Global taxonomic, functional, and phylogenetic diversity of bees in apple orchards

An essential prerequisite to safeguard pollinator species is characterisation of the multifaceted diversity of crop pollinators and identification of the drivers of pollinator community changes across biogeographical gradients. The extent to which intensive agriculture is associated with the homogenisation of biological communities at large spatial scales remains poorly understood. In this study, we investigated diversity drivers for 644 bee species/morphospecies in 177 commercial apple orchards across 33 countries and four global biogeographical biomes. Our findings reveal significant taxonomic dissimilarity among biogeographical zones. Interestingly, despite this dissimilarity, species from different zones share similar higher-level phylogenetic groups and similar ecological and behavioural traits (i.e. functional traits), likely due to habitat filtering caused by perennial monoculture systems managed intensively for crop production. Honey bee species dominated orchard communities, while other managed/manageable and wild species were collected in lower numbers. Moreover, the presence of herbaceous, uncultivated open areas and organic management practices were associated with increased wild bee diversity. Overall, our study sheds light on the importance of large-scale analyses contributing to the emerging fields of functional and phylogenetic diversity, which can be related to ecosystem function to promote biodiversity as a key asset in agroecosystems in the face of global change pressures.

Upper Extremity Trauma in Costa Rica - Evaluating Epidemiology and Identifying Opportunities

Background

Traffic accidents and musculoskeletal injuries represent a major cause of morbidity and mortality in Costa Rica. To inform capacity building efforts, we conducted a survey study of hand and upper extremity (UE) fellowship-trained surgeons in Costa Rica to evaluate the epidemiology, complications, and challenges in care of UE trauma.

Methods

Aiming to capture all hand and UE trained surgeons in Costa Rica, we compiled a list of nine surgeons and sent a survey in Spanish using Qualtrics. Assessment questions were developed to understand the burden, complications, practice patterns, challenges, and capacity associated with care of UE trauma. Questions were designed to focus on opportunities for future investigation. Questions were translated and adapted by two bilingual speakers. Data were reported descriptively and open-ended responses were analyzed using content analysis.

Results

Nine (100%) surgeons completed the survey. Distal radius fractures, hand and finger fractures, and tendon injuries are the most frequently noted conditions. Stiffness and infection are the most common complications. About 29% of patients are unable to get necessary therapy and 13% do not return for follow-up care with monetary, distance, and transportation limitations being the greatest challenges.

Conclusions

The burden of UE trauma in Costa Rica is high. Identifying common conditions, complications, challenges, and capacity allows for a tailored approach to partnership and capacity building (e.g. directing capacity building and/or research infrastructure toward distal radius fractures). These insights represent opportunities to inform community-driven care improvement and research initiatives, such as Delphi consensus approaches to identify priorities or the development of outcome measurement systems.

Prolonged vs short-term infusion of β-lactam antibiotics for the treatment of febrile neutropenia: A systematic review and meta-analysis

BACKGROUND

The optimisation of the use of β-lactam antibiotics (BLA) via prolonged infusions in life-threatening complications such as febrile neutropenia (FN) is still controversial. This systematic review and meta-analysis aim to evaluate the efficacy of this strategy in onco-haematological patients with FN.

METHODS

A systematic search was performed of PubMed, Web of Science, Cochrane, EMBASE, World Health Organization, and ClinicalTrials.gov, from database inception until December 2022. The search included randomised controlled trials (RCTs) and observational studies that compared prolonged vs short-term infusions of the same BLA. The primary outcome was all-cause mortality. Secondary outcomes were defervescence, requirement of vasoactive drugs, length of hospital stay and adverse events. Pooled risk ratios were calculated using random effects models.

RESULTS

Five studies were included, comprising 691 episodes of FN, mainly in haematological patients. Prolonged infusion was not associated with a reduction in all-cause mortality (pRR 0.83; 95% confidence interval 0.47-1.48). Nor differences were found in secondary outcomes.

CONCLUSIONS

The limited data available did not show significant differences in terms of all-cause mortality or significant secondary outcomes in patients with FN receiving BLA in prolonged vs. short-term infusion. High-quality RCTs are needed to determine whether there are subgroups of FN patients who would benefit from prolonged BLA infusion.

Patient Follow-up After Orthopaedic Outreach Trips - Do We Know Whether Patients are Improving?

Background

The burden of traumatic musculoskeletal injuries falls greatest on low- and middle-income countries (LMICs). To help address this burden, organizations host over 6,000 outreach trips annually, 20% of which are orthopaedic. Monitoring post-surgical outcomes is critical to ensuring care quality; however, the implementation of such monitoring is unknown. The purpose of this review is to identify published follow-up practices of short-term orthopaedic surgery outreach trips to LMICs.

Methods

We completed a systematic review of Pubmed, Web of Science, EMBASE, and ProQuest following PRISMA guidelines. Follow-up method, rate, duration, and types of outcomes measured along with barriers to follow-up were collected and reported.

Results

The initial search yielded 1,452 articles, 18 of which were eligible. The mean follow-up time was 5.4 months (range: 15 days-7 years). The mean follow-up rate was 65.8% (range: 22%-100%), the weighted rate was 57.5%. Fifteen studies reported follow-up at or after 3 months while eight studies reported follow-up at or after 9 months. Fifteen studies reported follow-up in person, three reported follow-up via phone call or SMS. Outcome reporting varied among mortality, complications, and patient-reported outcomes. The majority (75%) outlined barriers to follow-up, most commonly noting transportation and costs of follow-up to the patient.

Conclusions

There is minimal and heterogeneous public reporting of patient outcomes and follow-up after outreach trips to LMICs, limiting quality assessment and improvement. Future work should address the design and implementation of tools and guidelines to improve follow-up as well as outcome measurement to ensure provision of high-quality care.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00268-022-06630-w.

AB0310 STUDY “AR-CAT INICI”: MANAGEMENT OF EARLY RHEUMATOID ARTHRITIS IN CATALONIA

Background

Given the progressive change in the management of inflammatory diseases,an observational study was conducted on the management of Early Rheumatoid Arthritis (ERA) in Catalonia.

Objectives

To know the management of ERA in Catalonia, to assess whether the recommendations of the EULAR/ACR guidelines are followed and to study the causes of management variability,to set improvement objectives.

Methods

An observational,descriptive,and cross-sectional study was conducted,with data collection from June 15 to 30, 2021.The rheumatologists’ partners of the Catalan Society of Rheumatology were the object of study. An online survey was conducted with 304 members on the management of the ERA. Variables related to the characteristics of the respondents,the derivation and variables of the disease including clinical variables,type of treatment and outcomes used for follow-up including the impact of the SARS-CoV2 pandemic were included.The univariate study was performed using a study of proportions with Pearson’s correlation.

Results

A total of 105 members (34.5%) responded to the survey.11.6%>60 y, only 7.8% <30y. 99% were in public assistance.The number of rheumatologists per service is 7.2[1-17],but 34.2% had< 5 rheumatologists,with a reference population of 200,000-300,000p in 42% of respondents.The number of weekly visits made is 67.5[20-130].42.2% do not have a monographic RA or ERA dispensary and 30.4%not have specialized nursing.Characteristics of ERA:77.5% are derived from primary care(PC),52% have been between 6 weeks,42.1%>3 months.54.9% make a first visit within 2-4 weeks of PC referral and 14.7%> 8 weeks.100%provide previous analysis,only 47% had had RX performed.98% were previously treated(50.4%NSAIDs + CG,36.1%NSAIDs,12.3% CG).4.3% had GC doses>10 mg/day,11.3%> to 20mg/day.The treatment:DMARDs of choice in 100% is MTX,44.1% start doses of 10mg/week and 3.9%7.5 mg/week.The route of choice is oral(55.9% vs 44.1%).92.2% associate GC and 31.7% have not withdrawn them after 6 m.57.8% consider the maximum of MTX 25mg/W.87.1% use doses<10 mg/day,with the most used dose being 5 mg/day(35.6%).Follow-up after the start of DMARDs is performed 72.5% between 4-6 weeks and 12.7% is performed by nursing.100% use DAS 28 and 53.5% also CDAI.31.4% perform PROs(HAQ 83.3%,RAPID 3 14.3%).The use of systematic ultrasound is collected in 33%, being himself who performs it in 59.9% and an expert rheumatologist in 46.1%.Finally, when asked about incidence of pandemic in the follow-up,53.3% consider that it is doing the same as before. 46.1% consider that telephone visits are not suitable for the follow-up of the ERAvs14.7% who consider that Yes.When questioning the situations in which they consider them to be appropriate,75.9% that it was adequate in the control after the beginning of the DMARDs.Regarding the treatment of ERA, 66% delayed the onset of biological DMARDs, 72.1% due to difficulty of follow-up and only 8.8% due to an increased risk of infection. When performing the univariate analysis, it is evident that having a monographic dispensary is associated with earlier onset of MTX(p< 0.001)and at doses≥15 mg/W(p = 0.05),greater nursing intervention(p< 0.001),greater use of PROs(p = 0.008)and there is a tendency to a shorter waiting time for first visits(p = 0.07).It is also associated with not considering telephone visits(p< 0.001), making them in less than 25%(p< 0.0001).Similarly,hospital level is directly proportional to initiation at higher doses of MTX(p< 0.0001),lower use of GC<10mg.Among the rest of the variables, no association has been found.

Conclusion

The recommendations of EULAR/ACR in the treatment and follow-up of ERA are consistently followed,although the wide use of MTX orally is striking.It is evident that the variable that most influences the early onset of FAME and at higher doses,is a monographic dispensary,as well as greater presence of nursing and performance of PROs.

Acknowledgements

Thanks to all the members of the Catalan society of reuamtology who participated in the survey

Disclosure of Interests

None declared

AB0251 * FATIGUE IN RHEUMATOID ARTHRITIS: DOES PATIENT AGE INFLUENCE?

Background

Fatigue in RA has a multi-causal pathway. It is recommended that it should be measured in all RA studies using a validated instrument. Fatigue in elderly patients could have a different perception than in younger patients, identifying the associated factors could be a key to the management of this complex symptom.

Objectives

To compare fatigue and its associated factors in young and elderly patients with RA from two university hospitals.

Methods

A cross-sectional analysis was performed in 167 RA patients diagnosed according to the 2010 ACR-EULAR criteria. Patients were divided into two groups based on age (≥60 and <60) for comparative purposes. Fatigue was assessed using 4 instruments: the Bristol Rheumatoid Arthritis Fatigue Multidimensional Questionnaire (BRAF-MDQ), the fatigue subscale of the Short-form 36 survey (fatigue-SF36), the Visual Analogic scale of fatigue (VASf) and the Functional Assessment of chronic illness Therapy Fatigue Scale (FACIT-F). To compare the mean of fatigue between groups we used a T-Test.

To determine in each group of patients (young and elderly patients) the relationship between the 4 subscales of fatigue (assessed by BRAF-MDQ) and the other variables (DAS28, CPR, ESR, hemoglobin, vitamin D, HAQ, RAID [Rheumatoid Arthritis Impact of Disease], SF36, Hospital Anxiety and depression Scale [HAD] and Brief Pain Inventory) a Spearman correlation was performed. A value of p < 0.05 was accepted as statistically significant.

Results

A total of 167 patients were included, 81 (48.5%) young and 86 (51.5%) elderly patients. We found fatigue (using 4 instruments) has not significant differences in young and elderly patients (Table 1). In young and elderly patients, physical, living, cognitive and emotional fatigue were correlated to RAID, SF36, HAD and pain but they were not associated to CRP, ESR, hemoglobin and vitamin D. In young patients, all dimensions of fatigue were associated with DAS28. Furthermore, in elderly patients we found a relationship between physical (p-value 0.044) and living fatigue (p-value 0.012) with DAS28, nevertheless cognitive and emotional fatigue (p-value 0.078 and 0.079 respectively) were not related.

Table 1.

Scores of the Fatigue Questionnaires used to assess fatigue in young and elderly patients with RA.

Young Mean (SD)Elderly Mean (SD)p-valueFACIT-F36.5 (12.5)35.9 (11.7)0.2963VAS-F4.3 (2.8)3.8 (2.8)0.119SF36-Fatigue50.9 (23.9)51.0 (21.9)0.628BRAF-MDQ Physical9.2 (6.2)8.5 (6.3)0.4670 Living5.3 (5.6)4.2 (4.6)0.1446 Cognitive3.3 (3.8)4.2 (4.6)0.2932 Emotional3.5 (3.5)2.6 (2.7)0.0932

Conclusion

In young and elderly patients, all dimensions of fatigue appear to be related with subjective but not with objective variables. In young patients, all dimensions of fatigue were associated with DAS28 but in elderly patients only physical and living fatigue were correlate to disease activity. These results could indicate that it is important to evaluate fatigue in a multidimensional perspective in elderly patients.

References

[1]Belza BL, Henke CJ, Yelin EH, Epstein WV, Gilliss CL. Correlates of fatigue in older adults with rheumatoid arthritis. Nurs Res. 1993 Mar-Apr;42(2):93-9.

[2]Hewlett S, Dures E, Almeida C. Measures of fatigue: Bristol Rheumatoid Arthritis Fatigue MultiDimensional Questionnaire (BRAF MDQ), Bristol Rheumatoid Arthritis Fatigue Numerical Rating Scales (BRAF NRS) for severity, effect, and coping, Chalder Fatigue Questionnaire (CFQ), Checklist Individual Strength (CIS20R and CIS8R), Fatigue Severity Scale (FSS), Functional Assessment Chronic Illness Therapy (Fatigue) (FACIT-F), Multi-Dimensional Assessment of Fatigue (MAF), Multi-Dimensional Fatigue Inventory (MFI), Pediatric Quality Of Life (PedsQL) Multi-Dimensional Fatigue Scale, Profile of Fatigue (ProF), Short Form 36 Vitality Subscale (SF36 VT), and Visual Analog Scales (VAS). Arthritis Care Res (Hoboken). 2011 Nov;63 Suppl 11:S263-86.

Disclosure of Interests

None declared

Call the Psychiatrist! - Study about Delirium in the context of liaison psychiatry

Introduction

Delirium is characterized as a short-term consciousness and cognition disturbance which tends to fluctuate during the course of the day. It is a common and serious problem, mainly in hospitalized older adults, potentially avoidable and often poorly recognized.

Objectives

We propose an analysis on the theme through a work that evaluates the requests for psychiatric consultation made in a district hospital in Portugal during the course of 12 months.

Methods

We identified all patients on the requests for psychiatric consultation and obtained a demographic, clinical and consultation requests by medical specialties data and conducted statistical analysis using Excel.

Results

We identified 106 consultation requests, in which 41 cases were eventually diagnosed as delirium. Most (83%) were hyperactive delirium, 12% were hypoactive delirium and 5% were mixed delirium. Incidence was higher in males (59%) and in those aged between 66 and 80 years old (56.1%). Most consultation requests were made by Internal Medicine (46.3%), followed by General Surgery (26.8%), Pulmonology (14.6%), Orthopedics (9.8%) and Neurology (2.5%). Finally, we analyzed which symptoms mentioned in the request made physicians consider requesting a psychiatric evaluation. Approximately half of the cases (48.8%) reported psychomotor agitation, followed by temporal/spatial disorientation (41.5%) and aggressive behaviour (17.1%).

Conclusions

We highlight a still notorious lack of proper identification of delirium, resulting in symptoms being incorrectly interpreted as a psychiatric disorder. This may cause a delay in the adequate diagnosis and management of the condition, increasing the morbidity and mortality of patients.

Disclosure

No significant relationships.

POS1350 UVEITIS DUE TO IMMUNE-MEDIATED INFLAMMATORY DISEASES TREATED WITH CERTOLIZUMAB PEGOL. MULTICENTER STUDY OF 80 PATIENTS

Background

Adalimumab remains the only biologic approved by the EMA and FDA for the treatment of non-infectious uveitis [1-6]. The reports on efficacy of other anti-TNF drugs such as Certolizumab Pegol (CZP) are scarce.

Objectives

to determine the efficacy and safety of CZP in refractory uveitis secondary to Immune-mediated Inflammatory Diseases (IMIDs).

Methods

national multicenter study of 80 patients with uveitis due to IMID refractory to glucocorticoids and conventional immunosuppressants treated with CZP. Efficacy was assessed with the following ocular parameters: best corrected visual acuity (BCVA), anterior chamber cells, vitritis, macular thickness and presence of retinal vasculitis. The efficacy of CZP was compared between the baseline visit, 1st week, 1st and 6th month, and 1st year. Statistical analysis was performed with IBM SPSS Statistics v.23.

Results

we studied 80 patients/111 affected eyes (33 men/47 women) with a mean age of 41.6±11.7 years. The IMIDs included were: spondyloarthritis (n=43), Behçet’s disease (10), psoriatic arthritis (8), Crohn’s disease (4), sarcoidosis (2), JIA (1), reactive arthritis (1), rheumatoid arthritis (1), relapsing polychondritis (1), TINU (1), pars planitis (1), Birdshot (1) and idiopathic uveitis (6). Anterior was the most frequent uveitis pattern (n=61).

In 20 patients, besides the presence of refractory uveitis, desire of pregnancy was the reason for CZP initiation.

Prior to CZP, patients had received: methotrexate (n=38), sulfasalazine (28), azathioprine (14), cyclosporine (10), leflunomide (3), mycophenolate mofetil (4), and cyclophosphamide (1). Previous biologic therapy was administered in 52 patients (63%), with a median [IQR] of 2 [1-3] drugs per patient. The most used biologic was adalimumab (n=48), followed by infliximab (32), golimumab (15), tocilizumab (5), etanercept (7), rituximab (1), anakinra (1) and secukinumab (1). CZP was administered as monotherapy in 39 patients.

After 24 [12-36] months of follow-up, all parameters analyzed showed a rapid and maintained improvement (Table 1). A decrease in the mean number of uveitis flares was observed before and after CZP, (2.6±2.3 vs. 0.6±0.4, p<0.001). CZP was discontinued in 16 patients due to: ocular remission (n=3), insufficient ocular response (4) and incomplete response of extraocular manifestations (9). No serious adverse effects were found.

Table 1.

main ocular parameters analyzed in 80 patients with uveitis due to IMID and treated with CZP.

Baseline1st week1st month3rd month6th month1st yearBCVA (mean±SD)0.68±0.270.73±0.26*0.79±0.26*0.82±0.25*0.85±0.24*0.86±0.23*Tyndall improvement, n (%)Patients with Tyndall + at baseline (n=57)-23 (40.3)45 (78.9)47 (82.4)57 (100)57 (100)Vitritis improvement, n (%)Patients with Vitritis at baseline (n=14)-5 (35.7)8 (57.1)13 (92.8)14 (100)14 (100)OCT (µm) (mean±SD)297.5±48.1297.1±45.5286.5±39.8*277.6±43.3*271.5±38.6*269.0±38.8*Choroiditis, affected eyes, n (%)3 (2.4)3 (2.4)2 (1.6)2 (1.6)1 (0.8)1 (0.8)Retinal vasculitis, affected eyes, n (%)3 (2.4)2 (1.6)1 (0.8)0 (0)0 (0)0 (0)

*p<0.01

Conclusion

CZP seems to be effective and safe in the control of uveitis associated to different IMIDs.

References

[1]Jaffe GJ, et al. N Engl J Med 2016;375:932-43. doi: 10.1056/NEJMoa1509852.

[2]Nguyen QD, et al. Lancet 2016;388:1183-92. doi: 10.1016/S0140-6736(16)31339-3.

[3]Martín-Varillas JL, et al. Ophthalmology 2018; 125:1444-1451 doi: 10.1016/j.ophtha.2018.02.020

[4]Martín-Varillas JL, et al. J Rheumatol. 2021;48:741-750. doi: 10.3899/jrheum.200300

[5]Atienza-Mateo B. Arthritis Rheumatol. 2019;71:2081-2089. doi: 10.1002/art.41026.

[6]Vegas-Revenga N et al Am J Ophthalmol. 2019;200:85-94. doi: 10.1016/j.ajo.2018.12.019

Disclosure of Interests

None declared

Blue Bonds - Antidepressant use during pregnancy and risk of autism spectrum disorder

Introduction

Epidemiological studies suggested that antidepressant usage amongst pregnant women increased by 3- to 7-fold in the past 2 decades and that up to 13% of fetuses are exposed to antidepressants. There are concerns regarding the impact of prenatal antidepressant use on the offspring.

Objectives

We aim to review more recent evidence of antidepressant use during pregnancy and the risk of autism spectrum disorder (ASD) in the offspring.

Methods

Non-systematic review based on the PubMed® database.

Results

A recent meta-analyses suggested children of mothers who used antidepressants during their pregnancy may be at a higher risk of ASD, compared to mothers who do not use these medications. Other suggested that the use of any antidepressants in the first 2 trimesters was related to significantly risk of developing ASD. Despite higher risks with the use of antidepressants, the absolute risk appears to be low. In addition, confounding factors should be considered while interpreting the results. Studies concluded that the comparator group selection strongly influences the observed antidepressant-ASD relationship. Associations derived from general population studies might have been mediated by unmeasured maternal psychiatric burden or transdiagnostic genetic liability. The observed increase in risk may also be associated with depression, not its treatment.

Conclusions

The findings of these studies have important implications, and often result in drug discontinuation with a significant impact on maternal and infant health. Future research should include investigation of the severity of depression in this association, assessment of antidepressant dose and use of antidepressants in pregnant women with other pathologies.

Disclosure

No significant relationships.

A Lung Cancer Screening Education Program Impacts both Referral Rates and Provider and Medical Assistant Knowledge at Two Federally Qualified Health Centers

BACKGROUND

Federally Qualified Health Centers (FQHCs) serve minority and low-socioeconomic populations and provide care to high-risk smokers. These centers frequently experience barriers, including low provider and medical assistant (MA) knowledge around lung cancer screening (LCS). Subsequent low LCS referral rates by providers at FQHCs limit utilization of LCS in eligible, high-risk, underserved patients.

METHODS

Providers and MAs from two FQHCs participated in a LCS educational session. A pre-educational survey was administered at the start of the session and a post-educational survey at the end. The intervention included a presentation with education around non-small cell lung cancer, LCS, tobacco cessation, and shared-decision making. Both surveys were used to evaluate changes in provider and MA ability to determine eligible patients for LCS. The Pearson's Chi-squared test with Yates' continuity correction was used to measure the impact.

RESULTS

A total of 29 providers and 28 MAs enrolled in the study from two FQHCs. There was an improvement, P < .009 and P < .015 respectively, in provider and MA confidence in identifying patients for LCS. Additionally, one year prior to the program, 9 low-dose computed tomography (LDCTs) were ordered at one of the FQHCs and 0 at the other. After the program, over 100 LDCTs were ordered at each FQHC.

CONCLUSIONS

A targeted LCS educational program improves provider and MAs' ability to identify eligible LCS patients and is associated with an increase in the number of patients referred to LDCT at FQHCs.

Evaluation of data quality in the Spanish EURECCA Esophagogastric Cancer Registry

BACKGROUND

Although the number of nationwide clinical registries in upper gastrointestinal cancer is increasing, few of them perform regular clinical audits. The Spanish EURECCA Esophagogastric Cancer Registry (SEEGCR) was launched in 2013. The aim of this study was to assess the reliability of the data in terms of completeness and accuracy.

METHODS

Patients who were registered (2014-2017) in the online SEEGCR and underwent esophagectomy or gastrectomy with curative intent were selected for auditing. Independent teams of surgeons visited each center between July 2018 and December 2019 and checked the reliability of data entered into the registry. Completeness was established by comparing the cases reported in the registry with those provided by the Medical Documentation Service of each center. Twenty percent of randomly selected cases per hospital were checked during on-site visits for testing the accuracy of data (27 items per patient file). Correlation between the quality of the data and the hospital volume was also assessed.

RESULTS

Some 1839 patients from 19 centers were included in the registry. The mean completeness rate in the whole series was 97.8% (range 82.8-100%). For the accuracy, 462 (25.1%) cases were checked. Out of 12,312 items, 10,905 were available for verification, resulting in a perfect agreement of 95% (87.1-98.7%). There were 509 (4.7%) incorrect and 35 (0.3%) missing entries. No correlation between hospital volume and the rate of completeness and accuracy was observed.

CONCLUSIONS

Our results indicate that the SEEGCR contains reliable data.

Perspectives on the Implementation of Screening and Treatment for Depression and Alcohol Use Disorder in Primary Care in Colombia

Depression and alcohol use disorder (AUD) greatly contribute to the burden of disease worldwide, and have large impact on Colombia's population. In this study, a qualitative analysis evaluates the implementation of a technology-supported model for screening, decision support, and digital therapy for depression and AUD in Colombian primary care clinics. Patient, provider, and administrator interviews were conducted, exploring attitudes towards depression and AUD, attitudes towards technology, and implementation successes and challenges. Researchers used qualitative methods to analyze interview themes. Despite stigma around depression and AUD, the model improved provider capacity to diagnose and manage patients, helped patients feel supported, and provided useful prevalence data for administrators. Challenges included limited provider time and questions about sustainability. The implementation facilitated the identification, diagnosis, and care of patients with depression and AUD. There is ongoing need to decrease stigma, create stronger networks of mental health professionals, and transition intervention ownership to the healthcare center.

Tourette’s syndrome: Alternative approaches to a clinical case refractory to conventional therapy

Introduction

Tourette’s syndrome is a neuropsychiatric disorder marked by motor and phonic tics frequently associated with psychiatric comorbidities, beginning in childhood. While most cases improve or resolve with age, some are refractory.

Objectives

To review new strategies for the management of Tourette’s Syndrome, following an outpatient clinical vignette.

Methods

We performed a review based on the PubMed® database.

Results

A 50-years-old female patient with a long-term outpatient psychiatric follow-up presented with motor tics appearing in adolescence, including winking and facial grimacing, as well as episodes of coprolalia. Over the years, she developed an anxiety disorder and social isolation. In addition to psychological therapy, pharmacological therapy had already been approached with the use alpha-adrenergic agonists and several antipsychotics, such as risperidone and aripiprazole, with the patient showing only partial response to pimozide. In Tourette’s syndrome, the therapy must be adequate to the patient’s individual needs. Emerging treatments for refractory cases, such as anticonvulsants, cannabinoids or antiglutamatergic drugs have been the target of several studies. Botulinum toxin injections are particularly effective in patients with focal motor tics and complex phonic tics. Non-pharmacological treatment options, such as electroconvulsive therapy and deep brain stimulation may prove effective in some cases.

Conclusions

A significant proportion of patients fail to respond to conventional strategies. Thus, new pharmacological and non-pharmacological therapies are on the horizon and may represent an important step in treatment algorithms for refractory cases in the future.

Engineered probiotics for local tumor delivery of checkpoint blockade nanobodies

Checkpoint inhibitors have revolutionized cancer therapy but only work in a subset of patients and can lead to a multitude of toxicities, suggesting the need for more targeted delivery systems. Because of their preferential colonization of tumors, microbes are a natural platform for the local delivery of cancer therapeutics. Here, we engineer a probiotic bacteria system for the controlled production and intratumoral release of nanobodies targeting programmed cell death-ligand 1 (PD-L1) and cytotoxic T lymphocyte-associated protein-4 (CTLA-4) using a stabilized lysing release mechanism. We used computational modeling coupled with experimental validation of lysis circuit dynamics to determine the optimal genetic circuit parameters for maximal therapeutic efficacy. A single injection of this engineered system demonstrated an enhanced therapeutic response compared to analogous clinically relevant antibodies, resulting in tumor regression in syngeneic mouse models. Supporting the potentiation of a systemic immune response, we observed a relative increase in activated T cells, an abscopal effect, and corresponding increases in systemic T cell memory populations in mice treated with probiotically delivered checkpoint inhibitors. Last, we leveraged the modularity of our platform to achieve enhanced therapeutic efficacy in a poorly immunogenic syngeneic mouse model through effective combinations with a probiotically produced cytokine, granulocyte-macrophage colony-stimulating factor (GM-CSF). Together, these results demonstrate that our engineered probiotic system bridges synthetic biology and immunology to improve upon checkpoint blockade delivery.

Fit-for-Discharge Criteria after Esophagectomy: An International Expert Delphi Consensus

There are no internationally recognized criteria available to determine preparedness for hospital discharge after esophagectomy. This study aims to achieve international consensus using Delphi methodology. The expert panel consisted of 40 esophageal surgeons spanning 16 countries and 4 continents. During a 3-round, web-based Delphi process, experts voted for discharge criteria using 5-point Likert scales. Data were analyzed using descriptive statistics. Consensus was reached if agreement was ≥75% in round 3. Consensus was achieved for the following basic criteria: nutritional requirements are met by oral intake of at least liquids with optional supplementary nutrition via jejunal feeding tube. The patient should have passed flatus and does not require oxygen during mobilization or at rest. Central venous catheters should be removed. Adequate analgesia at rest and during mobilization is achieved using both oral opioid and non-opioid analgesics. All vital signs should be normal unless abnormal preoperatively. Inflammatory parameters should be trending down and close to normal (leucocyte count ≤12G/l and C-reactive protein ≤80 mg/dl). This multinational Delphi survey represents the first expert-led process for consensus criteria to determine 'fit-for-discharge' status after esophagectomy. Results of this Delphi survey may be applied to clinical outcomes research as an objective measure of short-term recovery. Furthermore, standardized endpoints identified through this process may be used in clinical practice to guide decisions regarding patient discharge and may help to reduce the risk of premature discharge or prolonged admission.

The impact of income and education on lung cancer screening utilization, eligibility, and outcomes: a narrative review of socioeconomic disparities in lung cancer screening

Non-small cell lung cancer (NSCLC) is the leading cause of cancer deaths in the US and worldwide. In particular, vulnerable populations such as those of low socioeconomic status (SES) are at the highest risk for and suffer the highest mortality from NSCLC. Although lung cancer screening (LCS) has been demonstrated to be a powerful tool to lower NSCLC mortality, it is underutilized by eligible smokers, and disparities in screening are likely to contribute to inequities in NSCLC outcomes. It is imperative that we collect and analyze LCS data focused on individuals of low socioeconomic position to identify and address barriers to LCS utilization and help close the gaps in NSCLC mortality along socioeconomic lines. Toward this end, this review aims to examine published studies that have evaluated the impact of income and education on LCS utilization, eligibility, and outcomes. We searched the PubMed, Ovid MEDLINE, and CINAHL Plus databases for all studies published from January 1, 2010, to October 21, 2020, that discussed socioeconomic-based LCS outcomes. The review reveals that income and education have impact on LCS utilization, eligibility, false positive rates and smoking cessation attempts; however, there is a lack of studies evaluating the impact of SES on LCS follow-up, stage at diagnosis, and treatment. We recommend the intentional inclusion of lower SES participants in LCS studies in order to clarify appropriate eligibility criteria, risk-based metrics and outcomes in this high-risk group. We also anticipate that low SES smokers and their providers will require increased support and education regarding smoking cessation and shared decision-making efforts.

POS1340 MULTICENTER STUDY OF 71 PATIENTS WITH REFRACTORY UVEITIS RELATED TO IMMUNE-MEDIATED INFLAMMATORY DISEASES ON CERTOLIZUMAB PEGOL TREATMENT

Background:

Prognosis of non-infectious refractory uveitis has improved markedly with biologic therapy (BT) (1-5). Most data are with monoclonal anti-TNF drugs, especially Adalimumab (ADA) and Infliximab (IFX). However, there is not enough evidence for the use of Certolizumab Pegol (CZP).

Objectives:

To evaluate the efficacy and safety of CZP in refractory uveitis secondary to Immune-Mediated Inflammatory Diseases (IMID).

Methods:

Multicenter study of 71 patients with uveitis due to IMID refractory to glucocorticoids and conventional immunosuppressants. Efficacy was assessed with the following ocular parameters: best corrected visual acuity (BCVA), anterior chamber cells, vitritis, macular thickness and presence of retinal vasculitis. These outcomes were compared between baseline, 1st week, 1st and 6th month, and 1st and 2nd year. Statistical analysis was performed with IBM SPSS Statistics v.23.

Results:

71 patients/100 affected eyes (29 men/42 women) with mean age of 40.0±11.3 years were studied. Underlying IMIDs were: spondyloarthritis (n=38), Behçet (10), psoriatic arthritis (8), Crohn disease (3), sarcoidosis (2), JIA (1), reactive arthritis (1), rheumatoid arthritis (1), relapsing polychondritis (1), TINU (1), pars planitis (1), Birdshot (1) and idiopathic uveitis (3). Uveitis pattern was anterior (n=55), posterior (6), panuveitis (6) and intermediate (4).

Prior to CZP, patients had received: methotrexate (37), sulfasalazine (26), azathioprine (14), cyclosporine (10), leflunomide (3), mycophenolate mofetil (3) and cyclophosphamide (1). Previous BT was administered in 48 (67.6%) patients, with a mean of 1.4±1.3 drugs per patient as follows: ADA (n=56), IFX (27), golimumab (14), tocilizumab (5) and etanercept (3). Pregnancy was the reason for prescribing CZP in 19 patients. CZP was administered in monotherapy (n=39) or combined with conventional immunosuppressants (n=32).

After a mean follow-up of 27.1±21.1 months, most of the ocular variables showed a rapid and significantly improvement (Table 1). A decrease in the median number [IQR] of flares of uveitis before and after CZP, (3 [1-4] vs. 0 [0-1], p<0.001) was observed. CZP was discontinued in 15 patients due to remission (n=2), ocular insufficient response (2) and incomplete response of extraocular manifestations (11). No serious adverse events were reported.

Conclusion:

CZP seems to be effective and safe in patients with refractory uveitis due to IMID.

References:

[1]Martín-Varillas JL, et al. Ophthalmology 2018; 125:1444-1451. doi: 10.1016/j.ophtha.2018.02.020.

[2]Atienza-Mateo B, et al. Arthritis Rheumatol 2019; 71:2081-2089. doi: 10.1002/art.41026.

[3]Santos-Gómez M, et al. Clin Exp Rheumatol 2016; 34(6 Suppl 102):S34-S40. PMID: 27054359

[4]Vegas-Revenga N, et al. Am J Ophthalmol 2019; 200:85-94. doi: 10.1016/j.ajo.2018.12.019

[5]Calvo-Río V, et al. Clin Exp Rheumatol. 2014; 32 (4 Suppl 84):S54-7. PMID: 25005576

Table 1.Baseline1stweek1stMonth6thMonth1styear2ndyearBCVA (mean±SD)0.68±0.270.72±0.27*0.79±0.25*0.84±0.24*0.85±0.25*0.87±0.22*Improvement in AC Cells, n (%)Patients with AC cells at baseline (n=48)-21 (43.7)30 (62.5)*41 (85.4)*48 (100)*48 (100)*Improvement in Vitritis, n (%)Patients with vitritis at baseline (n=13)-3 (23.1)8 (61.5)*11 (84.6)*13 (100)*13 (100)*OCT (µ) (mean±SD)292.5±47.7294±47.4286.7±41.9*274.7±38.7*272.8±38.9*266.31±36.2*Choroiditis; affected eyes, n, (%)3 (4.2)3 (4.2)2 (2.8)2 (2.8)1 (1.4)0 (0)Retinal Vasculitis; affected eyes, n, (%)2 (2.8)0 (0)1 (1.4)0 (0)0 (0)0 (0)

*p<0.001

Disclosure of Interests:

None declared

Patient-reported outcomes after oesophagectomy in the multicentre LASER study

BACKGROUND

Data on the long-term symptom burden in patients surviving oesophageal cancer surgery are scarce. The aim of this study was to identify the most prevalent symptoms and their interactions with health-related quality of life.

METHODS

This was a cross-sectional cohort study of patients who underwent oesophageal cancer surgery in 20 European centres between 2010 and 2016. Patients had to be disease-free for at least 1 year. They were asked to complete a 28-symptom questionnaire at a single time point, at least 1 year after surgery. Principal component analysis was used to assess for clustering and association of symptoms. Risk factors associated with the development of severe symptoms were identified by multivariable logistic regression models.

RESULTS

Of 1081 invited patients, 876 (81.0 per cent) responded. Symptoms in the preceding 6 months associated with previous surgery were experienced by 586 patients (66.9 per cent). The most common severe symptoms included reduced energy or activity tolerance (30.7 per cent), feeling of early fullness after eating (30.0 per cent), tiredness (28.7 per cent), and heartburn/acid or bile regurgitation (19.6 per cent). Clustering analysis showed that symptoms clustered into six domains: lethargy, musculoskeletal pain, dumping, lower gastrointestinal symptoms, regurgitation/reflux, and swallowing/conduit problems; the latter two were the most closely associated. Surgical approach, neoadjuvant therapy, patient age, and sex were factors associated with severe symptoms.

CONCLUSION

A long-term symptom burden is common after oesophageal cancer surgery.

Teaching and learning in a multilingual Europe: findings from a cross-European study

School classrooms within the EU are multilingual learning environments. The diversity of pupils in classrooms raises significant challenges for teachers, but to date, there are no data from large-scale surveys that compare views within and across European countries. A bespoke questionnaire was designed to examine views of current classroom learning environments with respect to the multilingualism. The questionnaire was piloted and subsequently completed by 2792 teachers across different European countries. Eleven countries provided sufficient data for analyses. Results from structural equation modelling showed that teachers’ attitudes could be reliably measured across Europe with the use of carefully devised questionnaire, whose loading and factor structure remained invariant across countries. Teachers’ views about multilingualism were most challenged by the numbers of children in their classes, not the percentage of multilingual pupils in the class. Countries differed in how they perceived multilingualism, with their differences leading to distinctive country clusters. Gender and education level (elementary vs. secondary) differences were also observed irrespective of country. These findings enhance our understanding of the role that the characteristics of teachers and their classrooms play in a multilingual setting across diverse European settings. The practical relevance of the results and new opportunities for teacher training are discussed.

Prevalence and prognostic value of left ventricular late gadolinium enhancement in patients with idiopathic outflow tract ventricular arrhythmias

Background

Patients with idiopathic outflow tract ventricular arrhythmias (OTVAs) and structurally normal heart by ECG and echocardiogram often undergo cardiac magnetic resonance (CMR) study to evaluate for presence of concealed myocardial abnormalities with late gadolinium enhancement (LGE). However, the clinical impact of incidental LGE finding in the left ventricle (LV) in patients with idiopathic OT-VAs is unclear. Accordingly, the aim of the present study was to investigate the prevalence, characteristics and prognostic significance of isolated LV LGE in a large population of patients with OTVA undergoing CMR.

Methods

A total of 364 consecutive patients (43±16 years, 53% male) with OTVA and negative routine diagnostic work-up were included. All patients underwent a CMR study with LGE imaging for detection of scar/replacement fibrosis. Presence of LGE was correlated with long term major adverse cardiovascular events including sudden cardiac death (SCD), resuscitated cardiac arrest and nonfatal documented sustained ventricular tachycardia.

Results

Isolated LGE in the LV was identified in 15 patients (4%), typically involving the inferolateral wall (11 cases, 73%) and having a median extension of 3 (2–5)% of the LV mass. All cases showed a midmyocardial/subepicardial distribution consistent with a possible prior myocarditis. Patients with incidental finding of LV-LGE were older (55±13 years vs. 42±16 years; p&lt;0.01) and were more frequently males (80% vs. 51%; p=0.03). After a median follow-up of 69 (47–98) months, none of the patients in the LV-LGE group and 1 patient (0.3%) in the non-LGE group (p=1.0) experienced the composite end-point which consisted in an episode of sustained VT with hypotension and dizziness. The patient subsequently underwent effective radiofrequency ablation of the VT from the right ventricular outflow tract.

Conclusion

In this large CMR study, isolated LV scar was found in 4% of patients with idiopathic OT-VAs, was small in size with distribution consistent with prior myocarditis. The LGE abnormality did not portend a negative prognosis.

Funding Acknowledgement

Type of funding source: None

Prognostic value of non-ischemic ring-like left ventricular scar pattern in patients with apparently idiopathic ventricular arrhythmias: a CMR imaging study

Background

The presence of left ventricular (LV) late gadolinium enhancement (LGE) at cardiac magnetic resonance (CMR) has been correlated to life-threatening arrhythmic events in patients with apparently idiopathic ventricular arrhythmias (VAs). Aim of the present study was to investigate the prognostic significance of a specific LV-LGE phenotype characterized by a subepicardial/midmyocardial “ring-like” pattern of fibrosis.

Methods

Out of a total of 518 consecutive patients with apparently idiopathic VAs who underwent CMR study, 79 (15%) had evidence of LV-LGE. Of these, 23 (4%) patients had LV LGE with ring-like pattern, defined as subepicardial or midmyocardial LGE involving at least 3 contiguous segments in the same slice (group A), while 56 (11%) patients had LV LGE with no ring-like pattern (group B). The remaining 439 patients had no LGE (group C). The end-point of the study was a composite SCD, resuscitated cardiac arrest and nonfatal episodes of ventricular fibrillation or documented sustained ventricular tachycardia.

Results

Group A patients were more frequently males compared to groups B and C (96% vs. 79% vs. 52%; p&lt;0.01) and had more frequently a family history of SCD and/or cardiomyopathy (30% vs. 11% vs. 5%; p&lt;0.01). All patients in Group A showed VAs with a predominant RBBB morphology vs. 38 (68%) patients in Group B and 65 (15%) in Group C (p&lt;0.01). During a follow-up of 63±39 months, the composite outcome occurred in 13 patients (57%) in Group A vs. 11 (20%) in Group B and 2 (1%) in Group C (p&lt;0.01).

Conclusion

In patients with apparently idiopathic VAs, a nonischemic LV-LGE with a ring-like pattern at CMR is associated with a high rate of malignant arrhythmic events during follow-up.

Funding Acknowledgement

Type of funding source: None

Abstract 6317: 3D multicellular coculture platform enables rapid engineering of tumor-homing bacteria

Engineering tumor-homing bacteria to locally deliver therapeutics is an emerging approach for next-generation living therapy for cancer. However, the lack of physiologically-relevant in vitro testing environments to rapidly and quantitatively characterize complex multicellular interactions of bacteria and cancer cells is a major bottleneck for clinical translation.

We recently developed a 3D multicellular coculture platform that grow various bacteria within the necrotic core of multicellular spheroids, recapitulating selective bacterial growth in solid tumor in vivo. Tumor spheroids were generated from CT26 colorectal cell lines in a round-bottom low-adhesion 96 well plate. Bacteria were inoculated into the media containing tumor spheroids and gentamicin, a poorly diffusible antimicrobial agent, were added to confine bacterial growth to spheroid cores. Time-lapse microscopy was utilized to track growth dynamics and spatial profiles. To validate efficacy, mice with hind flank tumors were treated with engineered bacteria and measured for the therapeutic effect on tumor size.

The multicellular coculture platform allowed for parallel and continuous culture of bacteria in tumor spheroids. Notably, bacteria stably grew within the spheroid necrotic cores, representing tumor colonization in animals and patients. Leveraging the high throughput nature of the platform, we screened a library of ten cytotoxic molecules delivered by clinically relevant tumor-homing S. typhimurium. We validated similarities in efficacies using a syngeneic mouse model and identified novel therapeutic candidates that reduced tumor growth significantly. Additionally, we utilized the tumor spheroid to construct bacterial biosensors. As tumor microenvironment such as oxygen, pH, and metabolite gradients are recapitulated in the 3D spheroid setting, we tested hypoxia, acid and lactate sensors and confirmed their activity in tumor environment. Constructing an AND-gate logic circuit for bacterial growth using synthetic biology tools, we rapidly tested the bacterial containment capability to the spheroid cores. This strain demonstrated a 100-fold reduction in off-target colonization compared to the wildtype strain in an animal model.

Rapid and quantitative characterization of dynamical bacteria-cancer cell interactions can predict therapeutic performance more accurately. We hope this scalable approach serves to accelerate future clinical development of bacterial applications for cancer therapy.

Citation Format: Tetsuhiro Harimoto, Zakary Singer, Oscar Velazquez, Joanna Zhang, Samuel Castro, Taylor Hinchliffe, William Mather, Tal Danino. 3D multicellular coculture platform enables rapid engineering of tumor-homing bacteria [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 6317.

Abstract 6248: Engineered probiotics for local delivery of checkpoint blockade nanobodies

Checkpoint inhibitors have revolutionized cancer therapy but only work in a subset of patients and can lead to a multitude of toxicities, suggesting the need for more targeted delivery systems. Because of their preferential colonization of tumors, microbes are a natural platform for the local delivery of cancer therapeutics. Here, we engineer a probiotic bacteria system for the controlled production and intratumoral release of nanobodies targeting programmed cell death-ligand 1 (PD-L1) and cytotoxic T lymphocyte-associated protein-4 (CTLA-4) using a stabilized lysing release mechanism. We used computational modeling coupled with experimental validation of lysis circuit dynamics to determine the optimal genetic circuit parameters for maximal therapeutic efficacy. A single injection of this engineered system demonstrated an enhanced therapeutic response compared to analogous clinically relevant antibodies, resulting in tumor regression in syngeneic mouse models. Supporting the potentiation of a systemic immune response, we observed a relative increase in activated T cells, an abscopal effect, and corresponding increases in systemic T cell memory populations in mice treated with probiotically delivered checkpoint inhibitors. Last, we leveraged the modularity of our platform to achieve enhanced therapeutic efficacy in a poorly immunogenic syngeneic mouse model through effective combinations with a probiotically produced cytokine, granulocyte-macrophage colony-stimulating factor (GM-CSF). Together, these results demonstrate that our engineered probiotic system bridges synthetic biology and immunology to improve upon checkpoint blockade delivery.

Citation Format: Candice Gurbatri, Ioana Lia, Rosa Vincent, Courtney Coker, Samuel Castro, Piper Treuting, Taylor Hinchliffe, Nicholas Arpaia, Tal Danino. Engineered probiotics for local delivery of checkpoint blockade nanobodies [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 6248.

Abstract 1074: Programmable bacteria induce durable tumor regression and systemic antitumor immunity

Synthetic biology is driving a new era of medicine through the engineering of living cells. This transformative approach allows for the creation of systems that intelligently sense and respond to diverse environments, adding specificity and efficacy beyond the capabilities of molecular-based therapeutics. One particular area of focus has been the engineering of bacteria as therapeutic delivery systems to selectively release therapeutic payloads in vivo. We recently engineered a non-pathogenic Escherichia coli strain to specifically lyse within the tumor microenvironment and release an encoded nanobody antagonist of CD47 (CD47nb), an anti-phagocytic receptor that is commonly overexpressed in several human cancer types. We show that delivery of CD47nb by tumor-colonizing bacteria increases activation of tumor-infiltrating T cells, stimulates rapid tumor regression, prevents metastasis and leads to long-term survival in a syngeneic tumor model in mice. Moreover, we report that local injection of CD47nb-expressing bacteria stimulates systemic tumor-antigen-specific immune responses that reduce the growth of untreated tumors, providing proof-of-concept for an abscopal effect induced by an engineered bacterial immunotherapy. We have expanded this approach to include additional human and murine specific immunotherapeutic payloads and evaluate efficacy in multiple tumor model systems.

Citation Format: Sreyan Chowdhury, Kelly Pu, Clare Nimura, Samuel Castro, Courtney Coker, Taylor Hinchliffe, Nicholas Arpaia, Tal Danino. Programmable bacteria induce durable tumor regression and systemic antitumor immunity [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 1074.

Thermal Conductivity Performance of 2D hBN/MoS2/Hybrid Nanostructures Used on Natural and Synthetic Esters

In this paper, the thermal conductivity behavior of synthetic and natural esters reinforced with 2D nanostructures-single hexagonal boron nitride (h-BN), single molybdenum disulfide (MoS₂), and hybrid h-BN/MOS₂-were studied and compared to each other. As a basis for the synthesis of nanofluids, three biodegradable insulating lubricants were used: FR3^TM and VG-100 were used as natural esters and MIDEL 7131 as a synthetic ester. Two-dimensional nanosheets of h-BN, MoS_2, and their hybrid nanofillers (50/50 ratio percent) were incorporated into matrix lubricants without surfactants or additives. Nanofluids were prepared at 0.01, 0.05, 0.10, 0.15, and 0.25 weight percent of filler fraction. The experimental results revealed improvements in thermal conductivity in the range of 20-32% at 323 K with the addition of 2D nanostructures, and a synergistic behavior was observed for the hybrid h-BN/MoS₂ nanostructures.

SAT0075 ABATACEPT IN COMBINATION WITH METOTREXATE IN PATIENTS WITH RHEUMATOID ARTHRITIS ASSOCIATED TO INTERSTITIAL LUNG DISEASE: NATIONAL MULTICENTER STUDY OF 263 PATIENTS

Background:

Interstitial Lung Disease (ILD) is an extra-articular complication of rheumatoid arthritis (RA) that is associated with increased morbidity and mortality. Conventional disease-modifying drugs (DMARDs) such as methotrexate (MTX) have been implicated in the development and exacerbation of a pre-existing ILD.

Objectives:

The aim of our study was to check the influence of combined MTX treatment in patients with RA-ILD treated with abatacept (ABA).

Methods:

National multicentre retrospective registry of 263 patients with RA-ILD treated with ABA. RA was diagnosed according to the ACR classification criteria of 1987 or by the EULAR/ACR criteria of 2010. ILD was diagnosed by high resolution computed tomography (HRCT). In this study we have done a subanalysis of the 46 patients treated with ABA in combination with MTX (ABA+MTX) vs. 217 patients treated with ABA in monotherapy or in combination with other synthetic DMARDs. Efficacy was evaluated according to the following parameters: a) Dyspnoea (MMRC) considering variations ≥ 1; b) Lung function test (LFT) considering variations ≥ 10% in FVC and a variation of DLCO ≥ 10%; c) Imaging test (HRCT) d) DAS28 score e) prednisone dose. Variables were collected at the beginning of the study and at months 3, 6, 12 and then every 12 months until a maximum of 60 months.

Results:

263 patients with ILD associated with RA were included in the study with mean age 64.64±10 years. RF or CCPA were positive in 235 (89.4%) and 233 (88.6%) cases, respectively, with a mean follow-up of 22.7±19.7 months. Baseline characteristics of both groups are shown in table 1, while data obtained during evolution of this complication are presented in Figure 1.

Conclusion:

Despite the baseline differences of both groups, the good evolution in the ABA+MTX subgroup suggests that this therapeutic strategy can be a safe combination for patients with RA-ILD.

ABA with MTX (n=46)ABA w/t MTX (n=217)PSex (F/M)28/18122/950.625Age (years)65.11±10.216.2±9.80.202RF/CCPA + (%)91.3/91.389.8/90.10.810Smoking or past smoking (%)47.855.10.417Follow-up (months)22.73±18.0022.3±20.850.916DAS28 at baseline4.08±1.514.61±1.470.056DAS28 at last visit3.00±1.463.13±1.310.642Prednisone at baseline, median (IQR) (mg)5 (5-7.5)7.75 (5-15)0.008*Prednisone at the end of study, median (IQR) (mg)5 (1-5)5 (5-7.5)0.032*DLCO at baseline (%)66.85±19.0465.43±18.210.823DLCO at the end of study (%)66.05±20.9565.17±19.720.831FVC at baseline (%)90.06±17.7785.40±21.560.164FVC at the end of study (%)90.58±15,4584.21±21.490.038*

Disclosure of Interests:

Carlos Fernández-Díaz Speakers bureau: Brystol Meyers Squibb, Santos Castañeda: None declared, Rafael Melero: None declared, J. Loricera: None declared, Francisco Ortiz-Sanjuán: None declared, A. Juan-Mas: None declared, Carmen Carrasco-Cubero Speakers bureau: Janssen, MSD, AbbVie, Novartis, Bristol Myers Squibb, and Celgene, S, Rodriguéz-Muguruza: None declared, S. Rodrigez -Garcia: None declared, R. Castellanos-Moreira: None declared, RAQUEL ALMODOVAR Speakers bureau: Abbvie, Celgene, Janssen, Lilly, Novartis, Pfizer.

, CLARA AGUILERA CROS: None declared, Ignacio Villa-Blanco Consultant of: UCB, Speakers bureau: Novartis, MSD, Lilly, Sergi Ordoñez: None declared, Susana Romero-Yuste: None declared, C. Ojeda-Garcia: None declared, Manuel Moreno: None declared, Gemma Bonilla: None declared, I. Hernández-Rodriguez: None declared, Mireia Lopez Corbeto: None declared, José Luis Andréu Sánchez: None declared, Trinidad Pérez Sandoval: None declared, Alejandra López Robles: None declared, Patricia Carreira Grant/research support from: Actelion, Roche, MSD, Consultant of: GlaxoSmithKline, VivaCell Biotechnology, Emerald Health Pharmaceuticals, Boehringer Ingelheim, Roche, Speakers bureau: Actelion, GlaxoSmithKline, Roche, Natalia Mena-Vázquez: None declared, C. Peralta-Ginés: None declared, ANA URRUTICOECHEA-ARANA: None declared, Luis Marcelino Arboleya Rodríguez: None declared, J. Narváez: None declared, DESEADA PALMA SANCHEZ: None declared, Olga Maiz-Alonso: None declared, J. Fernández-Leroy: None declared, I. Cabezas-Rodriguez: None declared, Ivan Castellví Consultant of: Boehringer Ingelheim, Actelion, Kern Pharma, Speakers bureau: Boehringer Ingelheim, Actelion, Bristol-Myers Squibb, Roche, A. Ruibal-Escribano: None declared, JR De Dios-Jiménez Aberásturi: None declared, Paloma Vela-Casasempere: None declared, C. González-Montagut Gómez: None declared, J M Blanco: None declared, Noelia Alvarez-Rivas: None declared, N. Del-Val: None declared, M. Rodíguez-Gómez: None declared, Eva Salgado-Pérez: None declared, Carlos Fernández-López: None declared, E.C. Cervantes Pérez: None declared, A. Devicente-DelMas: None declared, Blanca Garcia-Magallon Consultant of: MSD, Speakers bureau: Pfizer, Amgen, Celgene, MSD, Cristina Hidalgo: None declared, Sabela Fernández: None declared, Edilia García-Fernández: None declared, R. López-Sánchez: None declared, S. Castro: None declared, P. Morales-Garrido: None declared, Andrea García-Valle: None declared, Rosa Expósito: None declared, L. Exposito-Perez: None declared, Lorena Pérez Albaladejo: None declared, Ángel García-Aparicio: None declared, Ricardo Blanco Grant/research support from: AbbVie, MSD, and Roche, Speakers bureau: AbbVie, Pfizer, Roche, Bristol-Myers, Janssen, and MSD, Miguel A González-Gay Grant/research support from: Pfizer, Abbvie, MSD, Speakers bureau: Pfizer, Abbvie, MSD

SAT0035 RESPONSE TO ABATACEPT OF DIFFERENT PATTERNS OF INTERSTITIAL LUNG DISEASE IN RHEUMATOID ARTHRITIS: NATIONAL MULTICENTER STUDY OF 263 PATIENTS

Background:

Interstitial Lung Disease (ILD) is a severe extraarticular manifestation of rheumatoid arthritis (RA). In this line, several radiological patterns of RA-ILD have been described: i) usual interstitial pneumonia (UIP), ii) nonspecific interstitial pneumonia (NSIP), iii) obliterating bronchiolitis, iv) organized pneumonia and mixed patterns. Abatacept (ABA) could be an effective and safe option for patients with RA-ILD, although the response in the different radiological patterns is not well defined.

Objectives:

Our aim was to assess the response to ABA in different radiological patterns of ILD.

Methods:

Observational retrospective multicenter study of RA-ILD treated with ABA. ILD was diagnosed by HRCT and classified by radiological patterns in 3 different subgroups of RA-ILD: a) UIP, b) NSIP and c) “other”. ABA was used sc. or iv. at standard dose. We assessed: a) Dyspnoea (MMRC scale; significant variation ≥1); b) Respiratory function tests (significant changes ≥10% in FVC and DLCO); c) HRCT imaging; d) DAS28 e)prednisone dose.

Variables were collected at months 0, 3, 6, 12 months and subsequently every 12 months until a maximum of 60 months.

Results:

We included 263 patients: 106 UIP, 84 NSIP and 73 others (150 women / 113 men), mean age 64.64±10 years. Total patients positive for RF or CCPA were 235 (89.4%) and 233 (88.6%), respectively. In 26 out of 263 patients, the development of ILD was closely related to the administration of sDMARDs (MTX n = 11 and LFN n = 1) or bDMARDs (ETN n = 5, ADA n = 4, CZP n = 2 and IFX n = 3). Patient characteristics are shown in table 1. Figure 1 shows the evolution of the cases with available data after a mean follow-up of 22.7±19.7 months. Mean DLCO and FVC remained stable in the 3 groups without statistically significant changes, and all the groups showed a statistically significant reduction in DAS28 and prednisone dose.

Conclusion:

ABA could be a good choice of treatment in patients with RA-ILD independently of the radiological pattern of ILD.

Disclosure of Interests:

Carlos Fernández-Díaz Speakers bureau: Brystol Meyers Squibb, Santos Castañeda: None declared, Rafael Melero: None declared, J. Loricera: None declared, Francisco Ortiz-Sanjuán: None declared, A. Juan-Mas: None declared, Carmen Carrasco-Cubero Speakers bureau: Janssen, MSD, AbbVie, Novartis, Bristol Myers Squibb, and Celgene, S, Rodriguéz-Muguruza: None declared, S. Rodrigez -Garcia: None declared, R. Castellanos-Moreira: None declared, RAQUEL ALMODOVAR Speakers bureau: Abbvie, Celgene, Janssen, Lilly, Novartis, Pfizer.

, CLARA AGUILERA CROS: None declared, Ignacio Villa-Blanco Consultant of: UCB, Speakers bureau: Novartis, MSD, Lilly, Sergi Ordoñez: None declared, Susana Romero-Yuste: None declared, C. Ojeda-Garcia: None declared, Manuel Moreno: None declared, Gemma Bonilla: None declared, I. Hernández-Rodriguez: None declared, Mireia Lopez Corbeto: None declared, José Luis Andréu Sánchez: None declared, Trinidad Pérez Sandoval: None declared, Alejandra López Robles: None declared, Patricia Carreira Grant/research support from: Actelion, Roche, MSD, Consultant of: GlaxoSmithKline, VivaCell Biotechnology, Emerald Health Pharmaceuticals, Boehringer Ingelheim, Roche, Speakers bureau: Actelion, GlaxoSmithKline, Roche, Natalia Mena-Vázquez: None declared, C. Peralta-Ginés: None declared, ANA URRUTICOECHEA-ARANA: None declared, Luis Marcelino Arboleya Rodríguez: None declared, J. Narváez: None declared, DESEADA PALMA SANCHEZ: None declared, Olga Maiz-Alonso: None declared, J. Fernández-Leroy: None declared, I. Cabezas-Rodriguez: None declared, Ivan Castellví Consultant of: Boehringer Ingelheim, Actelion, Kern Pharma, Speakers bureau: Boehringer Ingelheim, Actelion, Bristol-Myers Squibb, Roche, A. Ruibal-Escribano: None declared, JR De Dios-Jiménez Aberásturi: None declared, Paloma Vela-Casasempere: None declared, C. González-Montagut Gómez: None declared, J M Blanco: None declared, Noelia Alvarez-Rivas: None declared, N. Del-Val: None declared, M. Rodíguez-Gómez: None declared, Eva Salgado-Pérez: None declared, Carlos Fernández-López: None declared, E.C. Cervantes Pérez: None declared, A. Devicente-DelMas: None declared, Blanca Garcia-Magallon Consultant of: MSD, Speakers bureau: Pfizer, Amgen, Celgene, MSD, Cristina Hidalgo: None declared, Sabela Fernández: None declared, R. López-Sánchez: None declared, Edilia García-Fernández: None declared, S. Castro: None declared, P. Morales-Garrido: None declared, Andrea García-Valle: None declared, Rosa Expósito: None declared, L. Exposito-Perez: None declared, Lorena Pérez Albaladejo: None declared, Ángel García-Aparicio: None declared, Miguel A González-Gay Grant/research support from: Pfizer, Abbvie, MSD, Speakers bureau: Pfizer, Abbvie, MSD, Ricardo Blanco Grant/research support from: AbbVie, MSD, and Roche, Speakers bureau: AbbVie, Pfizer, Roche, Bristol-Myers, Janssen, and MSD

OP0212 ABATACEPT IN INTERSTITIAL LUNG DISEASE ASSOCIATED WITH RHEUMATOID ARTHRITIS. NATIONAL MULTICENTER STUDY OF 263 PATIENTS

Background:

Interstitial Lung Disease (ILD) is a severe complication of Rheumatoid Arthritis (RA). Several conventional disease-modifying anti-rheumatic drugs (cDMARDs) and biologic (b) DMARDs may induce or impaired ILD-RA. Abatacept (ABA) may be useful in ILD-RA (1).

Objectives:

To assess the efficacy and safety of ABA in a large series of ILD-RA for a long-term follow-up.

Methods:

Multicenter open-level study of ILD-RA treated with at least 1 dose of ABA. ILD was diagnosed by high-resolution computed tomography (HRTC). We study these outcomes: a) 1-point change Modied Medical Research Council (MMRC); b) forced vital capacity (FVC) and/or DLCO improvement or decline ≥10%; c) change in HRCT, d) change in DAS28. e) Prednisone dose. Values were collected at 0, 3, 6, 12 and then every 12 months.

Results:

We studied 263 patients (150 women/113 men) (mean age;64.6±10 years), with ILD-RA. At ABA-onset they were smokers or exsmoker (53.8%), positive APCC (88.6%), median [IQR] duration of ILD of 12 [3-41.25] months, mean DLCO (65.7±18.3) and FVC (85.9±21.8).

The ILD-pattern were usual interstitial pneumonia (UIP) (40.3%), non-specific interstitial pneumonia (NSIP) (31.9%) and others (27.8%).

ABA was prescribed at standard subcutaneous (125 mg/w) in 196 (74.5%) or intravenously (10 mg/kg/4 w) in 67 (25.5%); in monotherapy (n=111) or combined with cDMARDs (n=152); especially leflunomide (n=55), MTX (n=46), or antimarials (n=21).

After a mean follow-up of 22.7±19.7 months most outcomes remain stable (Figure). Moreover, DAS28 improved from 4.5±1.5 to 3.1±1.3; prednisone dose reduced from a median 7.5 [5-10] to 5 mg [5-7.5] and retention rate was 76.4%. The main adverse effects were serious infections (n=28), neoplasia (n=3), serious infusion reaction (n=1) and myocardial infarction (n=1).

Conclusion:

ABA seems effective and relatively safe in ILD-RA.

References:

[1]Fernández-Díaz C et al. Semin Arthritis Rheum. 2018; 48:22-27

Disclosure of Interests:

Carlos Fernández-Díaz Speakers bureau: Brystol Meyers Squibb, Santos Castañeda: None declared, Rafael Melero: None declared, J. Loricera: None declared, Francisco Ortiz-Sanjuán: None declared, A. Juan-Mas: None declared, Carmen Carrasco-Cubero Speakers bureau: Janssen, MSD, AbbVie, Novartis, Bristol Myers Squibb, and Celgene, S, Rodriguéz-Muguruza: None declared, S. Rodrigez -Garcia: None declared, R. Castellanos-Moreira: None declared, RAQUEL ALMODOVAR Speakers bureau: Abbvie, Celgene, Janssen, Lilly, Novartis, Pfizer.

CLARA AGUILERA CROS: None declared, Ignacio Villa-Blanco Consultant of: UCB, Speakers bureau: Novartis, MSD, Lilly, Sergi Ordoñez: None declared, Susana Romero-Yuste: None declared, C. Ojeda-Garcia: None declared, Manuel Moreno: None declared, Gemma Bonilla: None declared, I. Hernández-Rodriguez: None declared, Mireia Lopez Corbeto: None declared, José Luis Andréu Sánchez: None declared, Trinidad Pérez Sandoval: None declared, Alejandra López Robles: None declared, Patricia Carreira Grant/research support from: Actelion, Roche, MSD, Consultant of: GlaxoSmithKline, VivaCell Biotechnology, Emerald Health Pharmaceuticals, Boehringer Ingelheim, Roche, Speakers bureau: Actelion, GlaxoSmithKline, Roche, Natalia Mena-Vázquez: None declared, C. Peralta-Ginés: None declared, ANA URRUTICOECHEA-ARANA: None declared, Luis Marcelino Arboleya Rodríguez: None declared, J. Narváez: None declared, DESEADA PALMA SANCHEZ: None declared, Olga Maiz-Alonso: None declared, J. Fernández-Leroy: None declared, I. Cabezas-Rodriguez: None declared, Ivan Castellví Consultant of: Boehringer Ingelheim, Actelion, Kern Pharma, Speakers bureau: Boehringer Ingelheim, Actelion, Bristol-Myers Squibb, Roche, A. Ruibal-Escribano: None declared, JR De Dios-Jiménez Aberásturi: None declared, Paloma Vela-Casasempere: None declared, C. González-Montagut Gómez: None declared, J M Blanco: None declared, Noelia Alvarez-Rivas: None declared, N. Del-Val: None declared, M. Rodíguez-Gómez: None declared, Eva Salgado-Pérez: None declared, Carlos Fernández-López: None declared, E.C. Cervantes Pérez: None declared, A. Devicente-DelMas: None declared, Blanca Garcia-Magallon Consultant of: MSD, Speakers bureau: Pfizer, Amgen, Celgene, MSD, Cristina Hidalgo: None declared, Sabela Fernández: None declared, Edilia García-Fernández: None declared, R. López-Sánchez: None declared, S. Castro: None declared, P. Morales-Garrido: None declared, Andrea García-Valle: None declared, Rosa Expósito: None declared, L. Exposito-Perez: None declared, Lorena Pérez Albaladejo: None declared, Ángel García-Aparicio: None declared, Miguel A González-Gay Grant/research support from: Pfizer, Abbvie, MSD, Speakers bureau: Pfizer, Abbvie, MSD, Ricardo Blanco Grant/research support from: AbbVie, MSD, and Roche, Speakers bureau: AbbVie, Pfizer, Roche, Bristol-Myers, Janssen, and MSD

OPTN/SRTR 2018 Annual Data Report: Kidney

Despite the ongoing severe mismatch between organ need and supply, data from 2018 revealed some promising trends. For the fourth year in a row, the number of patients waiting for a kidney transplant in the US declined and numbers of both deceased and living donor kidney transplants increased. These encouraging trends are tempered by ongoing challenges, such as a large proportion of listed patients with dialysis time longer than 5 years. The proportion of candidates aged 65 years or older continued to rise, and the proportion undergoing transplant within 5 years of listing continued to vary dramatically nationwide, from 10% to nearly 80% across donation service areas. Increasing trends in the recovery of organs from hepatitis C positive donors and donors with anoxic brain injury warrant ongoing monitoring, as does the ongoing discard of nearly 20% of recovered organs. While the number of living donor transplants increased, racial disparities persisted in the proportion of living versus deceased donors. Strikingly, the total number of kidney transplant recipients alive with a functioning graft is on track to pass 250,000 in the next 1-2 years. The total number of pediatric kidney transplants remained steady at 756 in 2018. Deeply concerning to the pediatric community is the persistently low level of living donor kidney transplants, representing only 36.2% in 2018.

A real-life analysis on the indications and prognostic relevance of perioperative chemotherapy in locally advanced resectable gastric adenocarcinoma

BACKGROUND AND PURPOSE

Perioperative chemotherapy (periCTX) based on the "MAGIC" scheme has become a standard treatment in Europe for locally advanced oesophagogastric cancer. We assessed implementation and long-term oncological outcomes of MAGIC periCTX for locally advanced gastric cancer.

METHODS

Population-based cohort study of all patients with locally advanced gastric cancer undergoing surgical resection with curative intent in Catalonia and Navarra (the first two autonomous communities included in the EURECCA Upper GI Spanish Working Group) between January 2011 and December 2013. The main variable was the percentage of patients treated with MAGIC periCTX. Kaplan-Meier analysis and Cox proportional hazards model were used to assess the survival benefit of periCTX.

RESULTS

Among 814 patients, 217 (26.6%) received periCTX (especially patients more likely to receive it: aged < 70 years, with proximal tumors, low anesthetic risk, and cT3-4/cN+ clinical stage). 35% did not complete perioperative chemotherapy, with no relationship with age. PeriCTX showed no effect on postoperative morbimortality. Histological tumor regression was more often absent or poor (38.2%) than total or almost total (27.8%), although clinico-pathological lymph-node downstaging was higher than expected by staging inaccuracy (38.7% vs. 24.2%). PeriCTX was associated with a better survival only in cT3-4 and cN+ patients, showing less prognostic relevance than optimal oncological surgery with D2 lymphadenectomy.

CONCLUSIONS

Only 26.6% of locally advanced resectable gastric cancer patients received PeriCTX. Pathological response was poor, although some degree of nodal downstaging was observed. Survival benefit of periCTX was limited to cT3-4 and cN+ patients, being less relevant than D2 lymphadenectomy.

Programmable bacteria induce durable tumor regression and systemic antitumor immunity

Synthetic biology is driving a new era of medicine through the genetic programming of living cells^1,2. This transformative approach allows for the creation of engineered systems that intelligently sense and respond to diverse environments, ultimately adding specificity and efficacy that extends beyond the capabilities of molecular-based therapeutics^3–6. One particular focus area has been the engineering of bacteria as therapeutic delivery systems to selectively release therapeutic payloads in vivo^7–11. Here, we engineered a non-pathogenic E. coli to specifically lyse within the tumor microenvironment and release an encoded nanobody antagonist of CD47 (CD47nb)¹², an anti-phagocytic receptor commonly overexpressed in several human cancers^13,14. We show that delivery of CD47nb by tumor-colonizing bacteria increases activation of tumor-infiltrating T cells, stimulates rapid tumor regression, prevents metastasis, and leads to long-term survival in a syngeneic tumor model. Moreover, we report that local injection of CD47nb bacteria stimulates systemic tumor antigen–specific immune responses that reduce the growth of untreated tumors – providing, to the best of our knowledge, the first demonstration of an abscopal effect induced by an engineered bacterial immunotherapy. Thus, engineered bacteria may be used for safe and local delivery of immunotherapeutic payloads leading to systemic antitumor immunity.

Rapid screening of engineered microbial therapies in a 3D multicellular model

Synthetic biology is transforming therapeutic paradigms by engineering living cells and microbes to intelligently sense and respond to diseases including inflammation, infections, metabolic disorders, and cancer. However, the ability to rapidly engineer new therapies far outpaces the throughput of animal-based testing regimes, creating a major bottleneck for clinical translation. In vitro approaches to address this challenge have been limited in scalability and broad applicability. Here, we present a bacteria-in-spheroid coculture (BSCC) platform that simultaneously tests host species, therapeutic payloads, and synthetic gene circuits of engineered bacteria within multicellular spheroids over a timescale of weeks. Long-term monitoring of bacterial dynamics and disease progression enables quantitative comparison of critical therapeutic parameters such as efficacy and biocontainment. Specifically, we screen Salmonella typhimurium strains expressing and delivering a library of antitumor therapeutic molecules via several synthetic gene circuits. We identify candidates exhibiting significant tumor reduction and demonstrate high similarity in their efficacies, using a syngeneic mouse model. Last, we show that our platform can be expanded to dynamically profile diverse microbial species including Listeria monocytogenes, Proteus mirabilis, and Escherichia coli in various host cell types. This high-throughput framework may serve to accelerate synthetic biology for clinical applications and for understanding the host-microbe interactions in disease sites.

OPTN/SRTR 2017 Annual Data Report: Kidney

Many positive trends in kidney transplantation were notable in 2017. Deceased donor kidney transplant rates and counts continued to rise, the kidney transplant waiting list declined for the third year in a row after decades of growth, and both short- and long-term allograft survival continued to improve year over year. In total, more than 220,000 patients were living in the United States with a functioning allograft. With 3 years of data available since implementation of the new kidney allocation system, better prediction of longer-term results of the allocation policy changes became possible. The data also reveal several areas in need of improvement and attention. Overall, the challenge of providing adequate access to kidney transplant persisted nationally, with additional dramatic regional variation. The proportion of living donor kidney transplants in both adults and children continued to fall, and racial disparities in living donor kidney transplant grew in the past decade.

How much do we know about the frequency of hybridisation and polyploidy in the Mediterranean region?

Natural hybridisation and polyploidy are currently recognised as drivers of biodiversity, despite early scepticism about their importance. The Mediterranean region is a biodiversity hotspot where geological and climatic events have created numerous opportunities for speciation through hybridisation and polyploidy. Still, our knowledge on the frequency of these mechanisms in the region is largely limited, despite both phenomena are frequently cited in studies of Mediterranean plants. We reviewed information available from biodiversity and cytogenetic databases to provide the first estimates of hybridisation and polyploidy frequency in the Mediterranean region. We also inspected the most comprehensive modern Mediterranean Flora (Flora iberica) to survey the frequency and taxonomic distribution of hybrids and polyploids in Iberian Peninsula. We found that <6% of Mediterranean plants were hybrids, although a higher frequency was estimated for the Iberian Peninsula (13%). Hybrids were concentrated in few families and in even fewer genera. The overall frequency of polyploidy (36.5%) was comparable with previous estimates in other regions; however our estimates increased when analysing the Iberian Peninsula (48.8%). A surprisingly high incidence of species harbouring two or more ploidy levels was also observed (21.7%). A review of the available literature also showed that the ecological factors driving emergence and establishment of new entities are still poorly studied in the Mediterranean flora, although geographic barriers seem to play a major role in polyploid complexes. Finally, this study reveals several gaps and limitations in our current knowledge about the frequency of hybridisation and polyploidy in the Mediterranean region. The obtained estimates might change in the future with the increasing number of studies; still, rather than setting the complete reality, we hope that this work triggers future studies on hybridisation and polyploidy in the Mediterranean region.

Niche differences may explain the geographic distribution of cytotypes in Erysimum mediohispanicum

Polyploidisation has played an important role in plant diversification, and variation in ploidy level may be found not only between species of the same genus, but also within a single species. Although establishing the adaptive significance of polyploidy to explain the geographic distribution of cytotypes is challenging, the occurrence of different cytotypes in different ecological niches may suggest an adaptive role of genome duplication. We studied the adaptive significance of the geographic distribution of cytotypes across the entire distribution range of the endemic Erysimum mediohispanicum (Brassicaceae). For that, we have used climate variables, population elevation and soil properties to model ecological niches for the different cytotypes. In addition, we analysed the effect that ploidy level has on the floral phenotype. We found a clear geographic pattern in the distribution of cytotypes, with diploid individuals occurring in the southernmost part of the distribution range, while tetraploids were found in the northern area. A contact (mosaic) zone between both cytotypes was identified, but diploids and tetraploids occur in sympatry in only one population (although in a highly unbalanced proportion). Gene flow between different cytotypes seems to be negligible, as evident from an almost complete absence of triploids and other minority cytotypes. Niches occupied by both cytotypes showed subtle, but significant differences, even in the contact zone. Precipitation was higher in regions occupied by tetraploid individuals, which present wider corolla tubes and thinner but taller stalks than diploids. Our findings highlight the potential role of polyploidy in the ecological adaptation of E. mediohispanicum to both abiotic factors and biotic interactions.

Organization in response to massive afflux of war victims in civilian practice - experimental feedback from the November 2015 Paris terrorist attacks

The arrival of a large number of war-weapon casualties at a civilian trauma center requires anticipation. A plan defining the management principles and the respective roles of the involved physicians and nurses and their interaction with each other is essential. Uni-directional patient flow associated with adequate numbers of staff physicians and nurses under the leadership of a medical director is essential to prevent the overwhelming of the trauma center. Routine and regular interaction between the pre-hospital medical flow control system and the medical director, on one hand, and between surgical teams and the medical director, on the other, are necessary to know when to apply "damage control" surgical techniques. Based on the feedback of a level 1 trauma center that received 53 victims of the November 13, 2015 terrorist attack in Paris, we present the factors of success, and the stumbling blocks.

Novel poly(ε-caprolactone)/gelatin wound dressings prepared by emulsion electrospinning with controlled release capacity of Ketoprofen anti-inflammatory drug

In the present study, a single and binary Ketoprofen-loaded mats of ultrathin fibers were developed by electrospinning and their physical properties and drug release capacity was analyzed. The single mat was prepared by solution electrospinning of poly(ε-caprolactone) (PCL) with Ketoprofen at a weight ratio of 5wt%. This Ketoprofen-containing PCL solution was also used as the oil phase in a 7:3 (wt/wt) emulsion with gelatin dissolved in acidified water. The resultant stable oil-in-water (O/W) emulsion of PCL-in-gelatin, also containing Ketoprofen at 5wt%, was electrospun to produce the binary mat. Cross-linking process was performed by means of glutaraldehyde vapor on the electrospun binary mat to prevent dissolution of the hydrophilic gelatin phase. The performed characterization indicated that Ketoprofen was successfully embedded in the single and binary electrospun mats, i.e. PCL and PCL/gelatin, and both mats showed high hydrophobicity but poor thermal resistance. In vitro release studies interestingly revealed that, in comparison to the single PCL electrospun mat, the binary PCL/gelatin mat significantly hindered Ketoprofen burst release and exhibited a sustained release capacity of the drug for up to 4days. In addition, the electrospun Ketoprofen-loaded mats showed enhanced attachment and proliferation of L929 mouse fibroblast cells, presenting the binary mat the highest cell growth yield due to its improved porosity. The here-developed electrospun materials clearly show a great deal of potential as novel wound dressings with an outstanding controlled capacity to release drugs.

Long-Term Stability of New Co-Amorphous Drug Binary Systems: Study of Glass Transitions as a Function of Composition and Shelf Time

The amorphous state is of particular interest in the pharmaceutical industry due to the higher solubility that amorphous active pharmaceutical ingredients show compared to their respective crystalline forms. Due to their thermodynamic instability, drugs in the amorphous state tend to recrystallize; in order to avoid crystallization, it has been a common strategy to add a second component to hinder the crystalline state and form a thermally stable co-amorphous system, that is to say, an amorphous binary system which retains its amorphous structure. The second component can be a small molecule excipient (such as a sugar or an aminoacid) or a second drug, with the advantage that a second active pharmaceutical ingredient could be used for complementary or combined therapeutic purposes. In most cases, the compositions studied are limited to 1:1, 2:1 and 1:2 molar ratios, leaving a gap of information about phase transitions and stability on the amorphous state in a wider range of compositions. In the present work, a study of novel co–amorphous formulations in which the selection of the active pharmaceutical ingredients was made according to the therapeutic effect is presented. Resistance against crystallization and behavior of glass transition temperature (Tg were studied through calorimetric measurements as a function of composition and shelf time. It was found that binary formulations with Tg temperatures higher than those of pure components presented long-term thermal stability. In addition, significant increments of Tg values, of as much as 15 ∘C, were detected as a result of glass relaxation at room temperature during storage time; this behavior of glass transition has not been previously reported for co-amorphous drugs. Based on these results, it can be concluded that monitoring behavior of Tg and relaxation processes during the first weeks of storage leads to a more objective evaluation of the thermomechanical stability of an amorphous formulation.

Erratum to: 36th International Symposium on Intensive Care and Emergency Medicine: Brussels, Belgium. 15-18 March 2016

[This corrects the article DOI: 10.1186/s13054-016-1208-6.].