)

1.aCalculated on available data.

Disclosure of Interests:

Philip G Conaghan Consultant of: AbbVie, BMS, Eli Lilly, EMD Serono, Flexion Therapeutics, Galapagos, GSK, Novartis, Pfizer, Speakers bureau: AbbVie, Eli Lilly, Novartis, Pfizer, Elizabeth Holdsworth Employee of: Adelphi Real World, Haijun Tian Shareholder of: Novartis Pharmaceutical Corporation, Employee of: Novartis Pharmaceutical Corporation, Nicola Booth Consultant of: Janssen, Papa Anthony: None declared, Niraj Modi Employee of: Novartis Healthcare Pvt Ltd, Dorothy Keininger Shareholder of: Novartis Pharma AG, Employee of: Novartis Pharma AG, Uta Kiltz Grant/research support from: AbbVie, Amgen, Biogen, Novartis, Pfizer, Consultant of: AbbVie, Biocad, Eli Lilly and Company, Grünenthal, Janssen, Novartis, Pfizer, UCB, Speakers bureau: AbbVie, MSD, Novartis, Pfizer, Roche, UCB

Effect of plastic coating on the density of plasma formed in Si foil targets irradiated by ultra-high-contrast relativistic laser pulses

The formation of high energy density matter occurs in inertial confinement fusion, astrophysical, and geophysical systems. In this context, it is important to couple as much energy as possible into a target while maintaining high density. A recent experimental campaign, using buried layer (or "sandwich" type) targets and the ultrahigh laser contrast Vulcan petawatt laser facility, resulted in 500 Mbar pressures in solid density plasmas (which corresponds to about 4.6×10^{7}J/cm^{3} energy density). The densities and temperatures of the generated plasma were measured based on the analysis of x-ray spectral line profiles and relative intensities.

Seeing is believing: The effect of prison-based insight-days on student nurses' perceptions of undertaking practice placements within a prison healthcare environment

Prisoners' access to healthcare should mirror that of the general public, but is adversely affected by challenges in recruiting nurses to work in custodial settings, potentially impacting on prisoner well-being. To address this issue prison-based insight-days have been developed jointly by one university and prison to positively influence students' views of undertaking placements in custodial settings because nurses are known to subsequently seek employment in areas where they have had positive student placements. A phenomenological investigation explored student nurses' lived experiences of prison-based insight-days. Questionnaires and interviews were used to gather qualitative data about students' feelings both prior to and following the insight-day (n = 17). All data was thematically analysed resulting in four themes: pre-placement curiosity, escalating admission anxiety, calming down inside and post-placement decision making. The empirical findings showed that first-hand exposure to prisoners, and to the realities of a working prison, were crucial factors in dispelling stereotypes and addressing negative preconceptions of prison healthcare environments, as students could find prison placements unexpectedly appealing. Drawing on the findings, this paper recommends that facilitating prison insight-days within custodial settings may be one way to encourage students to undertake prison placements.

A classification-based approach to low back pain in primary care - protocol for a benchmarking controlled trial

Background

Guidelines recommend a biopsychosocial framework for low back pain (LBP) management and the avoidance of inappropriate imaging. In clinical practice, care strategies are often inconsistent with evidence and guidelines, even though LBP is the most common disabling health condition worldwide. Unhelpful beliefs, attitudes and inappropriate imaging are common. LBP is understood to be a complex biopsychosocial phenomenon with many known multidimensional risk factors (symptom- and lifestyle-related, psychological and social) for persistent or prolonged disability, which should be identified and addressed by treatment. The STarT Back Tool (SBT) was developed for early identification of individual risk factors of LBP to enable targeted care. Stratified care according SBT has been shown to improve the effectiveness of care in a primary care setting. A biopsychosocially-oriented patient education booklet, which includes imaging guidelines and information, is one possible way to increase patients’ understanding of LBP and to reduce inappropriate imaging. Premeditated pathways, education of professionals, written material, and electronic patient registry support in health care organizations could help implement evidence-based care.

Methods

We will use a Benchmarking Controlled Trial (BCT) design in our study. We will prospectively collect data from three health care regions before and after the implementation of a classification-based approach to LBP in primary care. The primary outcome will be change in PROMIS (Patient-Reported Outcomes Measurement Information System) (short form 20a) over 12-month follow-up.

Discussion

The implementation of a classification-based biopsychosocial approach can potentially improve the care of LBP patients, reduce inappropriate imaging without increasing health-care costs, and decrease indirect costs by reducing work disability. Using the BCT we will be able to evaluate the effectiveness of the improvement strategy for the entire care pathway.

Trial registration

ISRCTN,ISRCTN13273552, retrospectively registered 13/05/2019.

High order mode structure of intense light fields generated via a laser-driven relativistic plasma aperture

The spatio-temporal and polarisation properties of intense light is important in wide-ranging topics at the forefront of extreme light-matter interactions, including ultrafast laser-driven particle acceleration, attosecond pulse generation, plasma photonics, high-field physics and laboratory astrophysics. Here, we experimentally demonstrate modifications to the polarisation and temporal properties of intense light measured at the rear of an ultrathin target foil irradiated by a relativistically intense laser pulse. The changes are shown to result from a superposition of coherent radiation, generated by a directly accelerated bipolar electron distribution, and the light transmitted due to the onset of relativistic self-induced transparency. Simulations show that the generated light has a high-order transverse electromagnetic mode structure in both the first and second laser harmonics that can evolve on intra-pulse time-scales. The mode structure and polarisation state vary with the interaction parameters, opening up the possibility of developing this approach to achieve dynamic control of structured light fields at ultrahigh intensities.

A new energy spectrum reconstruction method for time-of-flight diagnostics of high-energy laser-driven protons

The Time-of-Flight (TOF) technique coupled with semiconductorlike detectors, as silicon carbide and diamond, is one of the most promising diagnostic methods for high-energy, high repetition rate, laser-accelerated ions allowing a full on-line beam spectral characterization. A new analysis method for reconstructing the energy spectrum of high-energy laser-driven ion beams from TOF signals is hereby presented and discussed. The proposed method takes into account the detector's working principle, through the accurate calculation of the energy loss in the detector active layer, using Monte Carlo simulations. The analysis method was validated against well-established diagnostics, such as the Thomson parabola spectrometer, during an experimental campaign carried out at the Rutherford Appleton Laboratory (UK) with the high-energy laser-driven protons accelerated by the VULCAN Petawatt laser.

Neutron diffraction of deuterated tripalmitin and the influence of shear on its crystallisation

This neutron diffraction study of deuterated tripalmitin has provided further insight into a forensic observation of the crystallisation of lipids under high-shear conditions. To achieve this, an experimental set up was designed to enable simultaneous rheological data from a Couette cell to be recorded with neutron powder diffraction, enabling the influence of shear on the polymorph transformation on cooling to be monitored in real time. Tripalmitin was observed to directly transform from a liquid phase to a β polymorph under the influence of shear. Although the liquid to β transition was not observed to be influenced by shear rate, the degree of crystallinity, qualitatively denoted by an increase in the sharpness of the diffraction peaks, was observed at higher shear rates. Evidence is also presented that the rate of cooling influences the ordering in the β-polymorph produced in zero shear conditions.

Time-resolved measurements of fast electron recirculation for relativistically intense femtosecond scale laser-plasma interactions

A key issue in realising the development of a number of applications of high-intensity lasers is the dynamics of the fast electrons produced and how to diagnose them. We report on measurements of fast electron transport in aluminium targets in the ultra-intense, short-pulse (<50 fs) regime using a high resolution temporally and spatially resolved optical probe. The measurements show a rapidly (≈0.5c) expanding region of Ohmic heating at the rear of the target, driven by lateral transport of the fast electron population inside the target. Simulations demonstrate that a broad angular distribution of fast electrons on the order of 60° is required, in conjunction with extensive recirculation of the electron population, in order to drive such lateral transport. These results provide fundamental new insight into fast electron dynamics driven by ultra-short laser pulses, which is an important regime for the development of laser-based radiation and particle sources.

Using X-ray spectroscopy of relativistic laser plasma interaction to reveal parametric decay instabilities: a modeling tool for astrophysics

By analyzing profiles of experimental x-ray spectral lines of Si XIV and Al XIII, we found that both Langmuir and ion acoustic waves developed in plasmas produced via irradiation of thin Si foils by relativistic laser pulses (intensities ~10²¹ W/cm²). We prove that these waves are due to the parametric decay instability (PDI). This is the first time that the PDI-induced ion acoustic turbulence was discovered by the x-ray spectroscopy in laser-produced plasmas. These conclusions are also supported by PIC simulations. Our results can be used for laboratory modeling of physical processes in astrophysical objects and a better understanding of intense laser-plasma interactions.

Plasma scale-length effects on electron energy spectra in high-irradiance laser plasmas

An analysis of an electron spectrometer used to characterize fast electrons generated by ultraintense (10^{20}Wcm^{-2}) laser interaction with a preformed plasma of scale length measured by shadowgraphy is presented. The effects of fringing magnetic fields on the electron spectral measurements and the accuracy of density scale-length measurements are evaluated. 2D EPOCH PIC code simulations are found to be in agreement with measurements of the electron energy spectra showing that laser filamentation in plasma preformed by a prepulse is important with longer plasma scale lengths (>8 μm).

Laboratory measurements of resistivity in warm dense plasmas relevant to the microphysics of brown dwarfs

Since the observation of the first brown dwarf in 1995, numerous studies have led to a better understanding of the structures of these objects. Here we present a method for studying material resistivity in warm dense plasmas in the laboratory, which we relate to the microphysics of brown dwarfs through viscosity and electron collisions. Here we use X-ray polarimetry to determine the resistivity of a sulphur-doped plastic target heated to Brown Dwarf conditions by an ultra-intense laser. The resistivity is determined by matching the plasma physics model to the atomic physics calculations of the measured large, positive, polarization. The inferred resistivity is larger than predicted using standard resistivity models, suggesting that these commonly used models will not adequately describe the resistivity of warm dense plasma related to the viscosity of brown dwarfs.

Tunable mega-ampere electron current propagation in solids by dynamic control of lattice melt

The influence of lattice-melt-induced resistivity gradients on the transport of mega-ampere currents of fast electrons in solids is investigated numerically and experimentally using laser-accelerated protons to induce isochoric heating. Tailoring the heating profile enables the resistive magnetic fields which strongly influence the current propagation to be manipulated. This tunable laser-driven process enables important fast electron beam properties, including the beam divergence, profile, and symmetry to be actively tailored, and without recourse to complex target manufacture.

Annular fast electron transport in silicon arising from low-temperature resistivity

Fast electron transport in Si, driven by ultraintense laser pulses, is investigated experimentally and via 3D hybrid particle-in-cell simulations. A transition from a Gaussian-like to an annular fast electron beam profile is demonstrated and explained by resistively generated magnetic fields. The results highlight the potential to completely transform the beam transport pattern by tailoring the resistivity-temperature profile at temperatures as low as a few eV.

Exotic dense-matter states pumped by a relativistic laser plasma in the radiation-dominated regime

In high-spectral resolution experiments with the petawatt Vulcan laser, strong x-ray radiation of KK hollow atoms (atoms without n = 1 electrons) from thin Al foils was observed at pulse intensities of 3 × 10(20) W/cm(2). The observations of spectra from these exotic states of matter are supported by detailed kinetics calculations, and are consistent with a picture in which an intense polychromatic x-ray field, formed from Thomson scattering and bremsstrahlung in the electrostatic fields at the target surface, drives the KK hollow atom production. We estimate that this x-ray field has an intensity of >5 × 10(18) W/cm(2) and is in the 3 keV range.

Effects of continuous feeding of toxaphene to white leghorn layers

Graded levels of toxaphene 0, 0.5, 5.0, 50 and 100 ppm were added to the diets of female white leghorn chicks from one day of age. Each treatment consisted of 90 randomly selected birds divided into three replicates of 30 birds each. Birds fed the 5, 50, and 100 ppm level of toxaphene exhibited osteomalacia manifested by sternal deformities and extremely friable ribs. A decrease in egg shell strength was found in chickens eating feed containing 5 ppm level of toxaphene. Toxaphene did not significantly alter egg production, hatchability or fertility in this trial.

Opacity measurements of a hot iron plasma using an x-ray laser

The temporal evolution of the opacity of an iron plasma at high temperature (30-350 eV) and high density (0.001-0.2 g cm-3) has been measured using a nickel-like silver x-ray laser at 13.9 nm. The hot dense iron plasma was created in a thin (50 nm) iron layer buried 80 nm below the surface in a plastic target that was heated using a separate 80 ps pulse of 6-9 J, focused to a 100 microm diameter spot. The experimental opacities are compared with opacities evaluated from plasma conditions predicted using a fluid and atomic physics code.

Evaluation of estrogenic activity of plant extracts for the potential treatment of menopausal symptoms

Eight botanical preparations that are commonly used for the treatment of menopausal symptoms were tested for estrogenic activity. Methanol extracts of red clover (Trifolium pratense L.), chasteberry (Vitex agnus-castus L.), and hops (Humulus lupulus L.) showed significant competitive binding to estrogen receptors alpha (ER alpha) and beta (ER beta). With cultured Ishikawa (endometrial) cells, red clover and hops exhibited estrogenic activity as indicated by induction of alkaline phosphatase (AP) activity and up-regulation of progesterone receptor (PR) mRNA. Chasteberry also stimulated PR expression, but no induction of AP activity was observed. In S30 breast cancer cells, pS2 (presenelin-2), another estrogen-inducible gene, was up-regulated in the presence of red clover, hops, and chasteberry. Interestingly, extracts of Asian ginseng (Panax ginseng C.A. Meyer) and North American ginseng (Panax quinquefolius L.) induced pS2 mRNA expression in S30 cells, but no significant ER binding affinity, AP induction, or PR expression was noted in Ishikawa cells. Dong quai [Angelica sinensis (Oliv.) Diels] and licorice (Glycyrrhiza glabra L.) showed only weak ER binding and PR and pS2 mRNA induction. Black cohosh [Cimicifuga racemosa (L.) Nutt.] showed no activity in any of the above in vitro assays. Bioassay-guided isolation utilizing ER competitive binding as a monitor and screening using ultrafiltration LC-MS revealed that genistein was the most active component of red clover. Consistent with this observation, genistein was found to be the most effective of four red clover isoflavones tested in the above in vitro assays. Therefore, estrogenic components of plant extracts can be identified using assays for estrogenic activity along with screening and identification of the active components using ultrafiltration LC-MS. These data suggest a potential use for some dietary supplements, ingested by human beings, in the treatment of menopausal symptoms.

Attenuation and immunogenicity of a Brucella abortus htrA cycL double mutant in cattle

PHE1 is a htrA cycL double gene deletion mutant of virulent Brucella abortus strain 2308 (S2308) which has previously been evaluated in the murine and caprine models of bovine brucellosis. This report describes the results of studies conducted with this mutant in the natural bovine host. Six sexually mature, non-gravid heifers were inoculated via the conjunctival sac with 1 x 10(10) colony forming units (CFU) of either the parental S2308 or the htrA cycL gene deletion mutant, PHE1. At 4, 7 and 11 days post-inoculation, PHE1 was found to colonize the bovine host at lower levels than S2308. In a second experiment, eight heifers in mid-gestation were infected with 1 x 10(7) CFU of either strain via the conjunctival sac. The virulent S2308 caused abortions or weak calves in 4/4 cows, while all four cows infected with PHE1 had healthy calves. Furthermore, PHE1 exhibited decreased resistance to killing by cultured bovine neutrophils and macrophages compared to the parental strain. These studies demonstrate that the B. abortus htrA cycL gene deletion mutant PHE1 is highly attenuated in the bovine host when compared to the virulent parental S2308.

Suicide in the farming community: methods used and contact with health services

Farmers have a high rate of suicide (1% of suicides in England and Wales). This study sought to test whether farmers would be less likely to have been in contact with primary or mental health services before death due to their reluctance to seek help. The study also sought to identify other characteristics that differentiated suicide among male farmers from other professional groups. A retrospective case-control design was used comparing male farmers with an age and sex matched control group. Cases were all members of the farming community within the Exeter Health District on whom suicide or open verdict had been recorded between 1979 and 1994. 63 Cases were identified and entered into the study. Controls were non-farmers with the same verdict who were matched for age (5 year age bands) sex and social class. Farmers were significantly more likely to use firearms to kill themselves (42% of farmers v 11% controls). They were less likely to use a car exhaust or to die by poisoning (9% farmers v 50% controls). Farmers were significantly less likely to leave a suicide note (21% farmers v 41% controls). There was no significant difference between farmers and controls for numbers in contact with their general practitioner or mental health services in the 3 months before death. There may be some differences in help seeking behaviour between farmers and the general population as over 30% of farmers presented with exclusively physical symptoms. General practitioners should consider depressive and suicidal intention in farmers presenting with physical problems. When depression is diagnosed consideration should be given to the temporary removal of firearms as the high rate of suicide in the farming community may be strongly influenced by access to means.

Sex and relationships following childbirth: a first report from general practice of 131 couples

Changes in a couple's sexual relationship following childbirth may be more significant than previous studies have suggested. Around 50% of first-time parents in this study described their sex life as 'poor' or 'not very good' eight months after the birth of their baby, and one in five said that they would like help for this. First-time parents rating their general relationship as 'poor' or 'not very good' rose from 1% before pregnancy to 20% eight months after childbirth. Changes in the general relationship and the quality of sex life were associated in these couples.

Using scenarios in chronic disease management guidelines for primary care

The Prodigy system is a guideline-based decision-support system designed to assist general practitioners in England choose the appropriate therapeutic action for their patients. As part of the system, we developed a novel model for encoding clinical guidelines for managing patients with chronic diseases such as asthma and hypertension. The model structures a guideline as a set of choices to be made by the clinician. It models patient scenarios which drive decision making and are used to synchronize the management of a patient with guideline recommendations. The model is robust with respect to available input data and leaves the control of decision-making to the clinician. We have built execution engines to verify the computability of the model. We intend to test the model integrated in up to 200 live systems from at least four system vendors in English General practice.

The TextBase project--implementation of a base level message supporting electronic patient record transfer in English general practice

The TextBase project is a laboratory experiment to assess the feasibility of a common exchange format for sending a transcription of the contents of the Electronic Patient Record (EPR) between different general practices, when patients move from one practice to another in the NHS in England. The project was managed using a partnership arrangement between the four EPR systems vendors who agreed to collaborate and the project team. It lasted one year and consisted of an iterative design process followed by creation of message generation and reading modules within the collaborating EPR systems according to a software requirement specification created by the project team. The paper describes the creation of a common record display format, the implementation of transfer using a floppy disk in the lab, and considers the further barriers before a national implementation might be achieved.

The PRODIGY project--the iterative development of the release one model

We summarise the findings of the first two research phases of the PRODIGY project and describe the guidance model for Release One of the ensuing nationally available system. This model was a result of the iterative design process of the PRODIGY research project, which took place between 1995 and 1998 in up to 183 general practices in the England. Release One of PRODIGY is now being rolled out to all (27,000) General Practitioners in England during 1999-2000.

Plasminogen activator in acute myeloid leukaemic marrows: u-PA in contrast to t-PA in normal marrow

Leukaemic and normal bone marrow samples were compared in terms of their content of the fibrinolytic agents, tissue plasminogen activator (t-PA) and urokinase-type plasminogen activator (u-PA) and their inhibitors. plasminogen activator inhibitors 1 and 2 (PAI-1 and PAI-2). Normal marrow contained t-PA as the principal plasminogen activator, whereas in leukaemic marrow samples u-PA was the predominant activator. Both normal and leukaemic marrows contained PAI-1 in similar amounts, but whereas normal marrow contained significant amounts of PAI-2 the leukaemic marrows contained very little. Plasminogen activators were present in uncomplexed, active forms and plasmin-alpha2-antiplasmin complexes were generated locally more prominently in leukaemic marrows. u-PA associated with blast cells may contribute to the severe forms of haemorrhage sometimes occurring in myeloid types of leukaemia.

A critique of 'at risk' pressure sore assessment tools

This paper critiques pressure sore risk assessment tools. No attempt is made to describe individual tools in detail as this literature is available elsewhere. The economic case for risk assessment is presented along with the criteria for an effective risk assessment instrument. Reliability and validity studies are reviewed in relation to three risk assessment tools: Norton, Waterlow and Braden. Finally a number of issues related to threshold scores, research design and the need to view pressure sores as a clinical problem rather than a nursing problem are discussed.

What are the Read Codes?

The Read Codes were initially developed by a general practitioner, Dr James Read from Loughborough, in the early 1980s and rapidly gained acceptance by general practitioners as a popular and useful mechanism for storing structured information about patients in individual, patient-based records, which were beginning to become popular in a few general practices at the time. This short article aims to explain the past and future development of the coding system in the National Health Service as a whole.