Tinkering with care: Implementing extended-release buprenorphine depot treatment for opioid dependence

We examine how extended-release buprenorphine depot (BUP-XR) is put to use and made to work in implementation practices, attending to how care practices are challenged and adapted as a long-acting technology is introduced into service in opioid agonist treatment (OAT) in Australia. Our approach is informed by ideas in science and technology studies (STS) emphasising the irreducible entanglement of care practices and technology, and in particular the concept of 'tinkering' as a practice of adaptation. To make our analysis, we draw on qualitative interview accounts (n = 19) of service providers involved in BUP-XR implementation across five sites. Our analysis considers the disruptive novelty of BUP-XR. Tinkering to make a novel technology work in practice slows down the expectation of implementation in relation to transformative innovation, despite the promise of dramatic or rapid change. Tinkering allowed for more open relations, for new care practices that departed from the routine and familiar, opening potential for how BUP-XR could be put to use and made to work in its new situation, and as its situation evolved along-with its implementation. Flexibility and openness of altering relations was, however, at times, held in tension with inflexibility and closure. This analysis identifies a concern for what is made present and what is made absent in the altered care network affected by BUP-XR, with the multiple effects of supervised daily dosing practices thrown into relief as they become absented. Tinkering to implement BUP-XR locally connects with a broader assemblage of trial and movement in the constitution of treatment. The introduction of long-acting technologies prompts new questions about embedded implementation practices, including supervised dosing, urinalysis, the time and place of psychosocial support, and how other social aspects of care might be recalibrated in drug treatment.

The impact of COVID-19 public health measures on attendance and overdose at supervised injecting facilities in Australia

OBJECTIVES

The COVID-19 pandemic disrupted service provision of harm reduction and drug treatment services for people who inject drugs in many countries. The two supervised injecting facilities (SIFs) in Sydney and Melbourne were differentially impacted by the pandemic, requiring local procedural changes in each service. We aimed to examine the impact of pandemic responses (including restrictions on movement, known as 'lockdowns') on service use and key parameters such as client reports of drug injected and recorded overdose rates.

STUDY DESIGN

Time series analysis of weekly client visits and monthly overdoses occurring at each service.

METHODS

Administrative client data from the two SIFs (Sydney data from 1 January 2018 to 30 April 2022; Melbourne data from 1 July 2018 to 30 April 2022) were examined using interrupted time series analyses with lockdown dates in each state entered as interruption terms. We analysed weekly SIF visits overall and by drug type, and monthly rates of opioid overdose at each service.

RESULTS

Lockdowns resulted in decreased visits to both services. The number of weekly client visits decreased during the first national lockdown for both the Sydney (trend change = -57.9; 95% CI [-109.4, -6.4]) and Melbourne SIF (near sig trend change = -54.8 [-110.8, 1.05]). Trends in visit numbers increased after lockdowns were lifted in each city; however, visits in Sydney have not returned to the numbers recorded prior to the pandemic. Visits to the Melbourne SIF related to heroin use declined at each lockdown (trend 1 = -42.7 [-81.5, -3.9]; trend 2 = -56.1 [-94.6, -17.7]; trend 3 = -33.8 [-67.4, -0.2]); heroin visits to the Sydney SIF declined during the first lockdown and remained low (trend = -55.6 [-82.8, -28.3]). Methamphetamine visits to the Sydney SIF fluctuated, surpassing heroin visits at several timepoints. Rates of monthly opioid overdoses at both services declined immediately following the start of the first lockdown (Sydney = -16.6 [-26.1, -6.8]; Melbourne = -6.4 [-8.7, -4.1]), with increasing trends recorded at the end of the final lockdown in each jurisdiction (Sydney = 2.8 [0.6, 5.0]; Melbourne = 1.3 [0.72, 3.2]).

CONCLUSIONS

Public health restrictions related to the COVID-19 pandemic were associated with reduced client visits to, and overdoses in, Australian SIFs. Variations were noted in the drugs injected, likely reflecting changes in local drug markets. Shifts to other drugs during these periods were evident: methamphetamine in Sydney; co-injection of heroin and diphenhydramine in Melbourne.

Field Epidemiology and Public Health Microbiology training: capturing the alumni perspectives of the training's impact

We present the findings from the European Programme for Intervention Epidemiology Training (EPIET) Alumni Network (EAN) Member Survey conducted in October to December 2021. The EAN consists of field epidemiologists (EPIET) and public health microbiologists (European Public Health Microbiology Training Programme (EUPHEM)) who stay connected after their 2-year fellowship. This active alumni network provides opportunities for career development, mentorship, knowledge exchange and sharing of best practices for community members, affiliated professionals and public health organisations in Europe. Overall, 281 of 732 members participated in the survey. Of the 192 European fellowship alumni respondents, 173 (90%) indicated that skills and competencies acquired during their fellowship improved performance in their role compared with their abilities before the fellowship. Reported skills and competencies that could be further strengthened included data management/analysis, communication, mathematical modelling and leadership/team management. The EAN Member Survey provides valuable feedback to the EAN, as well as the fellowship programme offices at the European Centre for Disease Prevention and Control (ECDC) and affiliated field epidemiology programmes. The COVID-19 pandemic was a stark reminder of how essential cross-border collaborations are for continued European health security. Maintaining and increasing the professional, well-trained workforce remains crucial for optimal response to infectious diseases and protection of public health.

Increase in invasive group A streptococcal infections and emergence of novel, rapidly expanding sub-lineage of the virulent Streptococcus pyogenes M1 clone, Denmark, 2023

A highly virulent sub-lineage of the Streptococcus pyogenes M1 clone has been rapidly expanding throughout Denmark since late 2022 and now accounts for 30% of the new invasive group A streptococcal infections. We aimed to investigate whether a shift in variant composition can account for the high incidence rates observed over winter 2022/23, or if these are better explained by the impact of COVID-19-related restrictions on population immunity and carriage of group A Streptococcus.

Effect of discharge opioid on persistent postoperative opioid use: a retrospective cohort study comparing tapentadol with oxycodone

Opioid harm can vary by opioid type. This observational study examined the effect of opioid type (oxycodone vs. tapentadol) on rates of persistent postoperative opioid use ('persistence'). We linked hospital and community pharmacy data for surgical patients who were dispensed discharge opioids between 1 January 2016 and 30 September 2021. Patients were grouped by opioid experience ('opioid-naive' having received no opioids in the 3 months before discharge) and formulation of discharge opioid (immediate release only or modified release ± immediate release). Mixed-effects logistic regression models predicted persistence (continued use of any opioid at 90 days after discharge), controlling for key persistence risk factors. Of the 122,836 patients, 2.31% opioid-naive and 27.24% opioid-experienced patients met the criteria for persistence. For opioid-naive patients receiving immediate release opioids, there was no significant effect of opioid type. Tapentadol modified release was associated with significantly lower odds of persistence compared with oxycodone modified release, OR (95%CI) 0.81 (0.69-0.94) for opioid-naive patients and 0.81 (0.71-0.93) for opioid-experienced patients. Among patients who underwent orthopaedic surgery (n = 19,832), regardless of opioid experience or opioid formulation, the odds of persistence were significantly lower for those who received tapentadol compared with oxycodone. This was one of the largest and most extensive studies of persistent postoperative opioid use, and the first that specifically examined persistence with tapentadol. There appeared to be lower odds of persistence for tapentadol compared with oxycodone among key subgroups, including patients prescribed modified release opioids and those undergoing orthopaedic surgery.

Increasing prevalence of chronic hepatitis B virus infection and low linkage to care in Denmark on 31 December 2016 - an update based on nationwide registers

OBJECTIVES

We aimed to update the estimated prevalence of both diagnosed and undiagnosed chronic hepatitis B virus infection in Denmark. Moreover, we aimed to determine the number of people with chronic hepatitis B virus infection in specialised care and to assess the completeness of reporting to the national register of communicable diseases.

METHODS

Using four registers with national coverage, we identified all individuals registered with chronic hepatitis B virus infection, aged 16 years or older, and alive in Denmark on 31 December 2016. The diagnosed population was then estimated using capture-recapture analysis. The undiagnosed population was estimated using data from the Danish pregnancy screening program.

RESULTS

We estimated that 14,548 individuals were living with chronic hepatitis B virus infection corresponding to 0.3% of the Danish population. Of them, 13,530 (93%) were diagnosed and 7942 (55%) were registered in one or more of the source registers. Only 4297 (32%) diagnosed individuals had attended specialised care and only 3289 cases (24%) were reported to the Danish communicable disease register.

CONCLUSION

The prevalence of chronic hepatitis B virus infection increased from 2007 to 2017. The majority that had been diagnosed did not receive care as recommended by national guidelines and were not reported to the communicable diseases register responsible for hepatitis B virus surveillance. Future efforts should focus on linking individuals diagnosed with chronic hepatitis B virus infection to specialised care and improving reporting to the hepatitis B virus surveillance system.

POS1302 PATIENT AND PHYSICIAN REPORTED OUTCOMES OF JUVENILE SYSTEMIC SCLEROSIS PATIENTS SIGNIFICANTLY IMPROVE OVER 12 MONTHS OBSERVATION PERIOD IN THE JUVENILE SYSTEMIC SCLERODERMA INCEPTION COHORT. www.juvenile-scleroderma.com

Background

Juvenile systemic sclerosis (jSSc) is an orphan disease with a prevalence of 3 in 1 000 000 children (1). The Juvenile Systemic Scleroderma Inception cohort (jSScC) is the largest cohort of jSSc patients in the world. The jSScC collects longitudinal data prospectively in jSSc, allowing the evaluation of the development of organ involvement and patients and physician reported outcomes in jSSc over time.

Objectives

To review the changes in the clinical characteristics and patient and physician reported outcomes over 12 months observation period from the time of inclusion into the cohort.

Methods

The jSScC cohort enrolls jSSc patients who developed the first non-Raynaud´s symptom before the age of 16 years and are under the age of 18 years at the time of inclusion (2, 3). We reviewed jSScC patient clinical data and patient and physician reported outcomes, who had 12 months follow up from the time of inclusion until 1st of December 2021.

Results

We could extract data of 113 patients. The female/male ratio was 3.5:1. Median age of onset of Raynaud´s was 10.1 years and the median age of onset of non-Raynaud´s was 10.8 years. Eighty-eight percent of the patients were treated with disease modifying anti-rheumatic drugs (DMARDs) at time of inclusion in the cohort (T0) and 93% after 12 months (T12). Median disease duration was 2.5 years at T0. Antibody profile stayed unchanged. Only 3 clinical parameters changed and improved significantly, the median modified Rodnan skin score improved from 13 to 8 (p=0.002), the number of patients with swollen joints decreased from 17% to 8% (p=0.043) and number of patients with joints with pain on motion decreased from 20% to 12% (p=0.048). All other organ involvement did not show any statistically significant change from T0 to T12.

All collected patient reported outcomes improved significantly from T0 to T12: the patient reported disease activity (VAS 0 – 100) from 40 to 20 (p=0.011), the patient reported disease damage (VAS 0 – 100) from 40 to 20 (p=0.001), patient reported ulceration activity (VAS 0 – 100) from 10 to 0 (p=0.02) and the CHAQ score from 0.3 to 0.1 (p=0.002). Two of the three physician reported outcomes improved significantly, the physician global disease activity (VAS 0 – 100) from 30 to 20 (p=0.011) and physician reported global disease damage (VAS 0 – 100) from 30 to 25 (p=0.028).

Conclusion

Skin and musculoskeletal clinical features improved over 12 months, with almost all patients on DMARDs, supporting likely response of these features to therapy. It was promising that internal organ involvement, like cardiac and lung, although potentially stable, did not significantly worsen or increase. The most striking observation in the positive direction is improvement across several patient and physician reported outcome measures over the 12 month time period in this large international cohort.

References

[1]Beukelman T, Xie F, Foeldvari I. Assessing the prevalence of juvenile systemic sclerosis in childhood using administrative claims data from the United States. Journal of Scleroderma and Related Disorders. 2018;3(2):189-90.

[2]Foeldvari I, Klotsche J, Kasapcopur O, Adrovic A, Terreri MT, Sakamoto AP, et al. Differences sustained between diffuse and limited forms of juvenile systemic sclerosis in expanded international cohort. www.juvenile-scleroderma.com. Arthritis Care Res (Hoboken). 2021.

[3]Foeldvari I, Klotsche J, Torok KS, Kasapcopur O, Adrovic A, Stanevica V, et al. CHARACTERISTICS OF THE FIRST 80 PATIENTS AT TIMEPOINT OF FIRST ASSESSMENT INCLUDED IN THE JUVENILE SYSTEMIC SCLEROSIS INCEPTION COHORT. WWW.JUVENILESCLERODERMA.COM. Journal of Scleroderma and Related Disorders. 2018;4(1-13).

Disclosure of Interests

None declared

POS0172 DIFFUSE JUVENILE SYSTEMIC SCLEROSIS PATIENTS SHOW DISTINCT ORGAN INVOLVEMENT AND HAVE MORE SEVERE DISEASE IN THE LARGEST jSSc COHORT OF THE WORLD. RESULTS FROM THE THE JUVENILE SCLERODERMA INCEPTION COHORT. www.juvenile-scleroderma.com

Background

Juvenile systemic sclerosis (jSSc) is an orphan disease with a prevalence of 3 in 1 000 000 children (1). In adult patients there are significant differences between the clinical presentation of diffuse and limited subtypes (2). We reviewed clinical differences in presentation of subtypes in patients in the juvenile systemic scleroderma inception cohort up to 2021.

Objectives

To study the clinical presentation of jSSc patients with diffuse (djSSc) and limited (ljSSc) subtypes.

Methods

We reviewed the clinical baseline characteristics of the patients, who were recruited to the juvenile scleroderma inception cohort (jSScC) (3, 4) till 1st of December 2021. jSScC is a prospective cohort of jSSc patients, who developed the first non-Raynaud´s symptom before the age of 16 years and are under the age of 18 years at the time of inclusion.

Results

210 patients with jSSc were included in the cohort, 71% (n=162) had diffuse subtype. The median age at onset of Raynaud phenomenon was 10.4 years (7.3 – 12.9) and the median age at the first non-Raynaud symptom was 10.9 years (7.4 – 13.2). Median disease duration was 2.5 years (1 – 4.4) at the time of inclusion. The female/male ratio was significantly lower in the djSSc subtype (3.7:1 versus 5:1, p<0.001). Antibody profile was quite similar, with the exception of a significantly higher number of anticentromere positive patients in the ljSSc (12% versus 2%, p=0.013). Decreased FVC < 80% was found in approximately 30% and decreased DLCO < 80% was found in around 40% in both subtypes. Pulmonary hypertension assessed by ultrasound was identified in 5% in both groups. Patients with diffuse subtype had significantly higher modified Rodnan Skin Score (mRSS) (16 versus 4.5, p<0.001), sclerodactyly (84% versus 60%, p<0.001), history of digital ulceration (62% versus 31%, p<0.001), decreased Body Mass Index (BMI) < -2 z score (20% versus 4%, p=0.003) and decreased joint range of motion (64% versus 46%, p=0.019). Patients with ljSSc had significantly higher rate of cardiac involvement (13% versus 2%, p=0.001).

Regarding patient related outcomes djSSc patients had more severe disease, looking at patient reported global disease activity (VAS 0 – 100) (40 versus 25, p=0.039), patient reported global disease damage (VAS 0 – 100) (40 versus 25, p=0.021) and patient reported assessment of ulceration activity (10 versus 0, p=0.044). Regarding physician related outcomes the physician reported global disease activity (VAS 0 – 100) (32 versus 20, p<0.001) and physician reported global disease damage (VAS 0 – 100) (30 versus 15, p=0.014) was significantly higher in djSSc.

Conclusion

In this jSSc cohort, the largest in the world, djSSc patients have a significantly more severe disease than ljSSc patients. Interestingly, we found no differences regarding interstitial lung disease and pulmonary hypertension.

References

[1]Beukelman T, Xie F, Foeldvari I. Assessing the prevalence of juvenile systemic sclerosis in childhood using administrative claims data from the United States. Journal of Scleroderma and Related Disorders. 2018;3(2):189-90.

[2]Dougherty DH, Kwakkenbos L, Carrier ME, Salazar G, Assassi S, Baron M, et al. The Scleroderma Patient-Centered Intervention Network Cohort: baseline clinical features and comparison with other large scleroderma cohorts. Rheumatology (Oxford). 2018;57(9):1623-31.

[3]Foeldvari I, Klotsche J, Kasapcopur O, Adrovic A, Terreri MT, Sakamoto AP, et al. Differences sustained between diffuse and limited forms of juvenile systemic sclerosis in expanded international cohort. www.juvenile-scleroderma.com. Arthritis Care Res (Hoboken). 2021.

[4]Foeldvari I, Klotsche J, Torok KS, Kasapcopur O, Adrovic A, Stanevica V, et al. CHARACTERISTICS OF THE FIRST 80 PATIENTS AT TIMEPOINT OF FIRST ASSESSMENT INCLUDED IN THE JUVENILE SYSTEMIC SCLEROSIS INCEPTION COHORT. WWW.JUVENILESCLERODERMA.COM. Journal of Scleroderma and Related Disorders. 2018;4(1-13).

Disclosure of Interests

None declared

AB1236 CLINICAL CHARACTERISTICS OF JUVENILE ONSET SYSTEMIC SCLEROSIS PATIENTS FROM THE JUVENILE SCLERODERMA INCEPTION COHORT COMPARED TO ADULT AGE JUVENILE-ONSET PATIENTS FROM EUSTAR. ARE THESE DIFFERENCES SUGGESTING RISK FOR MORTALITY?

Background

Juvenile systemic sclerosis (jSSc) is an orphan autoimmune disease with a prevalence of 3 in 1 000 000 children. Information on long-term development of organ involvement and clinical characteristics of jSSc patients in adulthood are lacking. It was believed that patients in adult cohorts may represent a survival biased population.

Objectives

To assess differences in clinical characteristics of jSSc-onset patients from the pediatric age group, with a mean disease duration of 3 years, compared to the adult age jSSc-onset group, with a mean disease duration of 18.5 years.

Methods

We extracted clinical data at time of inclusion into the cohorts from the Juvenile Scleroderma Inception Cohort (jSScC) and data from juvenile-onset adult SSc patients from the European Trials and Research Group (EUSTAR) cohort. We compared the clinical characteristics of the patients by descriptive statistics.

Results

We extracted data of 187 jSSc patients from the jSScC and 236 patients from EUSTAR. The mean age at time of assessment was 13.4 years old in the jSScC and 32.4 years old in EUSTAR. The mean disease duration since first non-Raynaud was 3.0 years in jSScC and 18.5 years in the EUSTAR (Table 1).

We found significant differences between the cohorts. There were more female patients in EUSTAR (87.7% versus 80.2%, p=0.04). More patients had diffuse subtype in jSScC (72.2% versus 40%, p<0.001). The modified Rodnan skin score (mRSS) was significantly higher in jSScC (14.2 versus 12.1, p=0.02). Active digital ulceration occurred more often in EUSTAR (26.6%, versus 17.8% p=0.01), but history of active ulceration was more frequent in jSScC (54.1% versus 43%, p<0.001). Mean DLCO was lower in jSScC (75.4 versus 86.3, p<0.001). Intestinal involvement was significantly more common in jSSc (33.2% versus 23.8%, p=0.04). Esophageal involvement was more common in EUSTAR (63.7% versus 33.7%, p<0.001). (Table 1).

Table 1.

Clinical characteristics of juvenile onset SSc patients at time point of the inclusion into the juvenile scleroderma inception (jSScC) cohort and in the adult EUSTAR- cohort

jSScCEUSTAR CohortP valueNumber of patients1872360.04Age in years, mean (SD)13.4 (3.6)32.4 (15.4)Female patients, n (%)150 (80.2%)207 (87.7%)jSSC Subtype, n (%)diffuse135 (72.2%)87 (38.1%)<0.001limited52 (27.8%)121 (53.3%)Age at Raynaud onset in years, mean (SD)10.0 (3.9)13.7 (9.1)Age at non-Raynaud onset in years, mean (SD)10.3 (3.9)11.7 (3.7)Duration since first Raynaud symptoms in years, mean (SD)3.4 (2.7)20.6 (15.9)Duration since first non-Raynaud symptoms in years, mean (SD)3.0 (2.7)18.5 (15.6)Raynaud´s, n (%)170 (90.9%)222 (94.9%)ANA positive, n (%)166 (91.7%)210 (92.9%)0.99Anti-Scl 70 positive, n (%)62 (34.4%)73 (33.3%)0.68Modified Rodnan Skin Score, mean (SD)5%Data missingModified Rodnan Skin Score, mean (SD)14.2 (11.7)12.1 (14.5)0.02Digital ulceration, n (%)At the time of inclusion33 (17.8)21 (26.6%)0.01In the past history100 (54.1%)34 (43%)<0.001Telangiectasia62 (37.4%)42 (53.2%)0.04FVC, mean (SD)84.1 (18.6)84 (22.4)0.96DLCO, mean (SD)75.4 (19.2)86.3 (19.9)<0.001Arterial hypertension, n (%)10 (5.4%)20 (8.5%)0.26Renal crisis, n (%)03 (1.3%)0.26Esophageal involvement, n (%)63 (33.7%)149 (63.7%)<0.001Intestinal involvement, n (%)62 (33.2%)56 (23.8%)0.04Articular involvement, n (%)34 (18.3%)27 (11.6%)0.06Muscular involvement, n (%)31 (19.3%)46 (19.8%)0.45

Conclusion

Patients with jSSc-onset who are currently adult age (defined as >18 years of age) are less frequently male and from the diffuse subset, have lower mRSS, less digital ulcers and intestinal involvement. This might represent a combination of both survival bias and/or be explained by the longer observation time with less active disease (i.e. natural progression decreased mRSS over time). Further long-term observational studies with jSSc patients are required to address this issue.

Disclosure of Interests

None declared

Retrospective epidemiological analysis of SARS-CoV-2 wastewater surveillance and case notifications data - New South Wales, Australia, 2020

This epidemiological study analysed SARS-CoV-2 wastewater surveillance and case notifications data to inform evidence-based public health action in NSW. We investigated measures of association between SARS-CoV-2 RNA fragments detected in wastewater samples (n = 100) and case notifications (n = 1,367, as rates per 100,000 population) within wastewater catchment areas (n = 6); and evaluated the performance of wastewater testing as a population-level diagnostic tool. Furthermore, we modelled SARS-CoV-2 RNA fragment detection in wastewater given the case notification rate using logistic regression. The odds of a viral detection in wastewater samples increased by a factor of 5.68 (95% CI: 1.51-32.1, P = 0.004) with rates of one or more notified cases within a catchment. The diagnostic specificity of wastewater viral detection results was 0.88 (95% CI: 0.69-0.97); the overall diagnostic sensitivity was 0.44 (95% CI: 0.33-0.56). The probability of a viral detection result in wastewater exceeded 50% (95% CI: 36-64%) once the case rate within a catchment exceeded 10.5. Observed results suggest that in a low prevalence setting, wastewater viral detections are a more reliable indicator of the presence of recent virus shedding cases in a catchment, than non-detect results are of the absence of cases in a catchment.

SARS-CoV-2 serosurvey among adults involved in healthcare and health research in Guinea-Bissau, West Africa

Objectives

Many African countries have reported fewer COVID-19 cases than countries elsewhere. By the end of 2020, Guinea-Bissau, West Africa, had <2500 PCR-confirmed cases corresponding to 0.1% of the ∼1.8 million national population. We assessed the prevalence of SARS-CoV-2 antibodies in urban Guinea-Bissau to help guide the pandemic response in Guinea-Bissau.

Study design

Cross-sectional assessment of SARS-CoV-2 antibody in a cohort of staff at the Bandim Health Project.

Methods

We measured IgG antibodies using point-of-care rapid tests among 140 staff and associates at a biometric research field station in Bissau, the capital of Guinea-Bissau, during November 2020.

Results

Of 140 participants, 25 (18%) were IgG-positive. Among IgG-positives, 12 (48%) reported an episode of illness since the onset of the pandemic. Twenty-five (18%) participants had been PCR-tested between May and September; 7 (28%) had been PCR-positive. Four of these seven tested IgG-negative in the present study. Five participants reported that somebody had died in their house, corresponding crudely to an annual death rate of 4.5/1000 people; no death was attributed to COVID-19. Outdoor workers had a lower prevalence of IgG-positivity.

Conclusions

In spite of the low official number of COVID-19 cases, our serosurvey found a high prevalence of IgG-positivity. Most IgG-positives had not been ill. The official number of PCR-confirmed COVID-19 cases has thus grossly underestimated the prevalence of COVID-19 during the pandemic. The observed overall mortality rate in households of Bandim Health Project employees was not higher than the official Guinean mortality rate of 9.6/1000 people.

Coverage and factors associated with receiving campaign polio vaccines in an urban population in Guinea-Bissau

BACKGROUND

Polio eradication campaigns are intended to complement routine immunization. Studies addressing factors associated with campaign coverage are warranted to identify children missed by campaigns.

METHODS

Bandim Health Project runs demographic surveillance with registration of routine immunization and campaign participation data in urban Guinea-Bissau. We assessed coverage and factors associated with receiving campaign polio vaccines in children aged 0-35 months in two polio eradication campaigns conducted in 2017 and 2018 using univariate and multivariate regression models.

RESULTS

Campaign coverage reached 84% in 2017 and 88% in 2018. We found lower coverage among children of young and not formally educated mothers in univariate analyses; Children <9 months and Fula children had lower campaign coverage in both univariate and multivariate analyses.

CONCLUSIONS

To increase campaign coverage in urban Guinea-Bissau attention may be directed at informing young mothers, mothers of young children, mothers without formal education, and the Fula ethnic group about campaigns.

CHA2DS2-VASc below 3 predicts low one-year ischemic stroke risk in postoperative atrial fibrillation after CABG

Background

Ischemic stroke prevention is a major goal in patients with atrial fibrillation (AF). Neither the optimal risk assessment method, nor the risk-benefit-ratio of long-term use of oral anticoagulation (OAC) is, however, known in patients with new-onset AF (POAF) after cardiac surgery.

Purpose

To explore the feasibility of using the CHA2DS2-VASc scoring system in predicting the one-year ischemic stroke risk in patients with POAF after coronary artery bypass grafting (CABG).

Methods

All patients in Sweden with POAF after isolated CABG 2007–2017, with at least one year of follow-up, and without oral anticoagulation (OAC), were included in this observational, registry-based cohort study. POAF was defined as any new-onset AF during the index hospitalization for CABG. Primary endpoint was the one-year ischemic stroke risk at each step of the CHA2DS2-VASc score in POAF patients with at least one-year follow-up.

Results

Out of 6368 POAF patients without OAC neither at hospital discharge nor before the occurrence of events, 4467 (70.1%) had at least one year follow-up with altogether 124 ischemic strokes within one year from discharge. The one-year risk for ischemic stroke was &lt;1% for a CHA2DS2-VASc score &lt;3, 1–2% for a CHA2DS2-VASc score 3, and &gt;2% for a CHA2DS2-VASc score ≥4. The area under the receiver-operating-characteristic curve for predicting ischemic stroke was 0.67 (95% CI 0.64–0-69).

Conclusions

The CHA2DS2-VASc score was suitable for predicting low risk for ischemic stroke during the first year after hospital discharge in patients with POAF after CABG. A risk &lt;1% considered low was, however, observed at a considerably higher score than in patients with non-surgical/non-valvular AF described in previous studies.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Swedish Heart-Lung Foundation (grant 20150587 and 20180560 to Anders Jeppsson)Region Västra Götaland (grant VGFOUREG-847811 to Anders Jeppsson and grant VGFOUREG-648981 to Amar Taha) Event rates during one year

POS0079 PATIENTS WITH JUVENILE SYSTEMIC SCLEROSIS HAVE A DISTINCT PATTERN OF ORGAN INVOLVEMENT.RESULTS FROM THE JUVENILE SYSTEMIC SCLEROSIS INCEPTION COHORT. WWW.JUVENILE-SCLERODERMA.COM

Background:

Juvenile systemic sclerosis (jSSc) is a rare disease with a prevalence of around 3 in 1,000,000 children. To better capture the clinical manifestations of jSSc the juvenile systemic sclerosis inception cohort (jSScC) has been prospectively enrolling patients with predetermined clinical variables over the past 12 years. One of the goals is to study the demographic, clinical features, and physician and patient reported outcome differences between those with juvenile limited cutaneous (lc) compared to diffuse cutaneous (dc) disease subtypes, to determine if characteristics are similar or different between dc and lc jSSc.

Objectives:

Evaluation of the baseline clinical characteristics of jSSc patients in the jSScC. Compare clinical phenotype between diffuse (dcjSSc) and limited cutaneous (lcjSSc) subtypes.

Methods:

Demographic, physical examination, organ system evaluation, autoantibody profile, treatment, and patient and physician reported outcome variables were evaluated from the jSSc Inception cohort and summary statistics applied using chi-square test and Mann Whitney U-test comparing lcjSSc and dcjSSc subtypes.

Results:

At the time of data extraction, 175 jSSc patients were enrolled in the cohort, 81% were Caucasian and 81% female. Diffuse cutaneous jSSc subtype predominated (73%). Mean disease duration was 3.1 year (±2.7). Mean age at Raynaud´s was 10 years (+3.8) and mean age of first non-Raynaud´s was 10.2 years (±3.8). Significant differences were found between dcjSSc versus lcjSSc, regarding several clinical characteristics. Patients with diffuse cutaneous subtype had significantly higher modified Rodnan skin score (p=0.001), presence of sclerodactyly (p=0.02), presence of Gottron’s papules (p=0.003), presence of telangiectasia (p=0.001), history of digital tip ulceration (p=0.01), and frequency of elevated CK value (p=0.04). Cardiac involvement was significantly higher in limited cutaneous jSSc subtype (p=0.02). Diffuse cutaneous jSSc patients had significantly worse scores for Physician Global Assessment of disease activity (38 vs 25; p=0.002) and disease damage (34 vs 19; p=0.008).

Table 1.

Comparison of demographic data and significant differences between dcjSSc and lcjSSc at time of inclusion

Whole CohortN=175Diffuse SubtypeN=128Limited SubtypeN=47P valueFemale to Male Ratio4.3:1 (142/33)4.1:1 (103/25)4.8:1 (39/8)0.829Cutaneous subtypeDiffuse subtype73% (128)1280Limited subtype27% (47)047Mean Disease duration (years)3.1 (± 2.7)3.3 (± 2.9)2.6 (± 2.2)0.135Mean age of onset of Raynaud´s (years)10.0 (± 3.8)17 non-Raynaud9.8 (± 3.6)10 non-Raynaud10.6 (± 4.3)7 non-Raynaud0.219Mean age of onset of non-Raynaud´s (years)10.2 (± 3.9)10.0 (± 3.7)10.9 (± 4.3)0.173Disease modifying drugs88% (154)89% (114)85% (40)0.446CutaneousMean modified Rodnan skin score14.3 (0-51)17.4 (0-51)6.1 (0-24)0.001Gottron Papules27% (46/171)33% (41/124)11% (5)0.003Sclerodactyly78% (126/162)82% (98/119)65% (28/43)0.020Laboratory valuesElevated CK25% (30/122)30% (26/88)12% (4/34)0.041VascularTelangiectasia36% (56/154)44% (49/111)16% (7/43)0.001History of ulceration53% (91/173)61% (77/127)30% (14/46)0.001CardiacCardiac Involvement6% (10)2% (3)15% (7)0.002Patient Related OutcomesPhysician global disease activity(0-100) min -max35(0-90) n=14138(0-90) n=10825(0-80) n=330.002Physician global disease damage(0-100) min -max31(0-85) n=14034(0-85) n=10819(0-60) n=320.008

Conclusion:

Results from this large international cohort of jSSc patients demonstrate significant differences between dcjSSc and lcjSSc patients. According to the general organ involvement and physician global scores, the dcjSSc patients had significantly more severe disease. These observations strengthen our previous findings of the unique organ pattern of pediatric patients.

Supported by the “Joachim Herz Stiftung”

Disclosure of Interests:

None declared.

POS1304 JUVENILE SYSTEMIC SCLEROSIS (JSSC) PATIENTS WITH OVERLAP CHARACTERISTICS DO NOT HAVE MILD DISEASE. RESULTS FROM THE JSSC INCEPTION COHORT. WWW.JUVENILESCLERODERMA.COM

Background:

Juvenile systemic sclerosis (jSSc) is an orphan disease with a prevalence of around 3 in 1, 000,000 children. It is known that in pediatric jSSc cohorts, there are a significant number of patients with overlap features, such as arthritis and myositis. However, the disease burden between those with and without overlap features in jSSc has not been defined.

Objectives:

Compare the clinical phenotype between children with and without overlap features in the juvenile systemic scleroderma inception cohort (jSScC).

Methods:

A cross-sectional study was performed using baseline visit data. Demographic, organ system evaluation, autoantibody profile, treatment, and patient and physician reported outcome variables were extracted from jSScC. Comparison between patients with and without overlap features was performed using chi-square test and Mann Whitney U-test.

Results:

At the time of data extraction, 175 jSSc patients were enrolled in the cohort, 81% were Caucasian and 81% female. Mean disease duration was 3.1 year (±2.7). Mean age at Raynaud´s onset was 10 years (±3.8) and mean age of first non-Raynaud´s was 10.2 years (±3.8). Overlap features occurred 17% (n=30) of the cohort, 12.5% in the diffuse cutaneous (dc) jSSc and in 30% in the limited cutaneous (lc) jSSc. Significant differences in clinical characteristics were found between those patients with compared to without overlap characteristics. Patients with overlap features presented more frequently with Gottron papules (p=0.007), swollen joints (p=0.019), muscle weakness (p=0.003), and lung involvement documented by decreased DLCO < 80% (p=0.06) and/or abnormal high resolution computed tomography (p=0.049). Anti-PM/Scl autoantibodies were also more common in this group (p=0.001). Significantly more patients without overlap features had Raynaud´s (p=0.006). Physician Global Assessment of disease activity was significantly higher in patients with overlap features (41 vs 34; p=0.041). (Table 1.)

Table 1.

Demographic and clinical characteristics of jSSc patients with and without overlap features.

Whole CohortN=175Patients without overlapN=145Patients with overlapN=30P valueFemale to Male Ratio 4.3:1(142/33)4:1(116/29)6.5:1(26/4)0.395Cutaneous subtypeDiffuse subtype (N)73% (128)11216Limited subtype (N)27% (47)3317Mean disease duration (years)3.1 (± 2.7)3.2 (± 2.8)3.1 (± 2.2)0.291Mean age of onset of Raynaud´s (years)10.0 (± 3.8)17 non-Raynaud10.0 (± 3.8)10 non-Raynaud10.0 (± 3.7)7 non-Raynaud0.931Mean age of onset of non-Raynaud´s (years)10.2 (± 3.8)10.2 (± 3.9)9.8 (± 3.7)Disease modifying drugs (N)88% (154) 89% (129)83% (25)0.388Raynaud´s phenomenon90% (158)93% (135)77% (23)0.006Anti-PMScl18% (12/68)9% (5/53)47% (7/15)0.001Gottron Papules (N)27% (46/171)23% (33/144)48% (13/27)0.007DLCO <80% (N)44% (39/88)39% (28/71)65% (11/17)0.06Abnormal findings in HRCT (N)44% (59/133)40% (43/107)62% (16/26)0.049Proportion of patients with swollen joints 18% (32) 14% (21) 37% (11)0.019Muscle Weakness (N) 21% (31/149)16% (20/123) 42% (11/26)0.003Physician global disease activity(0-100) min -max35 (0-90) n=14134 (0-90) n=11441 (0-80) n=270.041

Conclusion:

Results from this large international cohort of jSSc patients demonstrate significant differences between patients with and without overlap features. Patients with overlap have significantly more interstitial lung disease and more physician rated disease activity and should not be considered to have more “mild disease”.

Supported by the “Joachim Herz Stiftung”

Disclosure of Interests:

None declared

Developing and Piloting a Standardized European Protocol for Hepatitis C Prevalence Surveys in the General Population (2016-2019)

Background: A robust estimate of the number of people with chronic hepatitis C virus (HCV) infection is essential for an appropriate public health response and for monitoring progress toward the WHO goal of eliminating viral hepatitis. Existing HCV prevalence studies in the European Union (EU)/European Economic Area (EEA) countries are heterogeneous and often of poor quality due to non-probability based sampling methods, small sample sizes and lack of standardization, leading to poor national representativeness. This project aimed to develop and pilot standardized protocols for undertaking nationally representative HCV prevalence surveys in the general adult population.

Methods: From 2016 to 2019 a team from the Robert Koch-Institute contracted by the European Centre for Disease Prevention and Control synthesized evidence on existing HCV prevalence surveys and survey methodology and drafted a protocol. The methodological elements of the protocol were piloted and evaluated in Bulgaria, Finland and Italy, and lessons learnt from the pilots were integrated in the final protocol. An international multidisciplinary expert group was consulted regularly.

Results: The protocol includes three alternative study approaches: a stand-alone survey; a “nested” survey within an existing health survey; and a retrospective testing survey approach. A decision algorithm advising which approach to use was developed. The protocol was piloted and finalized covering minimum and gold standards for all steps to be implemented from sampling, data protection and ethical issues, recruitment, specimen collection and laboratory testing options, staff training, data management and analysis and budget considerations. Through piloting, the survey approaches were effectively implemented to produce HCV prevalence estimates and the pilots highlighted the strengths and limitations of each approach and key lessons learnt were used to improve the protocol.

Conclusions: An evidence-based protocol for undertaking HCV prevalence serosurveys in the general population reflecting the different needs, resources and epidemiological situations has been developed, effectively implemented and refined through piloting. This technical guidance supports EU/EEA countries in their efforts to estimate their national hepatitis C burden as part of monitoring progress toward the elimination targets.

Cognitive impairments four months after COVID-19 hospital discharge: Pattern, severity and association with illness variables

The ongoing Coronavirus Disease 2019 (COVID-19) pandemic has affected more than 100 million people and clinics are being established for diagnosing and treating lingering symptoms, so called long-COVID. A key concern are neurological and long-term cognitive complications. At the same time, the prevalence and nature of the cognitive sequalae of COVID-19 are unclear. The present study aimed to investigate the frequency, pattern and severity of cognitive impairments 3-4 months after COVID-19 hospital discharge, their relation to subjective cognitive complaints, quality of life and illness variables. We recruited patients at their follow-up visit at the respiratory outpatient clinic, Copenhagen University Hospital, Bispebjerg, approximately four months after hospitalisation with COVID-19. Patients underwent pulmonary, functional and cognitive assessments. Twenty-nine patients were included. The percentage of patients with clinically significant cognitive impairment ranged from 59% to 65% depending on the applied cut-off for clinical relevance of cognitive impairment, with verbal learning and executive functions being most affected. Objective cognitive impairment scaled with subjective cognitive complaints, lower work function and poorer quality of life. Cognitive impairments were associated with d-dimer levels during acute illness and residual pulmonary dysfunction. In conclusion, these findings provide new evidence for frequent cognitive sequelae of COVID-19 and indicate an association with the severity of the lung affection and potentially restricted cerebral oxygen delivery. Further, the associations with quality of life and functioning call for systematic cognitive screening of patients after recovery from severe COVID-19 illness and implementation of targeted treatments for patients with persistent cognitive impairments.

Younger patients have an increased risk for dementia after coronary artery bypass grafting, a population-based cohort study from the SWEDEHEART registry

Background

Previous studies investigating the association between coronary artery bypass grafting (CABG) and risk for dementia show conflicting results.

Purpose

To compare the long-term risk for dementia in CABG patients to matched individuals in the general population, and to identify independent predictors for developing dementia after CABG.

Methods

Data from the SWEDEHEART registry and three other mandatory national registries were merged to compare all patients who underwent isolated CABG in Sweden from 1992 to 2015 (n=111.335) with an age- and sex-matched control individuals from the general population (n=222.396). Cumulative incidence adjusted for the competing risk for death and Cox regression models with Hazard Ratio (HR) and 95% confidence interval (CI) adjusted for age, gender, co-morbidity and socioeconomic variables, were used to calculate the risk of dementia. Median follow-up was 10.1 years (IQR 2.5–14.7) among CABG patients and 10.7 years (5.6–15.7) among the controls. Identified interactions of the excess risk for dementia with sex and age categories (&lt;65, 65-&lt;75, ≥75 years) resulted in analyses being stratified on those sub-cohorts.

Results

The overall cumulative incidence at 20 years follow up of all-cause dementia was 9.6% (95% CI 9.4–9.9) among CABG patients and 9.0 (8.8–9.2) among individuals in the general population. The adjusted relative risk for all-cause dementia was increased among CABG patients &lt;65 years and 65–75 years, (HR 1.29 (95% CI 1.17–1.41) and HR 1.06 (1.01–1.11), respectively (fig 1). The risk for all-cause dementia was higher in CABG women than in CABG men (HR 1.62 (1.30–2.03) vs HR 1.22 (1.10–1.35)). In the oldest age group (75 years and older) the risk for all cause dementia, vascular dementia and Alzheimer's disease was lower for CABG patients compared to controls (HR 0.73 (0.69–0.78). Female CABG patients &lt;65 years had an increased risk for Alzheimer's disease (HR 1.83 (1.06–3.15). Hypertension, diabetes, preoperative stroke, renal failure, heart failure, atrial fibrillation, depression and low income were independent predictors for all-cause dementia in CABG patients.

Conclusion

CABG patients younger than 75 years at the time of surgery have an increased risk of all-cause dementia compared to an age- and sex-matched population. Women younger than 65 years that underwent CABG had also a markedly higher risk for Alzheimer disease. Increased awareness of the higher risk for dementia in younger CABG patients is warranted to avoid delay of diagnosis and treatment.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): The Swedish Heart and Lung Foundation, Swedish State

Hepatitis C prevalence in Denmark in 2016-An updated estimate using multiple national registers

BACKGROUND

Chronic hepatitis C (CHC) can be eliminated as a public health threat by meeting the WHO targets: 90% of patients diagnosed and 80% treated by 2030. To achieve and monitor progress towards elimination, an updated estimate of the size of the CHC population is needed, but Denmark has no complete national CHC register. By combining existing registers in 2007, we estimated the population living with CHC to be 16,888 (0.38% of the adult population).

AIM

To estimate the population living with diagnosed and undiagnosed CHC in Denmark on 31 December 2016. Among additional aims were to estimate the proportion of patients attending specialised clinical care.

METHODS

People with diagnosed CHC were identified from four national registers. The total diagnosed population was estimated by capture-recapture analysis. The undiagnosed population was estimated by comparing the register data with data from two cross-sectional surveys.

RESULTS

The population living with diagnosed CHC in Denmark was 7,581 persons (95%CI: 7,416-12,661) of which 6,116 (81%) were identified in the four registers. The estimated undiagnosed fraction was 24%, so the total CHC infected population was 9,975 corresponding to 0.21% of the adult population (95%CI: 9,758-16,659; 0.21%-0.36%). Only 48% of diagnosed patients had received specialised clinical care.

CONCLUSION

CHC prevalence in Denmark is declining and 76% of patients have been diagnosed. Linking diagnosed patients to care and increasing efforts to test people with former or current drug use will be necessary to achieve CHC elimination.

Prevalence of hepatitis C in the adult population of Bulgaria: a pilot study

Objective

This study piloted a European technical protocol for conducting chronic hepatitis C prevalence surveys in the general population. The pilot study took place in the Bulgarian city of Stara Zagora in 2018, and results of setting up, conducting and evaluating the survey are presented.

Results

A probability-based sample of the general adult population was drawn from the local population registry, stratified by age and sex. A sample size of 999 was calculated, and accounting for 50% non-response, 1998 registered invitation letters were sent. Venous blood samples and questionnaire data were collected by the Regional Health Inspectorate in Stara Zagora. Blood samples were tested for anti-HCV, and if reactive for RNA. 252 (21.6%) of the participants were included in the study. Mean age and sex distribution differed between the participants (55.9 years, 60.3% females) and the total sample (48.9 years, 53.4%). The weighted chronic HCV prevalence among participants was 0.9% [95% CI 0.2–4.2%]. The approach of only sending registered letters contributed to a low response rate, and more efforts are needed to reduce non-response, especially among men and younger age groups. Results of the evaluation were integrated in the final technical protocol.

THU0499 IS THERE A DIFFERENT PRESENTATION OF JUVENILE SYSTEMIC DIFFUSE AND LIMITED SUBSET? DATA FROM THE JUVENILE SCLERODERMA INCEPTION COHORT. WWW.JUVENILE-SCLEORDERMA.COM

Background:

Juvenile systemic scleroderma (jSSc) is an orphan disease with a prevalence of 3 per 1 000 000 children. There are limited data regarding the clinical presentation of jSSc. The Juvenile Systemic Scleroderma Inception Cohort (JSSIC) is the largest multinational registry that prospectively collects information about jSSc patients.

Objectives:

Evaluation of the jSSc patients at the time of inclusion in the JSSIC.

Methods:

Patients were included in the JSSIC if they fulfilled the adult ACR/EULAR classification criteria for systemic scleroderma, if they presented the first non-Raynaud symptom before 16 years of age and if they were younger than 18 years of age at time of inclusion. Patients’ characteristics at time of inclusion were evaluated.

Results:

Until 15thof December 2019 hundred fifty patients were included, 83% of them being Caucasian and 80% female. The majority had the diffuse subtype (72%) and 17% of all jSSc had overlap features. The mean age of first presentation of Raynaud´s phenomenon was 9.8 years in the diffuse subtype (djSSc) and 10.7 years in the limited subtype (ljSSc) (p=.197). The mean age at first non-Raynaud’s symptoms was 10.0 years in the djSSc and 11.2 years in the ljSSc (p=0.247). Mean disease duration at time of inclusion was 3.4 years in the djSSc and 2.4 years in the ljSSc group.

Significant differences were found between the groups regarding mean modified Rodnan skin score, 18.2 in the djSSc vs 6.2 in the ljSSc (p=0.02); presence of Gottron´s papulae (djSSc 30% vs ljSSc 13%, p=0.43);presence of teleangiectasia (djSSc 42% vs 18% ljSS, p=0.01); history of ulceration (djSSc 42% vs 18% ljSSc,p=0.008); 6 Minute walk test below the 10thpercentile (djSSc 85% vs ljSSc 54%, p=0.044), total pulmonary involvement (djSSc 49% vs ljSSc 31%, p=0.045), cardiac involvement (ljSSc 17% vs djSSc 3%, p=0.002). djSSc patients had significantly worse scores for Physician Global Assessment of disease activity compared to ljSSc patients (VAS 0-100) (40 vs 15) (p=0.001) and for Physician Global Assessment of disease damage (VAS 0-100) (36 vs 17) (p=0.001).

There were no statistically significant differences in the other presentations. Pulmonary hypertension occurred in approximately 6% in both groups. No systemic hypertension or renal crisis was reported. ANA positivity was 90% in both groups. Anti-Scl70 was positive in 35% in djSSc and 36% in the ljSSc group. Anticentromere positivity occurred in 3% in the djSSc and 7% in the ljSSc group.

Conclusion:

In this unique large cohort of jSSc patients there were significant differences between djSSc and ljSSc patients at time of inclusion into the cohort regarding skin, vascular, pulmonary and cardiac involvement. According to the physician global scores the djSSc patients had a significantly more severe disease. Interestingly the antibody profile was similar in both scleroderma phenotypes.

Supported by the “Joachim Herz Stiftung”

Disclosure of Interests: :

Ivan Foeldvari Consultant of: Novartis, Jens Klotsche: None declared, Ozgur Kasapcopur: None declared, Amra Adrovic: None declared, Kathryn Torok: None declared, Maria T. Terreri: None declared, Ana Paula Sakamoto: None declared, Valda Stanevicha: None declared, Flávio R. Sztajnbok: None declared, Jordi Anton Grant/research support from: grants from Pfizer, abbvie, Novartis, Sobi. Gebro, Roche, Novimmune, Sanofi, Lilly, Amgen, Grant/research support from: Pfizer, abbvie, Novartis, Sobi. Gebro, Roche, Novimmune, Sanofi, Lilly, Amgen, Consultant of: Novartis, Sobi, Pfizer, abbvie, Consultant of: Novartis, Sobi, Pfizer, abbvie, Speakers bureau: abbvie, Pfizer, Roche, Novartis, Sobi, Gebro, Speakers bureau: abbvie, Pfizer, Roche, Novartis, Sobi, Gebro, Brian Feldman Consultant of: DSMB for Pfizer, OPTUM and AB2-Bio, Ekaterina Alexeeva Grant/research support from: Roche, Pfizer, Centocor, Novartis, Speakers bureau: Roche, Novartis, Pfizer., Maria Katsikas: None declared, Vanessa Smith Grant/research support from: The affiliated company received grants from Research Foundation - Flanders (FWO), Belgian Fund for Scientific Research in Rheumatic diseases (FWRO), Boehringer Ingelheim Pharma GmbH & Co and Janssen-Cilag NV, Consultant of: Boehringer-Ingelheim Pharma GmbH & Co, Speakers bureau: Actelion Pharmaceuticals Ltd, Boehringer-Ingelheim Pharma GmbH & Co and UCB Biopharma Sprl, edoardo marrani: None declared, Mikhail Kostik: None declared, Natalia Vasquez-Canizares: None declared, Simone Appenzeller: None declared, Mahesh Janarthanan: None declared, Monika Moll: None declared, Dana Nemcova: None declared, Anjali Patwardhan: None declared, Maria Jose Santos Speakers bureau: Novartis and Pfizer, Sujata Sawhney: None declared, Dieneke Schonenberg: None declared, Cristina Battagliotti: None declared, Lillemor Berntson Consultant of: paid by Abbvie as a consultant, Speakers bureau: paid by Abbvie for giving speaches about JIA, Blanca Bica: None declared, Juergen Brunner Grant/research support from: Pfizer, Novartis, Consultant of: Pfizer, Novartis, Abbvie, Roche, BMS, Speakers bureau: Pfizer, Novartis, Abbvie, Roche, BMS, Patricia Costa Reis: None declared, Despina Eleftheriou: None declared, Liora Harel: None declared, Gerd Horneff Grant/research support from: AbbVie, Chugai, Merck Sharp & Dohme, Novartis, Pfizer, Roche, Speakers bureau: AbbVie, Bayer, Chugai, Merck Sharp & Dohme, Novartis, Pfizer, Roche, Daniela Kaiser: None declared, Dragana Lazarevic: None declared, Kirsten Minden Consultant of: GlaxoSmithKline, Sanofi, Speakers bureau: Roche, Susan Nielsen: None declared, Farzana Nuruzzaman: None declared, Yosef Uziel: None declared, Nicola Helmus: None declared

FRI0454 UNDER DETECTION OF INTERSTITIAL LUNG DISEASE IN JUVENILE SYSTEMIC SCLEROSIS (JSSC) UTILIZING PULMONARY FUNCTION TESTS. RESULTS FROM THE JUVENILE SCLERODERMA INCEPTION COHORT

Background:

Juvenile systemic sclerosis (jSSc) is an orphan disease with a prevalence in around 3 in a million children. Pulmonary involvement in jSSc occurs in approximately 40 % in the inception cohort. Traditionally in jSSc, pulmonary function testing (PFT) with FVC and DLCO are used for screening and computed tomography (HRCT) was more reserved for those with abnormal PFTs. More recently, it has become apparent that PFTs might not be sensitive enough for detecting ILD in children.

Objectives:

Utilizing a prospective international juvenile systemic scleroderma cohort (JSScC) [2], to determine if pulmonary screening with FVC and DLCO is sufficient enough to assess the presence of interstitial lung disease in comparison to CT evaluation.

Methods:

The international juvenile systemic scleroderma cohort database was queried for available patients with recorded PFT parameters and HRCT performed to determine sensitivity of PFTs detecting disease process.

Results:

Of 129 patients in the jSScC, 67 patients had both CT imaging and an FVC reading from PFTs for direct comparison. DLCO readings were also captured but not in as many patients with tandem HRCT (n =55 DCLO and HRCT scan). Therefore, initial analyses focused on the sensitivity, specificity and accuracy of the FVC value from the PFTs to capture the diagnosis of interstitial lung disease as determined by HRCT.

Overall, 49% of the patients had ILD determined by HRCT, with 60% of patients having normal FVC (>80%) with positive HRCT findings, and 24% of patients having normal DLCO (> 80%) with positive HRCT findings. Fourteen percent (n = 3/21) of patients with both FVC and DLCO values within the normal range had a positive HRCT finding.

Conclusion:

The sensitivity of the FVC in the JSScC cohort in detecting ILD was only 39%. Relying on PFTs alone for screening for ILD in juvenile systemic sclerosis would have missed the detection of ILD in almost 2/3 of the sample cohort, supporting the use of HRCT for detection of ILD in children with SSc. In addition, the cut off utilized, of less than 80% of predicted FVC or DLCO could be too low for pediatric patients to exclude beginning ILD. This pilot data needs confirmation in a larger patient population.

Supported by the “Joachim Herz Stiftung”

Disclosure of Interests:

Ivan Foeldvari Consultant of: Novartis, Bernd Hinrichs: None declared, Kathryn Torok: None declared, Maria Jose Santos Speakers bureau: Novartis and Pfizer, Ozgur Kasapcopur: None declared, Amra Adrovic: None declared, Valda Stanevicha: None declared, Flávio R. Sztajnbok: None declared, Maria T. Terreri: None declared, Ana Paula Sakamoto: None declared, Ekaterina Alexeeva Grant/research support from: Roche, Pfizer, Centocor, Novartis, Speakers bureau: Roche, Novartis, Pfizer., Jordi Anton Grant/research support from: grants from Pfizer, abbvie, Novartis, Sobi. Gebro, Roche, Novimmune, Sanofi, Lilly, Amgen, Grant/research support from: Pfizer, abbvie, Novartis, Sobi. Gebro, Roche, Novimmune, Sanofi, Lilly, Amgen, Consultant of: Novartis, Sobi, Pfizer, abbvie, Consultant of: Novartis, Sobi, Pfizer, abbvie, Speakers bureau: abbvie, Pfizer, Roche, Novartis, Sobi, Gebro, Speakers bureau: abbvie, Pfizer, Roche, Novartis, Sobi, Gebro, Maria Katsikas: None declared, Vanessa Smith Grant/research support from: The affiliated company received grants from Research Foundation - Flanders (FWO), Belgian Fund for Scientific Research in Rheumatic diseases (FWRO), Boehringer Ingelheim Pharma GmbH & Co and Janssen-Cilag NV, Consultant of: Boehringer-Ingelheim Pharma GmbH & Co, Speakers bureau: Actelion Pharmaceuticals Ltd, Boehringer-Ingelheim Pharma GmbH & Co and UCB Biopharma Sprl, Rolando Cimaz: None declared, Mikhail Kostik: None declared, Simone Appenzeller: None declared, Mahesh Janarthanan: None declared, Monika Moll: None declared, Dana Nemcova: None declared, Dieneke Schonenberg: None declared, Cristina Battagliotti: None declared, Lillemor Berntson Consultant of: paid by Abbvie as a consultant, Speakers bureau: paid by Abbvie for giving speaches about JIA, Blanca Bica: None declared, Juergen Brunner Grant/research support from: Pfizer, Novartis, Consultant of: Pfizer, Novartis, Abbvie, Roche, BMS, Speakers bureau: Pfizer, Novartis, Abbvie, Roche, BMS, Patricia Costa Reis: None declared, Despina Eleftheriou: None declared, Liora Harel: None declared, Gerd Horneff Grant/research support from: AbbVie, Chugai, Merck Sharp & Dohme, Novartis, Pfizer, Roche, Speakers bureau: AbbVie, Bayer, Chugai, Merck Sharp & Dohme, Novartis, Pfizer, Roche, Dragana Lazarevic: None declared, Kirsten Minden Consultant of: GlaxoSmithKline, Sanofi, Speakers bureau: Roche, Susan Nielsen: None declared, Farzana Nuruzzaman: None declared, Anjali Patwardhan: None declared, Yosef Uziel: None declared, Nicola Helmus: None declared

High prevalence of hepatitis C virus infection and low level of awareness among people who recently started injecting drugs in a cross-sectional study in Germany, 2011-2014: missed opportunities for hepatitis C testing

Background

In Germany, risk of hepatitis C virus (HCV) infection is highest among people who inject drugs (PWID). New injectors (NI) are particularly vulnerable for HCV-acquisition, but little is known about health seeking behaviour and opportunities for intervention in this group. We describe characteristics, HCV prevalence, estimated HCV incidence and awareness of HCV-status among NIs and missed opportunities for hepatitis C testing.

Methods

People who had injected drugs in the last 12 months were recruited into a cross-sectional serobehavioural study using respondent-driven sampling in 8 German cities, 2011–2014. Data on sociodemographic characteristics, previous HCV testing and access to care were collected through questionnaire-based interviews. Capillary blood was tested for HCV. People injecting drugs < 5 years were considered NI.

Results

Of 2059 participants with available information on duration of injection drug use, 232 (11% were NI. Estimated HCV incidence among NI was 19.6 infections/100 person years at risk (95% CI 16–24). Thirty-six percent of NI were HCV-positive (thereof 76% with detectable RNA) and 41% of those HCV-positive were unaware of their HCV-status. Overall, 27% of NI reported never having been HCV-tested. Of NI with available information, more than 80% had attended low-threshold drug services in the last 30 days, 24% were released from prison in the last 12 months and medical care was most commonly accessed in hospitals, opioid substitution therapy (OST)-practices, practices without OST and prison hospitals.

Conclusion

We found high HCV-positivity and low HCV-status awareness among NI, often with missed opportunities for HCV-testing. To increase early diagnosis and facilitate treatment, HCV-testing should be offered in all facilities, where NI can be reached, especially low-threshold drug services and addiction therapy, but also prisons, hospitals and practices without OST.

2225“New-onset atrial fibrillation efter cardiac surgery is associated with increased long-term morbidity and mortality”: a population-based study from the SWEDEHEART-registry

Background

New-onset postoperative atrial fibrillation (POAF) is a common complication after cardiac surgery, but the prognostic implications are not settled. In contrast to previous reports, a recent Danish study in coronary bypass surgery (CABG) patients (Butt et al. JAMA Cardiol 2018) did not show any increased risk for thromboembolic complications in POAF patients.

Purpose

To compare long-term outcome in patients with vs. without POAF after CABG.

Methods

All CABG patients in Sweden 2005–2015 (n=38040) were included in a retrospective population-based cohort study. Data from the SWEDEHEART registry, the National Patient Registry and the National Population Registry were merged. POAF was defined as any new-onset atrial fibrillation (AF) episode up to the 30thpostoperative day. Inverse Probability Treatment Weighting (IPTW) adjusted Cox regression models were used to compare outcome variables after the first 30 postoperative days until the end of follow-up (median 5 years, range 0–10). The models were adjusted for age, gender, CHA2DS2-VASc score, co-morbidity, and medications.

Results

The mean age of the entire cohort was 68 years, 79% were men and 90% had a CHA2DS2-VASc score ≥2. The incidence of POAF was 28.5% (10845/38040). During follow-up POAF, patients had a significantly higher adjusted risk for all-cause mortality [Hazard Ratio (HR) 1.16 (95% CI 1.09–1.24)], ischemic stroke [HR 1.19 (1.09–1.30)], transient ischemic attack [HR 1.17 (1.03–1.33)], pulmonary embolism [HR 1.24 (1.01–1.54)], myocardial infarction [HR 1.14 (1.04–1.25)], heart failure hospitalizations [HR.1.46 (1.35–1.59)] and recurrent AF [HR 4.33 (4.09–4.65)].

Conclusions

POAF was in this comparatively large study associated with increased risk for mortality and morbidity during long-term follow-up after CABG and is hence not a trivial complication.

The Smallest Intestine (TSI)-a low volume in vitro model of the small intestine with increased throughput

There is a growing interest in understanding the fate and behaviour of probiotic microorganisms and bioactive compounds during passage of the human gastrointestinal tract (GIT). Here, we report the development of a small volume in vitro model called The smallest Intestine (TSI) with increased throughput focusing on simulating passage through the stomach and small intestine (SI). The basic TSI module consists of five reactors, with a working volume of 12 ml each. During the simulated passage through the SI, bile is absorbed and pH is adjusted to physiologically relevant values for duodenum, jejunum and ileum. A consortium of seven representative bacterial members of the ileum microbiota is included in the ileal stage of the model. The behaviour of three putative probiotic Lactobacillus strains during in vitro simulated upper GIT passage was tested in the model and results were compared to previous studies describing probiotic survival. It was found, that probiotic persistence is strongly related to whether food was ingested, but also to presence of the ileal microbiota, which significantly impacted probiotic survival. In conclusion, TSI allows testing a substantial number of samples, at low cost and short time, and is thus suitable as an in vitro screening platform.

Test uptake and hepatitis C prevalence in 5483 Danish people in drug use treatment from 1996 to 2015: a registry-based cohort study

BACKGROUND AND AIMS

The aims of this study were, in people in treatment for drug use in Funen, Denmark, to: (1) assess prevalence of hepatitis C virus (HCV) test uptake and prevalence of HCV; (2) identify predictors of test update and HCV infection; and (3) characterize changes between 1996 and 2015 in test uptake, HCV prevalence and drug use.

DESIGN

Cohort study linking the Danish National Registry on Drug Users in Treatment to the regional hepatitis test registry and the Danish Death Certificate Registry, thus combining longitudinal data on drug use with data on HCV testing and results.

SETTING AND PARTICIPANTS

People recorded as having received treatment for drug use between 1996 and 2015 (n = 5483) in Funen, Denmark. In the cohort, 24.8% were female, median age 23 years [interquartile range (IQR) = 20-32] at entry and 50% had self-reported injecting or had received opiate substitution therapy (OST).

MEASUREMENTS

The main outcomes were the test for HCV ever and latest HCV-RNA being positive. The main predictors were for test and infection investigated; ever receiving OST, self-reported injecting, age at entry and connection to treatment centre offering outreach hepatitis care.

FINDINGS

HCV test uptake was 52% and prevalence of current HCV-RNA+ was 21% in people alive at the end of follow-up. Positive predictors of having undergone HCV testing were: receiving OST [odds ratio (OR) = 3.7; 95% confidence interval (CI) = 3.2-4.5], self-reported injecting (OR = 2.3; 95% CI = 2.0-2.7), female gender (OR = 1.7; 95% CI = 1.4-1.9) and having been connected to centres with outreach hepatitis care (OR = 1.4; 95% CI = 1.2-1.7). In people alive, HCV-RNA+ prevalence was 31% if ever on OST or self-reported injecting. Among HCV-infected people, 69% were in drug use treatment at end of follow-up. For participants entering the cohort after 2010, only 5% reported opiates as main drug of use and 17% had experience of injecting.

CONCLUSION

Among Danish people in treatment for drug use from 1996 to 2015, receiving opiate substitution therapy had the largest associating to being tested for hepatitis C virus. As opiate use is declining, adapting test strategies will be necessary.

History of detention and the risk of hepatitis C among people who inject drugs in Germany

OBJECTIVES

The aim of this study was to investigate the association between detention experience and hepatitis C virus (HCV) status, the role of duration and frequency of detention, and whether risk behaviours practiced in detention could explain an observed increase in risk.

METHODS

Current drug injectors (injecting in the last 12 months) were recruited to participate in a sero-behavioural, cross-sectional survey using respondent-driven sampling in eight German cities during the years 2011-2014. Using multivariable logistic regression, the association between HCV status and reported detention experience was investigated.

RESULTS

A total of 1998 participants were included in the analysis. Of these, 19.9% reported no detention experience, 28.6% short and rare experience (≤3.5 years in total, ≤3 times), 12.1% short but frequent experience, 7.1% long but rare experience, and 32.4% long and frequent experience. After correcting for HCV risk factors, the association between detention experience and HCV status remained statistically significant. By adjusting the model for intramural risk behaviours, the odds ratios of detention experience were reduced but remained significant.

CONCLUSIONS

The proportion of people who inject drugs positive for HCV increased with both frequency and duration of their detention experience. As intramural risk behaviours could not fully explain this increase, it appears that transfers between community and custody may confer additional risks.

Observations of core ion cyclotron emission on ASDEX Upgrade tokamak

The B-dot probe diagnostic suite on the ASDEX Upgrade tokamak has recently been upgraded with a new 125 MHz, 14 bit resolution digitizer to study ion cyclotron emission (ICE). While classic edge emission from the low field side plasma is often observed, we also measure waves originating from the core with fast fusion protons or beam injected deuterons being a possible emission driver. Comparing the measured frequency values with ion cyclotron harmonics present in the plasma places the origin of this emission on the magnetic axis, with the fundamental hydrogen/second deuterium cyclotron harmonic matching the observed values. The actual values range from ∼27 MHz at the on-axis toroidal field B_T = -1.79 T to ∼40 MHz at B_T = -2.62 T. When the magnetic axis position evolves during this emission, the measured frequency values track the changes in the estimated on-axis cyclotron frequency values. Core ICE is usually a transient event lasting ∼100 ms during the neutral beam startup phase. However, in some cases, core emission occurs in steady-state plasmas and lasts for longer than 1 s. These observations suggest an attractive possibility of using a non-perturbing ICE-based diagnostic to passively monitor fusion alpha particles at the location of their birth in the plasma core, in deuterium-tritium burning devices such as ITER and DEMO.

Risk behaviours and viral infections among drug injecting migrants from the former Soviet Union in Germany: Results from the DRUCK-study

BACKGROUND

High prevalence of drug use and injection-related risk behaviours have been reported among former Soviet Union (FSU)-migrants. To investigate hepatitis C (HCV) and HIV seroprevalence and related risk behaviours in this subgroup in Germany, we compared first generation FSU-migrants and native Germans using data from a sero-behavioural survey of people who inject drugs (PWID).

METHODS

Current injectors were recruited using respondent-driven sampling in eight German cities in 2011-2014. Questionnaire-based interviews were conducted and dried blood spots collected and tested for anti-HCV, HCV-RNA, and anti-HIV1/2. Descriptive and multivariable analyses (MVA) were performed.

RESULTS

A total of 208 FSU-born and 1318 native German PWID were included in the analysis. FSU-migrants were younger than Germans (median age: 33 vs. 39 years), and more often male (83.1% vs. 75.9%, p = 0.022). HCV seroprevalence was 74.5% in FSU-migrants vs. 64.6% in Germans (p = 0.006), HIV seroprevalence was 5.8% and 4.6%, respectively (p = 0.443). The proportion of FSU-migrants reporting injecting-related risk behaviours was higher than among Germans: injecting daily (39.4% vs. 30.2%, p = 0.015), with friends (39.2% vs. 31.2%, p = 0.038), cocaine (32.7% vs. 23.8%, p = 0.044), more than one drug (18.2% vs. 9.6%, p = 0.006), and sharing filters/cookers (35.5% vs. 28.0%, p = 0.045). No statistically significant differences were observed in HIV/HCV testing rates (range: 50.7%-65.6%), opioid substitution treatment (43.9% vs. 50.5%), and access to clean needles/syringes (89.8% vs. 90.3%). In MVA, risk for HCV-infection was increased in male FSU-migrants compared to German males (OR 3.32, p = 0.006), no difference was identified between female FSU-migrants and German females (OR: 0.83, p = 0.633).

CONCLUSION

Male FSU-migrants were at highest risk of being HCV infected. Therefore, targeted actions are needed to ensure access and acceptance of harm reduction measures, including HCV-testing and -treatment for this subpopulation of PWID.

Abstract P5-19-04: Psychosocial impact of a multi-modality surveillance program for women at high-risk for breast cancer

Purpose: To evaluate the psychosocial impact of semi-annual dynamic contrast enhanced magnetic resonance imaging (DCE-MRI) screening in women at high-risk for breast cancer.

Background: For women with BRCA1 and BRCA2 mutations and/or a personal or family history of breast cancer, annual breast MRI has shown improved sensitivity and cancer detection compared to mammography. However, MRI's heightened sensitivity may lead to increased: false positives requiring additional follow-up biopsy/imaging; iatrogenic risk; and psychosocial distress, which all may negatively impact women's overall health-related quality of life.

Methods: Between 2004 and 2016, we assembled a prospective cohort of high-risk women undergoing semi-annual DCE-MRI and annual mammography. We reviewed a subset of this group. Participants completed psychosocial assessments at baseline and 6-month visits using the following measures: coping (MBSS); state/trait anxiety (STAI-S/T); depression (BDI-II); risk perception; and mental health (SF-36). Participants were classified according to Monitor or Blunter coping style. Mixed-effects logistic regressions models examined effects of demographics on psychosocial changes over time.

Results: 295 women were recruited to the study; 44% of the study participants had pathogenic mutations in BRCA1 or BRCA2 genes. 232 of 295 enrolled participants (78.6%) completed psychosocial assessments. For the total population: median age 44y (range: 21-73), 71% ≥college/post-graduate education; 84% Caucasian; 8% African American; 2% Latino; 99% with health insurance; 72% annual income of &gt;$60,000. One third of women had a personal cancer history. Participants were evenly split between baseline Monitoring and Blunting coping style (49% and 51%, respectively). No significant differences were found between demographics (age, race, income, mutation, cancer type, cancer history) or psychosocial factors (baseline trait anxiety (p =0.64), depression (p =0.65), SF36 global health (p=0.66). After adjusting for education, race, cancer history and coping, women with ≥$60,000 income had lower trait anxiety (p&lt;0.000) and greater mental health (p&lt;0.001) than those with &lt;$60,000 income. Over time, change in trait anxiety varied by coping (p=0.0006): Blunters did not experience significant changes in trait anxiety (p=0.072) while Monitors had significant diminished trait anxiety over time (p&lt;0.001). For depression, women with ≥$60,000 income and college educated had lower BDI-II depression (p&lt;0.000). Yet, women with a cancer history had significantly greater BDH-II depression (p= 0.048). Mental health over time varied by race as non-whites had greater gains in mental health (p=0.001) over time than whites (p=0.03).

Conclusion: Semi-annual DCE-MRI did not cause a significantly elevated state anxiety or depression, nor was there a significant decline in mental health over time for groups regardless of cancer history and genetic mutation status. Coping style may have an impact on psychosocial outcomes for those undergoing heightened surveillance over time.

Citation Format: Amico AL, Fang R, Raoul A, Wroblewski K, Nielsen S, Weipert C, Abe H, Sheth D, Romero I, Kulkarni K, Schacht D, Patrick-Miller L, Verp M, Bradbury AR, Hlubocky F, Olopade OI. Psychosocial impact of a multi-modality surveillance program for women at high-risk for breast cancer [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P5-19-04.

Nitrogen mineralisation and greenhouse gas emission from the soil application of sludge from reed bed mineralisation systems

A sludge treatment reed bed system (STRB) is a technology used for dewatering and stabilising sewage sludge via assisted biological mineralisation, which creates a sludge residue suitable for use as fertiliser on agricultural land. We evaluated the effect of sludge residue storage time (stabilisation time) for three STRBs on soil N mineralisation and CO₂ and N₂O emissions in soil. The experiment revealed that the N mineralisation rate and emissions of CO₂ and N₂O decreased as a function of treatment time in the STRBs. Mixed sludge residue (sludge residue subjected to different treatment times) for the three STRBs resulted in N mineralisation rates similar to the sludge residue subjected to a shorter treatment time but lower N₂O emissions similar to the values of the older sludge residue. This finding reveals that combining fresh and more stabilised sludge residue ensures high N availability and reduces N₂O emissions when applied to land.

A large proportion of people who inject drugs are susceptible to hepatitis B: Results from a bio-behavioural study in eight German cities

BACKGROUND

People who inject drugs (PWID) are at high risk of hepatitis B virus (HBV) infection by sharing needles and drug use paraphernalia. In Germany, no routine surveillance of HBV prevalence and vaccination coverage among PWID exists.

METHODS

Socio-demographic and behavioural data were collected between 2011 and 2014 through face-to-face interviews, during a bio-behavioural survey of PWID recruited in eight German cities. Dried blood spots (DBS) prepared with capillary blood were tested for HBV markers. Factors associated with past/current HBV infection and vaccination status were analysed by univariable and multivariable analysis using logistic regression. The validity of self-reported HBV infection and vaccination status was analysed by comparison to the laboratory results.

RESULTS

Among 2077 participants, the prevalence of current HBV infection was 1.1%, of past HBV infection was 24%, and of vaccine-induced HBV antibodies was 32%. No detectable HBV antibodies were found in 43%. HBV infection status was significantly associated with study city, age, years of injecting, use of stimulants, migration status, and homelessness; HBV vaccination status was significantly associated with study city, age, and level of education. Correct infection status was reported by 71% and correct vaccination status by 45%.

CONCLUSIONS

HBV seroprevalence among PWID was about five times higher than in the general population in Germany, confirming PWID as an important risk group. Targeted information campaigns on HBV and HBV prevention for PWID and professionals in contact with PWID need to be intensified. Routinely offered HBV vaccination during imprisonment and opioid substitution therapy would likely improve vaccination rates among PWID.

From slow to fast faulting: recent challenges in earthquake fault mechanics

Faults-thin zones of highly localized shear deformation in the Earth-accommodate strain on a momentous range of dimensions (millimetres to hundreds of kilometres for major plate boundaries) and of time intervals (from fractions of seconds during earthquake slip, to years of slow, aseismic slip and millions of years of intermittent activity). Traditionally, brittle faults have been distinguished from shear zones which deform by crystal plasticity (e.g. mylonites). However such brittle/plastic distinction becomes blurred when considering (i) deep earthquakes that happen under conditions of pressure and temperature where minerals are clearly in the plastic deformation regime (a clue for seismologists over several decades) and (ii) the extreme dynamic stress drop occurring during seismic slip acceleration on faults, requiring efficient weakening mechanisms. High strain rates (more than 10⁴ s^-1) are accommodated within paper-thin layers (principal slip zone), where co-seismic frictional heating triggers non-brittle weakening mechanisms. In addition, (iii) pervasive off-fault damage is observed, introducing energy sinks which are not accounted for by traditional frictional models. These observations challenge our traditional understanding of friction (rate-and-state laws), anelastic deformation (creep and flow of crystalline materials) and the scientific consensus on fault operation.This article is part of the themed issue 'Faulting, friction and weakening: from slow to fast motion'.