A262 NEONATAL ACUTE LIVER FAILURE DUE TO PRESUMED GESTATIONAL ALLOIMMUNE LIVER DISEASE - A CASE REPORT

Background

Neonatal acute liver failure (NALF) is a rare disease that is distinct from acute liver failure seen in older children and adults. Gestational alloimmune liver disease (GALD) is the most frequent cause, is initiated in utero by sensitization of the maternal immune system to a fetal hepatocyte antigen and subsequent production of maternal immunoglobulin G antibodies that cross the placenta. Maternal IgG binds to a fetal hepatocyte antigen and initiates an innate immune response involving the terminal complement cascade and membrane attach complex. The understanding of the alloimmune origin has led to the use of intravenous immunoglobulin (IVIG) treatment and exchange transfusion, significantly increasing survival. However, approximately 25% of patients may not respond and require salvage liver transplantation. In spite of an increased rate of comorbidities, concern for technical difficulties and limited graft availability, young infants eligible for transplant have been shown to have similar overall patient and graft survival rates compared to older children with other indications for liver transplant.

Purpose

The primary aim of our study is to report a case of NALF with successful liver transplant.

Method

We present the case of a preterm girl with NALF due to GALD refractory to medical management, requiring liver transplantation.

Result(s)

This is a 35-week preterm girl, with scant pre-natal care, birth weight of 1.825 kg and Apgar 9/9. She is the seventh child of non-consanguineous parents, with healthy siblings. On day-of-life (DOL) 1 she presented with acute kidney injury, progressive worsening metabolic acidosis and hyperammonemia and was found to be profoundly coagulopathic (INR 6), with normal liver enzymes and liver failure was diagnosed. Initial investigation ruled out congenital infections, sepsis, neonatal hemophagocytic lymphohistiocytosis and metabolic diseases. Magnetic resonance imaging of the body demonstrated findings in keeping with iron deposition in the thyroid, liver and pancreas, suggestive of GALD. Completed double volume exchange transfusion and IVIG on DOL 9 and repeat IVIG on DOL 13 and 15, with partial improvement in INR. Due to persistent ascites, conjugated hyperbilirubinemia and hyperammonemia she was transferred for urgent liver transplant assessment. Persistent liver dysfunction in the form of hyperammonemia, hypoglycemia and progressive coagulopathy led to transplant listing on DOL 30. ABO incompatible deceased donor liver transplant was completed on DOL 62 (4.075 kg, estimated dry weight 3.5 kg). The procedure was uncomplicated, liver enzymes normalized, coagulopathy and hypoglycemia resolved. She was transferred to the ward on post-operative day (POD) 6. and weaned off sedatives and transitioned to oral feeds within 2 weeks of transplant, with complex abdominal wound closure on POD 29.

Conclusion(s)

Successful liver transplantation is possible in neonates with acute liver failure due to GALD refractory to medical management and weighing 4kg or less.

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Disclosure of Interest

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MICROBIOME & MICROBIAL THERAPY

1103 AN EVALUATION OF A GERIATRICIAN-LED ACUTE MEDICAL ADMISSION UNIT AT MORRISTON HOSPITAL, SWANSEA

Introduction

The medical intake at Morriston Hospital is accepted on two units; Rapid Assessment Unit (RAU) and Acute Medical Assessment Unit. Both were acute physician-led until July 2021

Method

(Phase 1). From July 2021, RAU became geriatrician-led (Phase 2). This evaluation concerns the performance of RAU.

Phase 1 (Acute Physician-Led Unit) Between 01/08/2020-30/06/2021, there were 3102 admissions with a median length of stay (LOS) of 2 days on RAU. 37.2% of patients were discharged directly from the unit. (SBUHB data). A detailed analysis of 496 patients consecutively assessed between November 2020–January 2021 showed a median LOS on RAU of 1, 28.8% were discharged directly from RAU. Overall health board (HB) median LOS for the cohort was 7. In over 70 years, median LOS on RAU was 1, overall HB LOS 9.

Phase 2 (Geriatrician-Led Unit) 1237 patients were assessed July-December 2021, with a median LOS of 2 days. 42.8% of patients were discharged from RAU. (SBUHB data). A detailed analysis of 566 patients consecutively assessed between September-November 2021 showed a median LOS on RAU of 2, 41.7% discharged directly from RAU. Overall HB median LOS for the entire cohort was 5. For the > 70 years, median LOS on RAU was 2, overall HB LOS was 7. Patient flow through assessment areas is dependent on the function of downstream medical wards. Mean LOS within medicine at Morriston increased 1.5 days between Phase 1 and Phase 2.

Results

Acute geriatricians have delivered the 72hr LOS standard that SBUHB has set for assessment areas. The unit has achieved a reduction in overall LOS for the cohort of patients evaluated (p<.01), especially for the > 70 years (p=.007).

Conclusion

This data supported a change in practice; RAU has taken a frailty specific intake since January 2022.

Cost of post-deployment screening for mental illness in the UK military: findings from a cluster randomised controlled trial

BACKGROUND

Little is known about the economic impact of military mental health screening.

AIMS

To investigate (a) whether post-deployment screening of military personnel affects use and cost of services and (b) the impact of psychiatric morbidity on costs.

METHODS

Participants were recruited from UK Royal Marine and Army platoons and randomised to an intervention group (which received tailored advice predicated upon mental health status) or a control group (which received general advice following assessment of mental health status). The intervention costs were calculated while service use and associated costs were assessed at 12-month follow-up.

RESULTS

Data were available for 6323 participants. Mean screening cost was £34. Service costs were slightly higher in the control group compared to the intervention group (£1197 vs. £1147) which was not statistically significant (bootstrapped 95%CI, -£363 to £434. In both groups, screening and control, costs were significantly higher for those who screened positive for mental health problems.

CONCLUSIONS

Costs were not affected by screening. In countries that have already implemented post-deployment screening, the political cost of disinvestment needs careful consideration. Those who develop psychiatric morbidity have substantially higher care costs than those who do not.

Body mass index and survival in people with heart failure

Background

People with obesity are twice as likely to develop heart failure (HF) compared to people with a healthy body mass index (BMI) [1]. However, among people with HF a higher BMI has been linked to a reduced risk of all-cause mortality, a concept known as the “obesity paradox” [2].

Purpose

To examine the association between BMI and survival in patients with chronic HF among a large primary care cohort.

Methods

We extracted data from the Clinical Practice Research Datalink of primary care records from 1st January 2000 to 31st December 2017 and included 47,531 patients with an incident diagnosis of HF, who were aged 45 years and over and who had a recorded BMI. Patients were stratified into categories of baseline BMI as underweight (BMI <18.5 kg/m2), healthy weight (BMI 18.5 to 24.9 kg/m2), overweight (BMI 25.0 to 29.9 kg/m2) or obese, with obesity split into class I (30.0–34.9 kg/m2), class II (35.0–39.9 kg/m2) and class III (40 kg/m2 and over). The primary outcome was all-cause mortality. We used Kaplan-Meier curves and log rank tests to compare survival in people with HF, based on baseline BMI. We also report a Cox regression model for risk of all-cause mortality among people with HF comparing BMI categories.

Results

There were 25,013 deaths during the study follow-up. The average age of participants was 77.1 years (SD 10.6) and mean BMI was 27.9 (SD 6.1). In an age- and sex-adjusted analysis, people who were underweight were at increased risk of all-cause mortality compared to people with healthy weight (HR 1.52, 95% CI 1.41 to 1.64). People with overweight (HR 0.81, 95% CI 0.79 to 0.84), obesity class I (HR 0.79, 95% CI 0.76 to 0.82) and obesity class II (HR 0.78, 95% CI 0.74 to 0.82) were at decreased risk of all-cause mortality. People with obesity class III had no difference in risk of death compared to people with healthy weight (HR 0.95, 95% CI 0.88 to 1.02). In a Kaplan-Meier analysis, there was an inverse relationship between body weight and risk of death, even within the first year of follow-up.

Conclusion

In our large community cohort of people with HF, we found an inverse relationship between BMI and survival. Underweight people with HF have the poorest prognosis and should be identified as high-risk. Conversely, people with HF who are overweight or obese (class I and II) are at lower risk of death confirming the obesity paradox in a real-world primary care population. These findings suggest a more cautious approach to weight management in overweight and obese patients may be needed for people with HF in primary care.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): The SurviveHF study was funded by the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) Oxford at Oxford Health NHS Foundation Trust and the Wellcome Institutional Strategic Fund. The funders did not have any role in the design of the study, analysis and interpretation of the data, or writing of the results for publication.

Survival among people with heart failure and atrial fibrillation; a population cohort study

Background

People with chronic heart failure (HF) have a poor prognosis, with survival rates at five year follow-up close to 50%.1 More than half of patients with HF will develop atrial fibrillation (AF). The presence of AF in people with HF has been associated with a poor prognosis, irrespective of left ventricular ejection fraction. 2,3 However, the majority of studies to date have analysed prognosis among secondary care cohorts or randomised trial participants, who may not be representative of patients with chronic HF in the community.2

Purpose

To examine the association between survival in patients with HF and AF compared to either condition alone, among a large primary care cohort.

Methods

We extracted data from the Clinical Practice Research Datalink of primary care records from 1st January 2000 to 31st December 2018 and included all patients aged 45 years and over who were registered at an up-to-standard practice for a minimum of 12 months. Records were linked to Hospital Episode Statistics for secondary care data. The primary outcome was all-cause mortality. Exposure groups were defined as HF+AF, HF or AF, with exposure status treated as a time-varying covariate across follow-up. We used Cumulative Hazard plots to compare survival in people with HF and AF, compared to people with either condition alone or neither. We also report a Cox regression model for risk of all-cause mortality among people with HF and AF, adjusting for age, sex, ethnicity, smoking status and comorbid cardiovascular disease.

Results

There were 314,042 deaths during the study follow-up. The average age of participants was 58.0 years (SD 10.6) and 51.4% were women. At some point across follow-up, 94,990 people had HF alone, 147,815 had AF alone and 74,470 had both HF and AF. In an unadjusted Cox regression analysis, people with HF and AF were at the greatest risk of death (HR 17.94, 95% CI 17.75 to 18.13), followed by people with HF alone (HR 12.00, 95% CI 11.87 to 12.13), and AF alone (HR 6.14, 95% CI 6.08 to 6.21) compared to people with neither HF nor AF. In the fully adjusted analysis, the risk of death remained highest among people with HF and AF (HR 3.78, 95% CI 3.73 to 3.83), followed by people with HF alone (HR 3.06, 95% CI 3.02 to 3.10), then people with AF alone (HR 1.85, 95%, CI 1.82 to 1.87). In a cumulative hazard plot, the risk of death across follow-up was similar among people with HF and AF, compared to those with HF alone.

Conclusion

In our large community cohort, we found HF and AF was associated with a worse prognosis than either condition alone. Both HF and AF were also associated with a poor prognosis. These results support the findings of previous secondary care and trial studies regarding the importance of AF as a prognostic indicator among people with HF. Further research could aim to identify preventive strategies that might improve prognosis among this high-risk group of patients.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): The study was undertaken as part of NRJ's Doctoral Research Fellowship, supported by the Wellcome Trust (grant number 203921/Z/16/Z), with additional funding for this project from the National Institute for Health Research (NIHR) Collaboration for Applied Health Research (CLAHRC) Oxford at Oxford Health NHS Foundation Trust (P2-001).

Phenotypes of disease severity in a cohort of hospitalized COVID-19 patients: Results from the IMPACC study

BACKGROUND

Better understanding of the association between characteristics of patients hospitalized with coronavirus disease 2019 (COVID-19) and outcome is needed to further improve upon patient management.

METHODS

Immunophenotyping Assessment in a COVID-19 Cohort (IMPACC) is a prospective, observational study of 1164 patients from 20 hospitals across the United States. Disease severity was assessed using a 7-point ordinal scale based on degree of respiratory illness. Patients were prospectively surveyed for 1 year after discharge for post-acute sequalae of COVID-19 (PASC) through quarterly surveys. Demographics, comorbidities, radiographic findings, clinical laboratory values, SARS-CoV-2 PCR and serology were captured over a 28-day period. Multivariable logistic regression was performed.

FINDINGS

The median age was 59 years (interquartile range [IQR] 20); 711 (61%) were men; overall mortality was 14%, and 228 (20%) required invasive mechanical ventilation. Unsupervised clustering of ordinal score over time revealed distinct disease course trajectories. Risk factors associated with prolonged hospitalization or death by day 28 included age ≥ 65 years (odds ratio [OR], 2.01; 95% CI 1.28-3.17), Hispanic ethnicity (OR, 1.71; 95% CI 1.13-2.57), elevated baseline creatinine (OR 2.80; 95% CI 1.63- 4.80) or troponin (OR 1.89; 95% 1.03-3.47), baseline lymphopenia (OR 2.19; 95% CI 1.61-2.97), presence of infiltrate by chest imaging (OR 3.16; 95% CI 1.96-5.10), and high SARS-CoV2 viral load (OR 1.53; 95% CI 1.17-2.00). Fatal cases had the lowest ratio of SARS-CoV-2 antibody to viral load levels compared to other trajectories over time (p=0.001). 589 survivors (51%) completed at least one survey at follow-up with 305 (52%) having at least one symptom consistent with PASC, most commonly dyspnea (56% among symptomatic patients). Female sex was the only associated risk factor for PASC.

INTERPRETATION

Integration of PCR cycle threshold, and antibody values with demographics, comorbidities, and laboratory/radiographic findings identified risk factors for 28-day outcome severity, though only female sex was associated with PASC. Longitudinal clinical phenotyping offers important insights, and provides a framework for immunophenotyping for acute and long COVID-19.

FUNDING

NIH.

User attitudes towards virtual home assessment technologies

Telehealth has long been highlighted as a way to solve issues of efficiency and effectiveness in healthcare and to improve patients' care and has become fundamental to address patients' needs during the COVID-19 pandemic; however previous studies have shown mixed results in the user acceptance of such technologies. Whilst many previous studies have focussed on clinical application of telehealth, we focus on the adoption of telehealth for virtual assessments visits aimed to evaluate the suitability of a property where a patient is discharged, and eventual adaptations needed. We present a study of stakeholders' attitudes towards such virtual assessment visits. The study has been carried out with healthcare professionals and patients and allowed us to identify user attitudes, barriers and facilitators for the success of virtual assessment visits from the point of view of healthcare professionals and patients. Finally, we discuss implications for designers of telehealth services and guidelines that can be derived from our study.

Natriuretic peptide referral thresholds and heart failure diagnosis: population-based cohort study

Background

Natriuretic peptide (NP) testing is recommended by both the European Society of Cardiology (ESC) and the National Institute for Health and Care Excellence (NICE) for people presenting with symptoms of heart failure (HF) in primary care. However, ESC and NICE guidelines suggest different NP referral thresholds: ESC recommend referral at a lower NP level (BNP≥35pg/ml / NT-proBNP≥125pg/ml) compared to NICE (BNP≥100pg/ml/NT-proBNP≥400pg/ml).

Purpose

We aimed to evaluate NP test performance for HF diagnosis for ESC and NICE guideline-defined thresholds.

Methods

Population-based cohort study using linked primary and secondary care data from the Clinical Practice Research Datalink in England between 1st January 2000 and 31st December 2018. Participants were adults aged 45 years and above with a NP result: 74,233 had a BNP and 155,347 had a NT-proBNP measurement. The main outcome measures were diagnostic performance of NP test (sensitivity, specificity, positive predictive value, negative predictive value) by threshold.

Results

A total of 229,580 patients had a NP test and 21,102 (9.2%) were diagnosed with HF. The ESC NT-proBNP threshold of 125pg/ml had a sensitivity of 94.6% (94.2 to 95.0) and specificity of 50.0% (49.7 to 50.3) compared to sensitivity of 81.7% (81.0 to 82.3) and specificity of 80.3% (80.0 to 80.5) for the NICE NT-proBNP 400pg/ml threshold. For both guidelines, nearly all patients with a NP level below the threshold did not have HF (negative predictive value ESC 98.9% (98.8 to 99.0) and NICE 97.7% (97.6 to 97.8). Similar performance was found for BNP.

Conclusions

The performance of NP testing is dependent on the guideline-specified threshold for referral. In 100 people with HF, using the NICE threshold would falsely reassure 18 patients, whereas the lower ESC threshold would miss just 5 people but twice as many patients would be referred for diagnostic assessment. The optimal NP threshold for referral for HF diagnosis will depend on the healthcare setting. The trade-off between missing HF cases and overwhelming diagnostic services needs to be determined at a national level.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): National Institute for Health Research

Assessment of immune biomarkers and establishing a triple negative phenotype in gynecologic cancers

OBJECTIVE

Immuno-oncology (IO) has rapidly evolved, with many IO therapies either approved or under investigation for multiple malignancies. Biomarkers exist that can predict response to IO therapies including PD-L1 expression, microsatellite instability (MSI), and total mutation burden (TMB). This paper serves to analyze the presence of these biomarkers across gynecologic cancers.

METHODS

A total of 16,300 gynecologic cancer specimens submitted for molecular profiling to Caris Life Sciences were reviewed. Immunohistochemistry was performed using the SP142 anti-PD-L1 clone and assessed for intensity. Next-generation sequencing, immunohistochemistry, and fragment analysis were used to determine MSI status. TMB was measured by counting all non-synonymous missense mutations found per tumor not previously described as germline alterations. Chi-Square, Fisher Exact, and the Kruskal-Wallis test were used to compare cohorts.

RESULTS

Of 16,300 specimens, 54.1% were ovarian, 37.2% uterine, 7.2% cervical, 0.3% vulvar, 1.2% vaginal, with 0.1% unspecified. MSI-H was most frequent in uterine cancer (17.7%) and only 1% of ovarian cancers. PD-L1 expression was present in 38.3% of cervical and 62.5% of vulvar cancers, but less than 8% of ovarian and uterine cancers. TMB-H was present in 21.1% cervical, 19.7% uterine, and 5% ovarian cancers. Few specimens exhibited a "triple positive" phenotype - 0.3% ovarian, 1.5% uterine, and 1.5% cervical. Associations were seen between MSI, TMB, and PD-L1 across all cancer types.

CONCLUSIONS

The frequency of individual biomarkers pertinent to IO therapy varies by cancer type. HPV-driven genital tract cancers have higher frequencies of PD-L1 expression, MSI-H, and TMBH. Endometrial cancers are characterized by MSI-H and TMB, whereas ovarian cancers have a low frequency of MSI-H and modest PD-L1 or TMBH. The incidence of 'triple positive" cases was less than 2%.

Designing a survey to monitor multi-scale impacts of agri-environment schemes on mobile taxa

Agri-environment schemes (AES) are key mechanisms to deliver conservation policy, and include management to provide resources for target taxa. Mobile species may move to areas where resources are increased, without this necessarily having an effect across the wider countryside or on populations over time. Most assessments of AES efficacy have been at small spatial scales, over short timescales, and shown varying results. We developed a survey design based on orthogonal gradients of AES management at local and landscape scales, which will enable the response of several taxa to be monitored. An evidence review of management effects on butterflies, birds and pollinating insects provided data to score AES options. Predicted gradients were calculated using AES uptake, weighted by the evidence scores. Predicted AES gradients for each taxon correlated strongly, and with the average gradient across taxa, supporting the co-location of surveys across different taxa. Nine 1 × 1 km survey squares were selected in each of four regional blocks with broadly homogenous background habitat characteristics. Squares in each block covered orthogonal contrasts across the range of AES gradients at local and landscape scales. This allows the effects of AES on species at each scale, and the interaction between scales, to be tested. AES options and broad habitats were mapped in field surveys, to verify predicted gradients which were based on AES option uptake data. The verified AES gradient had a strong positive relationship with the predicted gradient. AES gradients were broadly independent of background habitat within each block, likely allowing AES effects to be distinguished from potential effects of other habitat variables. Surveys of several mobile taxa are ongoing. This design will allow mobile taxa responses to AES to be tested in the surrounding countryside, as well as on land under AES management, and potentially in terms of population change over time. The design developed here provides a novel, pseudo-experimental approach for assessing the response of mobile species to gradients of management at two spatial scales. A similar design process could be applied in other regions that require a standardized approach to monitoring the impacts of management interventions on target taxa at landscape scales, if equivalent spatial data are available.

The TLR7 agonist vesatolimod induced a modest delay in viral rebound in HIV controllers after cessation of antiretroviral therapy

Toll-like receptor 7 (TLR7) agonists, in combination with other therapies, can induce sustained control of simian-human immunodeficiency virus (SHIV) or simian immunodeficiency virus (SIV) in nonhuman primates. Here, we report the results of a randomized, double-blind, placebo-controlled phase 1b clinical trial of an oral TLR7 agonist, vesatolimod, in HIV-1-infected controllers on antiretroviral therapy (ART). We randomized participants 2:1 to receive vesatolimod (n = 17) or placebo (n = 8) once every other week for a total of 10 doses while continuing on ART. ART was then interrupted, and the time to viral rebound was analyzed using the Kaplan-Meier method. Vesatolimod was associated with induction of immune cell activation, decreases in intact proviral DNA during ART, and a modest increase in time to rebound after ART was interrupted. The delayed viral rebound was predicted by the lower intact proviral DNA at the end of vesatolimod treatment (13 days after the final dose). Inferred pathway analysis suggested increased dendritic cell and natural killer cell cross-talk and an increase in cytotoxicity potential after vesatolimod dosing. Larger clinical studies will be necessary to assess the efficacy of vesatolimod-based combination therapies aimed at long-term control of HIV infection.

POS0792 BASELINE FACTORS ASSOCIATED WITH LUPUS FLARES: A POST-HOC ANALYSIS OF PATIENTS WITH MODERATE TO SEVERE ACTIVE SYSTEMIC LUPUS ERYTHEMATOSUS ENROLLED IN A 48 WEEK PHASE II RANDOMIZED CLINICAL TRIAL

Background:

Systemic lupus erythematosus (SLE) is a chronic disease characterized by periodic flares associated with poor outcomes and subsequent organ damage (1-2). Flare prevention is important for optimal patient management and development of effective therapies.

Objectives:

To identify patient-level factors associated with flares among patients with moderate/severe SLE.

Methods:

We conducted a post-hoc analysis of 260 patients with active, autoantibody+ SLE enrolled in a phase II randomized clinical trial (Fenebrutinib) (3). The relationship between baseline demographic (age, gender, ethnicity, BMI), region (US/EU, outside US/EU), disease severity (PGA, SLEDAI-2K, BILAG domain involvement), disease duration, serologic markers (C3, C4, ANA, anti-dsDNA Ab, anti-Smith Ab), treatment arm, standard of care (SOC) and flares (BILAG and SFI) over 48 wks was assessed by survival analysis and multiple Cox Proportional Hazard models. We examined concordance between BILAG and SFI flares using Cohen’s Kappa Index.

Results:

The overall rate of flare was low (n=37 SFI flare, n=25 BILAG flare). Median time to first flare was 8 wks for SFI flares compared to 12 wks for BILAG flares. There was no difference in flare rate by treatment arm. Cumulative flare hazard increased over time. Concordance between SFI and BILAG flares was 0.14. Multivariable analyses identified a higher flare rate for both SFI and BILAG-defined flares in patients with severe disease at baseline (PGA >1.7, SLEDAI-2K ≥10) and <7 y disease duration.

Flares were more common in patients ANA, anti-dsDNA and anti-Smith+ at baseline compared to patients with <3 + markers (p<.001). Furthermore, anti-dsDNA (p = .03) and/or anti-Smith (p = .001) positivity at baseline were better indicators of higher flare rate compared to ANA (p = 0.5). Low baseline complement level (C3 and C4) was associated with a higher flare rate (p = .03 and p = .03 respectively).

Patients from non-US/EU regions had a higher flare rate compared to patients from the US/EU, despite receiving more frequent SOC therapy and higher baseline corticosteroid doses (≥10 mg/d). Overall, flare-free probability was comparable at 48 wks regardless of baseline corticosteroid dose but patients receiving <10 mg/d had a median time to flare of 4 vs 24 wks for those receiving ≥10 mg/d (p = .004).

Conclusion:

In this study, flares were more common among patients with more severe disease, shorter disease duration, multiple serologic markers, were from outside the US/EU, and received lower steroid doses at baseline.

References:

[1]Fernandez D and Kirou KA. Curr Rheumatol Rep 2016 18:14.

[2]Stoll T, et al. Rheum (Oxford) 2004 43(8):1039–44.

[3]Isenberg D, et al. Arth Rheum 2019 71 suppl 10.

Baseline Factors (%)No Flare n=206FlareBILAG n=25SFI n=37BILAG and SFI n=8Age (mean (SD))41.8 (12)35.2 (9)40.4 (10)34.9 (8)Female199 (97)24 (96)35 (95)7 (88)PGA (mean (SD))1.7 (0.5)1.7 (0.4)1.9 (0.5)1.7 (0.6)BILAG A/B any domain197 (96)23 (92)35 (95)7 (88)SLEDAI 2K >=1087 (42)18 (72)17 (46)4 (50)Disease duration (y) (mean (SD))9.4 (7)5.3 (4)6.6 (6)2.9 (3)ANA +203 (99)24 (96)35 (95)8 (100)anti-dsDNA +102 (50)18 (72)21 (57)5 (63)anti-Smith +45 (22)13 (52)12 (32)4 (50)Low C357 (28)12 (48)13 (35)3 (38)Low C426 (13)7 (28)4 (11)1 (13)Non US/EU157 (76)21 (84)32 (87)8 (100)Corticosteroid130 (63)14 (56)21 (57)5 (63) ≥10 mg/d80 (39)9 (36)14 (38)4 (50)Immunosuppressant74 (36)12 (48)15 (41)3 (38)Antimalarial135 (66)14 (56)21 (57)5 (63)

Notes: included patients 18-75 y; 1+ serologic marker of SLE; SLEDAI-2K >=8, PGA>=1; 1+ oral SOC treatment

SFI = SELENA- SLEDAI Flare Index

Disclosure of Interests:

Lisa Lindsay Shareholder of: Employee of Genentech, Inc., Employee of: Employee of Genentech, Inc., Huiyan (Ashley) Mao Shareholder of: Employee of Hoffmann-La Roche Limited, Employee of: Employee of Hoffmann-La Roche Limited, Ji (Emmy) Cheng Shareholder of: Employee of Hoffmann-La Roche Limited, Employee of: Employee of Hoffmann-La Roche Limited, Ching-Yi Chuo Shareholder of: Employee of Genentech, Inc., Employee of: Employee of Genentech, Inc., Nicholas Jones Shareholder of: Employee of Genentech, Inc., Employee of: Employee of Genentech, Inc., Matthew D. Cascino Shareholder of: Employee of Genentech, Inc., Employee of: Employee of Genentech, Inc., Katie Tuckwell Shareholder of: Employee of Genentech, Inc., Employee of: Employee of Genentech, Inc.

102 Peer Teaching in Hip Fracture: Responding to the Medical Needs of Surgical Patients and Educational Needs of Junior Doctors

Introduction

Fractured Neck of Femur (FNOF) patients are complex. A mortality project identified topics for a peer-led teaching programme.

Method

Eight bite-sized case-based sessions were devised, to provide a framework to approach the following topics: Anaemia, delirium/dementia, ECG abnormalities, metastatic cancer, osteoporosis, renal disease, respiratory disease, and vascular complications. Attendees were asked to complete pre- and post- teaching programme questionnaires using a Likert Scale to indicate agreement with statements relating to the topic areas chosen (1=strongly disagree and 5=strongly agree).

Result

Pre-programme questionnaire: respondents were neutral (average 3.04) when asked whether topic areas were currently “well managed”. Attendees lacked confidence, indicating preparedness as neutral (average 3.35). Trainees agreed that they would benefit from teaching (average 4.56).

Post-programme questionnaire: increased confidence was reported when considering preparedness (average 4.3). Attendees felt the teaching programme was “accessible” and the “topics well-chosen”. 100% of attendees regarded the teaching as ‘excellent’ or ‘very-good’.

Conclusions

Matching patient needs to an educational programme is important.

The “bite-sized” nature of the programme paired with case-based learning increased confidence. A peer-led teaching programme is a positive response to themes emerging from morbidity and mortality reviews.

Mental well-being interventions in the military: The ten key principles

Organisations including the United Kingdom Armed Forces should seek to implement mental health interventions to increase the psychological well-being of their workforce. This editorial briefly presents ten key principles that military forces should consider before implementing such interventions. These include job-focused training; evaluating interventions; the use of internal versus external training providers; the role of leaders; unit cohesion, single versus multiple session psychological interventions; not overgeneralising the applicability of interventions; the need for repeated skills practice; raising awareness and the fallibility of screening.

Impaired immune signaling and changes in the lung microbiome precede secondary bacterial pneumonia in COVID-19

Secondary bacterial infections, including ventilator-associated pneumonia (VAP), lead to worse clinical outcomes and increased mortality following viral respiratory infections including in patients with coronavirus disease 2019 (COVID-19). Using a combination of tracheal aspirate bulk and single-cell RNA sequencing (scRNA-seq) we assessed lower respiratory tract immune responses and microbiome dynamics in 28 COVID-19 patients, 15 of whom developed VAP, and eight critically ill uninfected controls. Two days before VAP onset we observed a transcriptional signature of bacterial infection. Two weeks prior to VAP onset, following intubation, we observed a striking impairment in immune signaling in COVID-19 patients who developed VAP. Longitudinal metatranscriptomic analysis revealed disruption of lung microbiome community composition in patients with VAP, providing a connection between dysregulated immune signaling and outgrowth of opportunistic pathogens. These findings suggest that COVID-19 patients who develop VAP have impaired antibacterial immune defense detectable weeks before secondary infection onset.

Do Junior Entrants to the UK Armed Forces have worse outcomes than Standard Entrants?

INTRODUCTION

The UK is the only permanent member of the UN Security Council that has a policy of recruiting 16 and 17 year old individuals into its regular Armed Forces. Little is known about the consequences of enlisting as a Junior Entrant (JE), although concerns have been expressed. We compare the mental health, deployment history, and pre-enlistment and post-enlistment experiences of personnel who had enlisted as JEs with personnel who joined as Standard Entrants (SEs).

METHOD

Participants from a large UK military cohort study completed a self-report questionnaire between 2014 and 2016 that included symptoms of probable post-traumatic stress disorder (PTSD), common mental disorders, alcohol consumption, physical symptoms and lifetime self-harm. Data from regular non-officer participants (n=4447) from all service branches were used in the analysis. JEs were defined as having enlisted before the age of 17.5 years. A subgroup analysis of participants who had joined or commenced adult service after April 2003 was carried out.

RESULTS

JEs were not more likely to deploy to Iraq or Afghanistan but were more likely to hold a combat role when they did (OR 1.25, 95% CI 1.00 to 1.56). There was no evidence of an increase in symptoms of common mental disorders, PTSD, multiple somatic symptoms (MSS), alcohol misuse or self-harm in JEs in the full sample, but there was an increase in alcohol misuse (OR 1.84, 95% CI 1.18 to 2.87), MSS (OR 1.51, 95% CI 1.04 to 2.20) and self-harm (OR 2.13, 95% CI 1.15 to 3.95) in JEs who had commenced adult service after April 2003. JEs remain in adult service for longer and do not have more difficulties when they leave service.

CONCLUSIONS

JEs do not have worse mental health than SEs, but there is uncertainty in relation to alcohol misuse, MSS and self-harm in more recent joiners. Monitoring these concerns is advisable.

A215 MDR3 DEFICIENCY MIMICKING WILSON DISEASE

Background

The chronic phenotype of ALF includes a broad differential diagnosis. Class III multi-drug resistance P-glycoprotein 3 (MDR3) deficiency, also referred to as progressive familial intrahepatic cholestasis type 3, is an autosomal recessive genetic disorder. It is caused by a defect on the ABCB4 gene located on chromosome 7, which encodes MDR3. MDR3 is responsible for transporting phosphatidylcholine across the canalicular membrane, thereby allowing it to be incorporated into bile micelles. MDR3 deficiency results in increased levels of free bile acids and detergent bile. Progressive cholangiopathy ensues from this detergent bile and indirectly leads to cholestasis and liver failure in severe cases. Significantly increased urinary and hepatic copper (Cu), which are hallmarks of Wilson disease, have also been reported in patients with acute hepatitis and cholestasis including patients with MDR3 deficiency

Aims

We report a case of a girl who presented with a chronic phenotype of PALF, who had multiple features of Wilson disease and so was treated as such until genetic analysis confirmed MDR3 deficiency

Methods

Results

A 6 year old girl presented to the ED with a 1mth history of epistaxis and a 1wk history of abdominal pain and distension, facial edema, pallor and fever. Her family history was significant for parental consanguinity and maternal itch during pregnancy. On examination she had clubbing, scleral icterus and a distended abdomen with hepatosplenomegaly. Her bloodwork showed bicytopenia (HGB 53 & Plts 63) along with liver dysfunction (INR 2.9, albumin 25, conjugated bilirubin 9) and raised liver enzymes (transaminases & GGT &gt;10xULN). Her total serum bile acids were raised at 134. An US showed hepatosplenomegaly with multiple hyperechoic nodules and perisplenic varices. She was extensively worked up for malignancy, autoimmune and metabolic disease. Serum ceruloplasmin was reduced, ophthalmology examination showed no KF rings and her 24hr urinary Cu was 10xULN. Liver Cu quantification was markedly raised at 40xULN. Liver biopsy showed cirrhosis with fibrosis related minimal non-specific portal and septal inflammation. Additionally, complete loss of canalicular staining on immunohistochemistry for MDR3 protein was noted, suggestive of MDR3 deficiency. Based on the Cu levels, a provisional diagnosis of Wilson disease was made and Cu chelation therapy was commenced pending genetic testing. A cholestatic gene panel subsequently showed homozygous pathogenic variant for the ABCB4 gene. Trientine was stopped and she was commenced on ursodeoxycholic acid. Though biochemically she remains largely unchanged, she is clinically stable whilst awaiting a liver transplant

Conclusions

This case highlights the diagnostic difficulties associated with Cu test result interpretation in patients with chronic cholestatic liver disease and urges a thorough consideration of alternative diagnoses of PALF

Funding Agencies

None

An evaluation of PlayStreets in the South Side neighborhood of Columbus, Ohio

AIMS

Outdoor play, physical activity, and social cohesion are crucial indicators of community health. PlayStreets, a street play initiative to engage local children and families in outdoor play, physical activity, and social interactions, were implemented in a low-income neighborhood in Columbus, Ohio throughout the summer of 2019. This article aims to describe the implementation of a hospital-sponsored PlayStreets model executed through support from a community health initiative and to assess neighborhood impact through parent and child surveys.

METHODS

Approximately 350 children attended the events and 69 surveys were collected. Descriptive statistics were used to analyze survey data.

RESULTS

The mean age of children was 7 years, and the majority of children who attended were male. If not for PlayStreets, 55% of caregivers reported that their children would be inside. Event satisfaction levels were high, and 54% of caregivers said that they had more contact with their neighbors because of the events.

CONCLUSIONS

Hospital buy-in and community support were crucial to the success of the event. We found that this model can successfully engage the local community while increasing opportunity for childhood outdoor play, physical activity, and neighborhood social interaction.

Single-Cell Mapping of Progressive Fetal-to-Adult Transition in Human Naive T Cells

Whereas the human fetal immune system is poised to generate immune tolerance and suppress inflammation in utero, an adult-like immune system emerges to orchestrate anti-pathogen immune responses in post-natal life. It has been posited that cells of the adult immune system arise as a discrete ontological "layer" of hematopoietic stem-progenitor cells (HSPCs) and their progeny; evidence supporting this model in humans has, however, been inconclusive. Here, we combine bulk and single-cell transcriptional profiling of lymphoid cells, myeloid cells, and HSPCs from fetal, perinatal, and adult developmental stages to demonstrate that the fetal-to-adult transition occurs progressively along a continuum of maturity-with a substantial degree of inter-individual variation at the time of birth-rather than via a transition between discrete waves. These findings have important implications for the design of strategies for prophylaxis against infection in the newborn and for the use of umbilical cord blood (UCB) in the setting of transplantation.

Circulating CD30+CD4+ T Cells Increase Before Human Immunodeficiency Virus Rebound After Analytical Antiretroviral Treatment Interruption

BACKGROUND

Identification of nonviral markers of human immunodeficiency virus (HIV) infection that increase before viral rebound during analytical treatment interruption (ATI) may affect HIV persistence research. We previously showed that HIV ribonucleic acid (RNA) is enriched in CD30+CD4+ T cells in many individuals. Here, we studied CD30+CD4+ T-cell dynamics before ATI, during ATI (before detectable plasma RNA), and after HIV rebound.

METHODS

Peripheral blood mononuclear cells from 23 participants collected longitudinally from 5 Adult AIDS Clinical Trials Group studies incorporating ATI were included in this study. Flow cytometric characterization of expression of CD30 and markers of T-cell activation and exhaustion were performed along with HIV-1 RNA and deoxyribonucleic acid quantification and measurement of soluble plasma CD30 and CD30 ligand.

RESULTS

The percentage of CD4+ T cells expressing CD30 significantly increased from pre-ATI to postinterruption time points before detectible viremia (1.65 mean relative increase, P = .005). Seventy-seven percent of participants experienced an increase in CD30+ cells before viral rebound. In contrast, there were no significant differences between pre-ATI and postinterruption pre-rebound time points in percentages of lymphocytes expressing CD69, CD38/HLA-DR, or PD-1 until after HIV recrudescence.

CONCLUSIONS

CD30 may be a surrogate marker of early replication or viral transcriptional activity before detection by routine peripheral blood sampling.

Drinking motivations in UK serving and ex-serving military personnel

BACKGROUND

Drinking motivations within the UK military have not been studied despite the high prevalence of alcohol misuse in this group.

AIMS

We aimed to characterize drinking motivations and their demographic, military and mental health associations in UK serving and ex-serving personnel.

METHODS

Serving and ex-serving personnel reporting mental health, stress or emotional problems occurring in the last 3 years were selected from an existing cohort study. A semi-structured telephone interview survey examined participants' mental health, help-seeking, alcohol use and drinking motivations.

RESULTS

Exploratory factor analysis of drinking motivations in military personnel (n = 1279; response rate = 84.6%) yielded 2 factors, labelled 'drinking to cope' and 'social pressure'. Higher drinking to cope motivations were associated with probable anxiety (rate ratio [RR] = 1.4; 95% confidence interval [CI] = 1.3-1.5), depression (RR = 1.3; 95% CI = 1.2-1.4) and post-traumatic stress disorder (RR = 1.4; 95% CI = 1.3-1.6). Higher social pressure motivations were associated with probable anxiety (odds ratio = 1.1; 95% CI = 1.0-1.1). Alcohol misuse and binge drinking were associated with reporting higher drinking to cope motivations, drinking at home and drinking alone.

CONCLUSIONS

Amongst military personnel with a stress, emotional or mental health problem, those who drink to cope with mental disorder symptoms or because of social pressure, in addition to those who drink at home or drink alone, are more likely to also drink excessively.

A systematic review of psychological training or interventions given to UK military personnel prior to deployment

INTRODUCTION

Predeployment stress management/mental health training is routinely delivered in an effort to mitigate potential adverse psychological effects. Little is known about the effectiveness of such interventions.

METHODS

A systematic literature review explored research outcomes related to this subject, using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses reporting guidelines. An electronic database search using key terms identified studies published between January 2007 and March 2019. Comprehensive inclusion/exclusion criteria were applied and study quality was appraised by two reviewers using 12 criteria adapted from the Critical Appraisal Skills Programme (CASP) checklist. Papers were excluded if they were allocated CASP scores ≤10 out of 24.

RESULTS

2003 references were identified; 15 papers fulfilled inclusion criteria and quality threshold requirements. Included studies were randomised controlled trial design (n=8), quasi-experimental (n=5), case report (n=1) and cross-sectional (n=1). Duration of follow-up assessment varied from immediately postintervention to 24 months. The included studies were heterogeneous so clear recommendations relating to predeployment training for military personnel could not be made. Although somewhat disparate, predeployment interventions shared the aim of promoting prior to, during and after deployment health and well-being. Social benefits such as improved cohesion and improved stress management skills were identified in some studies, although substantial mental health and well-being benefits were not found.

CONCLUSIONS

Evidence for the effectiveness of predeployment psychological interventions is scant. Every attempt should be made to use methods and measures to facilitate comparisons across studies, to attempt a longer follow-up timescale and to clarify key trainer characteristics.

Intervention planning for Antibiotic Review Kit (ARK): a digital and behavioural intervention to safely review and reduce antibiotic prescriptions in acute and general medicine

Background

Hospital antimicrobial stewardship strategies, such as ‘Start Smart, Then Focus’ in the UK, balance the need for prompt, effective antibiotic treatment with the need to limit antibiotic overuse using ‘review and revise’. However, only a minority of review decisions are to stop antibiotics. Research suggests that this is due to both behavioural and organizational factors.

Objectives

To develop and optimize the Antibiotic Review Kit (ARK) intervention. ARK is a complex digital, organizational and behavioural intervention that supports implementation of ‘review and revise’ to help healthcare professionals safely stop unnecessary antibiotics.

Methods

A theory-, evidence- and person-based approach was used to develop and optimize ARK and its implementation. This was done through iterative stakeholder consultation and in-depth qualitative research with doctors, nurses and pharmacists in UK hospitals. Barriers to and facilitators of the intervention and its implementation, and ways to address them, were identified and then used to inform the intervention’s development.

Results

A key barrier to stopping antibiotics was reportedly a lack of information about the original prescriber’s rationale for and their degree of certainty about the need for antibiotics. An integral component of ARK was the development and optimization of a Decision Aid and its implementation to increase transparency around initial prescribing decisions.

Conclusions

The key output of this research is a digital and behavioural intervention targeting important barriers to stopping antibiotics at review (see http://bsac-vle.com/ark-the-antibiotic-review-kit/ and http://antibioticreviewkit.org.uk/). ARK will be evaluated in a feasibility study and, if successful, a stepped-wedge cluster-randomized controlled trial at acute hospitals across the NHS.

Massive blood loss protocol 'Code Red' at Papworth Hospital: A closed loop audit

Aim

To investigate if the massive blood loss protocol ‘Code Red’ at a specialist cardiothoracic hospital was activated according to local and national guidelines by a closed loop audit.

Methods

Electronic and paper patient care systems were searched in 2015 and 2018 to access records for the ‘Code Red’ activations. Activation of the massive blood loss protocol was compared against the national standards set by The British Committee for Standards in Haematology. The percentage of cases meeting each of the ten standards in the specialist cardiac unit’s Protocol for the Management of Massive Blood Loss in Adults (adapted from the national standards) were evaluated.

Results

‘Code Red’ protocol was activated on 18 occasions in 2015 and nine occasions in 2018, representing just 0.83 and 0.26% of emergency surgeries, respectively. Between 2015 and 2018, there was a 6% increase of ‘Code Red’ cases being appropriately activated, a 26% increase in the prompt notification of the haematology department upon activation, alongside a 30% increase in the timely delivery of blood products, and a 25% decrease in the average amount of blood transferred prior to ‘Code Red’ activation.

Conclusion

There has been an improvement in the standards of care and management of massive blood loss this specialist cardiac centre despite the target timeframe being reduced from 30 to 15min between 2015 and 2018. Preparation for and anticipation of massive blood loss has likely decreased the number of incidences requiring ‘Code Red’ activation, permitting delivery of safe patient care.

Combat exposure and co-occurring mental health problems in UK Armed Forces personnel

ABSTARCTBackground: Mental disorders and alcohol misuse are often comorbid, and this comorbidity is more common in those who develop mental disorders following exposure to traumatic events.Aims: To investigate the relationship between combat exposure and operational role (support versus combat) with mental disorders and associated comorbidity in a UK military cohort.Methods: 4896 participants from a UK military cohort reported their operational role and frequency of exposure to combat events during deployment. Outcome measures included self-reported post-traumatic stress disorder, common mental disorder and alcohol misuse.Results: Personnel reporting higher levels of combat exposure were more likely to meet criteria for two or more co-occurring mental disorders (odds ratio [OR] 3.90, 95% confidence interval [CI] 2.73-5.58). While having a combat role increased the risk of developing co-occurring disorders compared to having a support role (OR 1.67, 95% CI 1.26-2.23), this effect diminished following adjustment for variables including combat exposure (OR 0.89, 95% CI 0.62-1.27).Conclusions: Combat exposure may play a greater role in the development of comorbid mental disorders than operational role, i.e. job title. Clinicians treating military personnel should be alert to the increased risk of comorbid mental disorders and alcohol misuse among those with a history of combat exposure.

Regional differences in presence of Shiga toxin-producing Escherichia coli virulence-associated genes in the environment in the North West and East Anglian regions of England

Shiga toxin-producing Escherichia coli is carried in the intestine of ruminant animals, and outbreaks have occurred after contact with ruminant animals or their environment. The presence of STEC virulence genes in the environment was investigated along recreational walking paths in the North West and East Anglia regions of England. In all, 720 boot sock samples from walkers' shoes were collected between April 2013 and July 2014. Multiplex PCR was used to detect E. coli based on the amplification of the uidA gene and investigate STEC-associated virulence genes eaeA, stx1 and stx2. The eaeA virulence gene was detected in 45·5% of the samples, where stx1 and/or stx2 was detected in 12·4% of samples. There was a difference between the two regions sampled, with the North West exhibiting a higher proportion of positive boot socks for stx compared to East Anglia. In univariate analysis, ground conditions, river flow and temperature were associated with positive boot socks. The detection of stx genes in the soil samples suggests that STEC is present in the English countryside and individuals may be at risk for infection after outdoor activities even if there is no direct contact with animals. SIGNIFICANCE AND IMPACT OF THE STUDY: Several outbreaks within the UK have highlighted the danger of contracting Shiga toxin-producing Escherichia coli from contact with areas recently vacated by livestock. This is more likely to occur for STEC infections compared to other zoonotic bacteria given the low infectious dose required. While studies have determined the prevalence of STEC within farms and petting zoos, determining the risk to individuals enjoying recreational outdoor activities that occur near where livestock may be present is less researched. This study describes the prevalence with which stx genes, indicative of STEC bacteria, were found in the environment in the English countryside.

The impact of military service on health and well-being

Background

While it is known that some UK Armed Forces (UK AF) personnel and veterans experience physical and mental health problems, the possible future healthcare needs of military veterans are unknown.

Aims

To estimate the number of military personnel who may experience physical and/or psychological health problems associated with their military service.

Methods

Data were obtained via Freedom of Information requests to several sources, including Defence Statistics. Raw data from research studies were also used where available. Data were analysed using meta-analytic methods to determine the rate of physical, mental or comorbid health problems in AF personnel.

Results

Musculoskeletal problems were the predominant reason for medical discharge from service. In terms of mental health, meta-analyses estimated that veteran reservists (part-time military members) previously deployed to operational areas had the highest proportion of general health problems (35%), previously deployed veteran regulars (those in full time military employment) and veteran reservists had the highest proportion of post-traumatic stress disorder (9%), and regular personnel with a deployment history had the highest proportion of alcohol problems (14%). Overall, our findings suggest that at least 67515 veterans are likely to suffer from mental and/or physical health problems at some point as a result of their service between 2001 and 2014.

Conclusions

The results of this study highlight that the difficulties personnel may face are largely musculoskeletal or mental health-related. These findings may help with planning the provision of future physical and mental health care and support for those who serve in the UK AF.

A115 MODELING CYSTIC FIBROSIS (CF) INTESTINAL DISEASE USING PATIENT DERIVED TISSUES

Background

Cystic Fibrosis is caused by mutations in the Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) gene, which encodes for a chloride/bicarbonate anion channel expressed on the apical membrane of most epithelial tissues, such as the lungs, liver, pancreas, small and large intestines, and reproductive tissues. CFTR is responsible for the transport of chloride and bicarbonate ions to maintain tissue surface hydration and pH balance of epithelial tissues. Historically, recurrent lung infections have been the most common cause of mortality in CF patients. With advances in clinical care and therapeutics, the current mean survival age of Canadian patients has increased to 52.3 years. However, this increase in survival has also been associated with an elevated risk of developing gastrointestinal cancers in CF adults. Compared to the general public, CF patients are 10 times more likely to develop cancer. This risk is increased to 25-20 times in patients that have undergone organ transplantations. Although the exact molecular mechanism regarding increased cancer risk in CF remains unclear, chronic intestinal inflammation has been known to contribute to elevated cancer development.

Aims

CF patients display an increased baseline inflammatory status that is exacerbated with microbiome exposure leading to possible increased risk for inflammation-mediated cancer development.

Methods

To reduce inter-patient heterogeneity, we have differentiated human intestinal organoids using induced pluripotent stem cells from homozygous F508del CF patients and gene edited isogenic non-CF (Wt-CFTR) controls. We conducted gene expression studies using RT-qPCR to determine baseline differences in gene expression prior to environmental exposures and following exposure to LPS and flagellin.

Results

We determined the expression levels of stem cell, intestinal epithelial cell, innate immunity genes and differentiation markers and found expression of such genes were not significantly different between 3D CF and gene-edited non-CF organoids. We are currently conducting RNA sequencing to survey expression pattern of all genes to definitively determine possible fundamental changes in the CF intestinal epithelium and determining the effect of LPS and flagellin treatment to determine if there is an altered response to inflammatory stimuli.

Conclusions

iPSC derived HIOs is a novel, patient based, and renewable model that can be used to dissect the primary intestinal pathologies in CF. Transcriptomic data of CF HIOs at steady state will provide insights to possible developmental defects. Complex interactions between the host intestinal epithelia and the commensal microbiome can also be investigated using this model.

Funding Agencies

CAG

UK military women: mental health, military service and occupational adjustment

Background

Recently, the UK Armed Forces have revised the ground close combat role to include women.

Aims

To assess the potential mental health impact of this initiative we examined gender differences in deployment patterns, work strain, occupational factors, mental health, alcohol use and help-seeking following operational deployment.

Methods

The study was a secondary analysis of self-report survey data; 8799 men (88%) and 1185 women (12%) provided data. A sub-sample (47%, n = 4659) provided data concerning post-deployment help-seeking. The latter consisted of 408 women (8.8%) and 4251 men (91%).

Results

With the exception of alcohol misuse, which was significantly lower for women, women reported significantly more common mental disorder symptoms, subjective depression and self-harm. Women were significantly more likely to seek help from healthcare providers. Men were significantly more likely to have deployed operationally and for longer cumulative periods. Subjective work strain, but not job control, was significantly lower for women whose military careers were significantly shorter. Post-traumatic stress disorder (PTSD) symptom intensity was similar to men.

Conclusions

With the exception of PTSD and alcohol misuse, UK military women experience more mental health-related problems than military men. This finding was not related to the more arduous aspects of military service as women served for shorter times, deployed less and for shorter cumulative periods and were less likely to report work-related stress.

Pre-service Military-related and Mental Disorder Factors Associated with Leaving the UK Armed Forces

Background: The UK Armed Forces (UKAF) have a substantial manning deficit as more personnel leave than join. This article identified pre-service, military, and mental health factors giving rise to leaving the UKAF and estimated the contributions to leaving of those factors which are potentially amenable to modification. Methods: This study utilized data from a three-phase cohort study (2004-2006, 2007-2009 and 2014-2016), commencing while respondents were serving in the UKAF (n = 10,836; 6,046 (55.8%) had left service). Associations between leaving the services and socio-demographics, military career and experiences, and mental health were determined using Cox regression. Contribution to leaving was based on population attributable fractions (PAF) from Cox regression. Analyses were stratified by rank due to the different career structures of Commissioned Officers and enlisted personnel. Results: Leaving the UKAF was associated with joining when older, being a woman with a child/children, Army service, combat role, lower education level, and poor mental health. Factors contributing a significant proportion of leaving among enlisted personnel were joining over the age of 17, history of externalizing behavior, being female, common mental disorders, and alcohol misuse. Among Commissioned Officers only age at joining and sex contributed significant proportions to leaving. Conclusions: The key factors for leaving are education and higher age at recruitment. These are not amenable to intervention, for policy, equity, and legal reasons. Heavy drinking and common mental disorder symptoms may be more amenable to modification and hence reduce rates of leaving the UKAF. Women are more likely to leave due to childbearing.

British military women: combat exposure, deployment and mental health

BACKGROUND

Internationally, women are about to undertake combat duties alongside their male colleagues. The psychological effect of this policy change is largely unknown.

AIMS

To explore the mental health impact of combat exposure among military women.

METHODS

Self-report, between-subjects survey data were collected in Iraq and Afghanistan on four occasions between 2009 and 2014 (n = 4139). Differences in mental health, stigmatization, deployment experiences, intimate relationship impact, perception of family support levels, unit cohesion, leadership and help-seeking were compared between deployed men and women. Comparisons were repeated with the study sample stratified by level of combat exposure. Outcomes were examined using logistic regression adjusted for socio-demographic, mental health and military factors.

RESULTS

Overall, 4.1% of women and 4.3% of men reported post-traumatic stress disorder (PTSD) (odds ratio (OR) 1.31, 95% confidence interval (95% CI) 0.70-2.46); 22% of women and 16% of men reported symptoms of common mental disorder (CMD) (OR 1.52, 95% CI 1.11-2.08). Women were less likely to report mental health-related stigmatization (OR 0.68, 95% CI 0.53-0.87), negative relationship impact from deployment (OR 0.69, 95% CI 0.49-0.98) and subjective unit cohesion (OR 0.69, 95% CI 0.53-0.90). Help-seeking for emotional problems was similar by gender (OR 1.22, 95% CI 0.84-1.77). Overall, outcomes were minimally impacted by level of combat exposure.

CONCLUSIONS

Although women experienced more CMD symptoms, PTSD symptoms were similar by gender. Subject to confirmation of the study findings, women may not require enhanced mental healthcare during deployment for exposure-based conditions such as PTSD when undertaking the ground close combat role.

Suicidal Ideation, Suicidal Attempts, and Self-Harm in the UK Armed Forces

INTRODUCTION

In the UK military, suicide is infrequent and studies of self-harm behavior in this population are rare.

OBJECTIVES

To compare lifetime self-harm rates estimated on three occasions between 2004 and 2016 and to explore the associates of lifetime self-harm.

METHOD

Three phases of a UK AF cohort study (n = 10,272, 9,990, and 8,581, respectively) provided data. Telephone interviews assessed associates of self-harm among cohort members who reported subjective mental health problems in the past 3 years (n = 1,448). Validated measures of mental health and related stigmatization, social support, and help-seeking were obtained.

RESULTS

Lifetime self-harm increased significantly (p < .001) from 1.8% among serving personnel and 3.8% among veterans in 2004/06 to 1.9% and 4.5% in 2007/09 and to 4.2% and 6.6% in 2014/16 in the two groups, respectively. Veterans were consistently significantly more likely to report lifetime self-harm than serving personnel. Significant determinants of lifetime self-harm included current mental disorder symptoms, stigmatization, poor social support, suicidal ideation, and seeking help from formal medical sources.

CONCLUSION

Self-harm has increased over time in the UK serving and veteran community. Suicide prevention should focus on ameliorating mental disorder by encouraging engagement with health care, reducing negative views of mental illness, and fostering social support.

Association of Systemic Inflammation With Retinal Vascular Caliber in Patients With AIDS

Purpose

To evaluate relationships among retinal vascular caliber and biomarkers of systemic inflammation in patients with AIDS.

Methods

A total of 454 participants with AIDS had retinal vascular caliber (central retinal artery equivalent and central retinal vein equivalent) determined from enrollment retinal photographs by reading center graders masked to clinical and biomarker information. Cryopreserved plasma specimens were assayed for inflammatory biomarkers, including C-reactive protein (CRP), IL-6, interferon-γ inducible protein (IP)-10, kynurenine/tryptophan (KT) ratio, and intestinal fatty acid binding protein (I-FABP).

Results

In the simple linear regression of retinal vascular caliber on plasma biomarkers, elevated CRP, IL-6, and IP-10 were associated with retinal venular dilation, and elevated KT ratio with retinal arteriolar narrowing. In the multiple linear regression, including baseline characteristics and plasma biomarkers, AMD was associated with dilation of retinal arterioles (mean difference: 9.1 μm; 95% confidence interval [CI] 5.2, 12.9; P < 0.001) and venules (mean difference, 10.9 μm; 95% CI, 5.3, 16.6; P < 0.001), as was black race (P < 0.001). Hyperlipidemia was associated with retinal venular narrowing (mean difference, -7.5 μm; 95% CI, -13.7, -1.2; P = 0.02); cardiovascular disease with arteriolar narrowing (mean difference, -5.2 μm; 95% CI, -10.3, -0.1; P = 0.05); age with arteriolar narrowing (slope, -0.26 μm/year; 95% CI, -0.46, -0.06; P = 0.009); and IL-6 with venular dilation (slope, 5.3 μm/standard deviation log10[plasma IL-6 concentration]; 95% CI, 2.7, 8.0; P < 0.001).

Conclusions

These data suggest that retinal vascular caliber is associated with age, race, AMD, hyperlipidemia, cardiovascular disease, and selected biomarkers of systemic inflammation.

2 The incidence of undiagnosed coeliac disease in patients presenting with stress fracture to a tertiary referral centre

Aim

Stress fracture aetiology is often multifactorial and laboratory blood tests (LBT) can unmask underlying metabolic bone risk factors and disorders. Coeliac disease (CD) is associated with low bone mineral density and an increased risk of fractures.1 In addition, there are rare reports of occult CD presenting with stress fractures.2 Anti-tissue transglutaminase antibody (TTG) testing has a high sensitivity and specificity for CD and is used as a screening test.3 This report examines the incidence of undiagnosed CD in patients presenting with stress fractures to a Sport and Exercise Medicine (SEM) clinic.

Methods

A retrospective analysis of 100 consecutive patients with radiologically proven stress fractures presenting to a single tertiary NHS SEM clinic was performed. Age, gender, fracture site, co-morbidities, TTG result and subsequent investigations were examined. Records were reviewed to confirm LBT, including TTG, had been performed at the time of diagnosis.

Results

Seventy patients (70%) were female and mean age was 37 years (range 18–69). Metatarsal (35%) and tibial (21%) fractures were most common. TTG was performed in 85 patients. Two patients were excluded due to pre-existing CD. Five patients (5/83 (6%), mean age 38 years (28–57), 80% female) had a positive TTG; three of whom had CD confirmed by endoscopic biopsy and two are awaiting investigation. Four patients with a positive TTG underwent dual energy X-ray absorptiometry, with osteopenia (T-Score between −1.0 and −2.5) found in 75% of cases, although only one had a Z-score less than -2.0.

Conclusion

In this cohort, the incidence of undiagnosed CD was between 3.6% to 6%, with a prevalence between 5% to 7%, approximately 5-fold higher than UK population estimates. We recommend that TTG screening should be performed in all patients presenting with stress fractures to identify underlying CD. Further work is required to confirm this association and elucidate potential underlying mechanisms.

References

Heikkilä K, Pearce J, Mäki M, et al. Celiac disease and bone fractures: a systematic review and meta-analysis. J Clin Endocrinol Metab 2015;100(1):25–34.

Gilbody J, Trevett M. Coeliac disease presenting with bilateral fibular stress fractures. Foot Ankle Surg 2009;15:96–100.

3. Downey L, Houten R, Murch S, Longson D, Group GD. Recognition, assessment, and management of coeliac disease: summary of updated NICE guidance. BMJ 2015;351:h4513.