bluuebunny/crossref_metadata_2025 huggingface dataset:
Facile preparation of a Ag/graphene electrocatalyst with high activity for the oxygen reduction reaction
Authors: Ren Yaqi , Zhao Hong , Li Jianpeng , Wang Rui , Wei Zhaohuan
Published: April 2020

Ag/graphene composite with small and well-dispersed Ag nanoparticles anchored onto the surface of graphene was prepared via a simple route from a disposal paper-cup, and exhibited superior electrocatalytic property for the oxygen reduction reaction.
Enhanced water oxidation performances of birnessite and magnetic birnessite nanocomposites by transition metal ion doping
Authors: Elmacı Gökhan , Özgenç Gökhan , Kurz Philipp , Zumreoglu-Karan Birgül
Published: April 2020

Co2+ and Ni2+ doped layered birnessite and birnessite-manganese ferrite core–shell catalysts displayed enhanced chemical stability and performance in chemical and electrochemical water oxidation reactions.
Importance of Cultural Competence in Supervisory Relationships
Authors: Subramanian Anu
Published: April 2020

Purpose

The purpose of this article is to discuss the importance of cultural competence in the area of supervision. The article uses a fictional scenario to consider the value of open conversations about cultural experiences and differences to begin a supervisory relationship.

Conclusion

It is important for clinical educators to be aware of their cultural identity, gather knowledge about other cultures, and develop positive attitudes about different cultures. Clinical educators should use their supervisory meetings to initiate discussions related to cultural influences and differences to ensure supervisee success.
Energy efficient aggregation technique‐based realisable secure aware routing protocol for wireless sensor network
Authors: Raja Basha Adam
Published: April 2020

Wireless sensor network (WSN) plays a predominant role from household equipment into military applications,sometimes utilised to handle most sensitive, personalised data like body sensors report, medical purposes in those cases, all kind of prescription and decisions are taken based on the sensor data. Many algorithms and techniques have been developed for these purposes among them trust‐based algorithms outperform the conventional techniques. A trust method provides ultimate security with integrity, authenticity and availability of data to all the nodes. Data overhead is the complication encountered while implementation trust‐based method which leads to complications like congestion into the system. And also directly affects the data aggregation process, as a cumulative effect, the overall lifetime of the network is drastically brought down. This study proposes a realisable secure aware routing (RSAR) protocol: RSAR method to overcome the said issue. The RSAR starts with the trust factor calculation of individual sensor node. Then the values are computed by optimal trust inference model using the conditional tug of war optimisation algorithm. The data aggregation help in reducing the instantaneous data flow of the individual node to multi‐hop and filters out the necessary data alone, then transmits the accumulated information to the receiving end. The energy efficiency of this proposed work is achieved through bypassing the repeated and fault data from the gathered information and in turn, it will maximise the WSN lifetime by saving its battery. Trust factor calculations introduced by this method help in identifying the attacks and mitigate by calculating the trust factors.
Implementation of a high‐power‐factor interior permanent magnet synchronous motor drive system with a small film DC‐link capacitor
Authors: Liu Tian‐Hua , Mubarok Muhammad Syahril , Yang Zhi‐Sheng
Published: April 2020

This study investigates a small film DC‐link capacitor inverter for a permanent magnet synchronous motor drive system. Two control methods, including a d –q ‐axis current control and a positive torque region current control, are originally proposed to improve the torque dynamics of the drive system. In addition, a damping compensation method is used to improve the input power factor and reduce the input current harmonics. A current‐loop predictive controller and a speed‐loop predictive controller are first proposed to improve the dynamic responses of the interior permanent magnet synchronous motor drive system. To implement the drive system, a digital signal processor, TMS 320LF2808, is used as a control centre to execute the control algorithms. Experimental results can validate the correctness and feasibility of the proposed methods.
Multiresolution matrix factorisation as a compression method for smart meter data
Authors: Ahmad Arfah , Datta Amitava , Sreeram Victor , Mishra Yateendra
Published: April 2020

The development of a smart grid electricity distribution network with advanced technology in smart metering will produce a massive amount of data. However, the limitation in communication network bandwidth makes it hard to transmit these data to the control center. Data compression is one of the best solutions to overcome this limitation. This study presents the use of multiresolution matrix factorisation (MMF) as a data compression technique for a smart distribution system. MMF will compress a data matrix into a core matrix with lower dimension via a series of orthogonal transformations. Experimental results gained from this study show that MMF is applicable in compressing large size data into lower dimension matrix with low error rates and high in speed. The MMF compression technique is able to reduce the volume of data to be transmitted through the communication network and thus save the bandwidth. Besides, MMF compression performs faster than the singular value decomposition method, especially with large size matrix. Findings from this study prove that MMF can serve as an alternative data compression technique for the smart distribution system, with a potential for an online application due to the high speed and high accuracy of the algorithm.
Diagnostik und Therapie von Schwerhörigkeit inkl. Cochlea-Implantat bei Migranten in Deutschland
Authors: Lesinski-Schiedat Anke , Lenarz Thomas , Illg Angelika
Published: April 2020

Die medizinische Versorgung von Migranten – verantwortet von Ärzten – ist eine administrative und regulatorische Herausforderung. Klar verständliche gesetzliche Vorgaben und administrative Strukturen stehen zur Verfügung 1. Ärztlicherseits und in der allgemeinen Presse wird oft diskutiert, dass zu wenige Ärzte über die Therapie von Asylbewerbern entscheiden, sondern die Sachbearbeiter der Gesundheitsämter 2. In dem folgenden Beitrag werden diese Aspekte erfahrungsbasiert erläutert.
Kardiozirkulatorische Zwischenfälle während der
Schwangerschaft – eine prekäre Reanimationskonstellation
Authors: Strauss Alexander , Gräsner Jan-Thorsten
Published: April 2020

Kollaps und akuter Herz-Kreislauf-Stillstand (SCA) können Personen
beiderlei Geschlechts betreffen. Obwohl die Inzidenz eines SCA mit steigendem
Lebensalter positiv korreliert, können (selten) auch schwangere Frauen
von derartigen zirkulatorischen Notfällen betroffen sein. Passagere
Alterationen des mütterlichen Kreislaufs bei
Vena-cava-Kompressionssyndrom und Kollaps sind von einem vollständigen
Herz-Kreislauf-Stillstand variabler Genese zu unterscheiden. Jedes dieser
Einzelereignisse bedarf eines unmittelbaren, koordinierten,
multidisziplinären Notfallteameinsatzes. Nach situationsbedingter
Ersteinschätzung stehen zum Notfallmanagement unterschiedliche
algorithmische Handlungspfade zur Verfügung. Zeitnähe des
Beginns und Beachtung schwangerschaftsbedingter Besonderheiten der
Wiederbelebungsmaßnahmen bis hin zum perimortalen Notfallkaiserschnitt
entscheiden die mütterliche und in der Folge auch die fetale Prognose.
Zur spezialisierten Befähigung der Protagonisten sind
interdisziplinäre/interprofessionelle
Simulationstrainingseinheiten effektiv.
T-shaped Transseptal Approach for Mitral Valve Surgery
Authors: El Beyrouti Hazem , Kornberger Angela , Oberhoffer Martin , Vahl Christian-Friedrich
Published: April 2020

We present a T-shaped transseptal approach for mitral valve surgery that makes adequate exposure possible under challenging anatomic and surgical circumstances, hence eliminating the need for forceful retraction on potentially fragile tissues. Particularly suited for patients with complex mitral pathology, it also facilitates juxta-annular transseptal right atrial anchoring, especially in cases of endocarditic anterior mitral annular destruction.
Comparison of Inflammatory Markers like C - Reactive Protein, Total Leukocyte Count and Erythrocyte Sedimentation Rate in Type II Diabetes Mellitus
Authors: Mungamuri Aditya , Y. Sunil Kumar , N. Suchetha Kumari , Devi Ullal Harshini
Published: April 2020

Background: Diabetes Mellitus (DM) has become an epidemic in the 21st century where India leads the world with largest number of patients. There is increasing evidence that inflammation is closely involved in the pathogenesis of type 2 diabetes and associated complications such as dyslipidaemia and atherosclerosis. Many previous studies indicate inflammatory markers like CRP, IL-6, IL-8, TNF-alpha, fibrinogen, total sialic acid, ceruloplasmin and total leucocyte count (TLC) are raised in Type II Diabetes Mellitus. However, not many studies have done association of ESR and TLC in DM.

Aims: In the present study inflammatory markers like CRP, total leukocyte count and ESR were compared in diabetic and non-diabetic patients.

Materials and Methods: 5mL of venous blood was taken from the study subjects.CRP, TLC and ESR was estimated.

Results: There was a significant rise in the CRP, TLC and ESR values seen in patients diagnosed with type II diabetes mellitus when compared to normal individuals. All three parameters (CRP, TLC, and ESR) were raised in a total of 7 cases (14%). 14 cases (28%) showed elevated levels of both CRP and ESR. A significant 8 cases (16%) showed elevation of CRP alone. There was a rise of ESR alone in 5 cases (10%).

Conclusion: CRP, TLC and ESR are elevated in diabetic patients in comparison to normal individuals. These increase the risk of diabetic related complications like atherosclerosis and dyslipaedemia. Hence, anti-inflammatory drugs in combination with antidiabetic treatment can delay these complications.
Oral Melanotic Macule – An Unusual Occurrence In Gingiva
Authors: R. Sajna H. , Thomas Biju , Ramesh Amitha , Bhandary Rahul , Kedlaya Madhurya N.
Published: April 2020

Melanotic macule is the most common benign pigmented lesion of the oral cavity characterised by a focal increase in the melanin deposition. A 34 year old female patient reported with a chief complaint of black pigmentation with respect to maxillary gingiva between the central incisors since one year. An excisional biopsy was done for histo pathological examination, which revealed the lesion as melanotic macule.
Legionnaires Disease
Authors: R. Sandeep K. , S. Sandhya Rani B.
Published: April 2020

Legionnaires' disease is a form of atypical pneumonia caused by any type of Legionella bacteria. The bacterium is found naturally in fresh water.[4] It can contaminate hot water tanks, hot tubs, and cooling towers of large air conditioners.[4] It is usually spread by breathing in mist that contains the bacteria.[4] It can also occur when contaminated water is aspirated.[4] It typically does not spread directly between people and most people who are exposed do not become infected.[4] Risk factors for infection include older age, history of smoking, chronic lung disease, and poor immune function.[5] There is still a low level of clinical awareness regarding Legionnaires' disease 25 years after it was first detected.
Arterial Blood Lactate in Children Primarily Submitted to Noninvasive Ventilation: A Time-Dependent ROC Analysis
Authors: Luz Luciana S. M. , Silva Andre Ricardo Araujo , Valete Cristina Ortiz Sobrinho
Published: April 2020

The purpose of this study was to evaluate blood lactate measurements and failure to noninvasive ventilation (NIV) in children admitted to a pediatric intensive care unit. This was a retrospective observational single-center study performed between June 2016 and June 2017. Dynamic lactate indices and failure to NIV in 63 children < 18 years and > 1 month old were examined; we considered blood lactate analyses at time 0, 6, 24, and 48 hours. NIV failure group had a higher pediatric risk of mortality (PRISM) score. Lactate indices decreased over time in the success group (p < 0.001). The best area under the curve observed was 69%, at 48 hours. Considering all measurements, the area under the curve for time-dependent receiver-operating characteristic curve was 58.6%. This study demonstrated blood lactate indices evolution over time in children submitted to NIV.
Multiple soil element and pH interactions constrain plant performance on tropical soils with a long history of fire
Authors: Rance Stan J. , Cameron David M. , Gosper Carl R. , Williams Emlyn R.
Published: April 2020

Agriculture and forestry in savanna soils worldwide are often constrained by multiple soil limitations. We measured the effect of fertilisation on growth of Pinus caribaea var. hondurensis in order to improve savanna soil productivity in the Northern Territory, Australia. Growth responses to nitrogen, potassium, sulfur and a combined trace element treatment (abbreviated to N × K × S × T) with basal phosphorus (P) application on three soils, and N × P × K × S × T on another three soils, were examined in glasshouse factorial experiments. Without P, there was little response to N, S or T. Growth was usually greatest on N + P + S treatments. The P applications increased soil pH and growth, while N and S applications decreased pH. Growth was consistently poor at soil pH < ~5.2; a pH where exchangeable cations can be leached from the soil and aluminium can become more mobile. Responses to P, N, S and K, and likely also to zinc, were consistent with savanna soils with a long history of nutrient losses due to fire and weathering. Establishing productive plantations or agriculture will require detailed knowledge of soil properties, careful attention to soil pH and balanced fertiliser applications so as not to produce perverse outcomes. Long-term protection from fires could improve soil conditions, to be balanced against the risks of crop loss through unplanned fire.
Analog synthesis of DAMASCENOLIDETM, an important aroma component of roses, and their odor properties
Authors: Miyazawa Yamato , Kawaguchi Kenji , Katsuta Ryo , Nukada Tomoo , Ishigami Ken
Published: April 2020

DAMASCENOLIDETM [1, 4-(4-methylpent-3-en-1-yl)furan-2(5H)-one], which has a citrus-like odor, is an important aroma component of roses. We have previously reported on the synthesis and odor evaluation of double-bond isomers of 1 and concluded that the position and the geometric isomerism of the double-bond had a significant effect on the odor. For the purpose of deepening knowledge about structure–odor relationships, we synthesized 13 analogs of compound 1 and evaluated their odors. As a result, it was found that the presence of two double-bonds and branched methyl group at the terminal position in the side chain was essential in order to have a citrus-like odor. Substitution of the side chain with appropriate length at the appropriate 4-position of the 2(5H)-furanone ring was also an important factor in determining the quality of the odor.
High-performance aramid fabric in infrared shielding by magnetron sputtering method
Authors: Jia Leilei , Fu Binhe , Lu Matthew Lee , Liang Hui-e , Wang Lei
Published: April 2020

In addition to providing basic protective functions, modern military uniforms are also being designed to provide special functions, such as infrared shielding. In this study, a nanoscale copper film was deposited on Kevlar para-1414 aramid fabric by magnetron sputtering technology to significantly enhance infrared shielding. The deposition of a uniform nano-copper film on the surface of the aramid fabric enhanced infrared shielding, tensile strain, and conductivity, which is of guiding significance for the development of infrared shielding garments.
LIPUS far-field exposimetry system for uniform stimulation of tissues in-vitro: development and validation with bovine intervertebral disc cells
Authors: Horne Devante A , Jones Peter D , Adams Matthew S , Lotz Jeffrey C , Diederich Chris J
Published: April 2020

Therapeutic Low-intensity Pulsed Ultrasound (LIPUS) has been applied clinically for bone fracture healing and has been shown to stimulate extracellular matrix (ECM) metabolism in numerous soft tissues including intervertebral disc (IVD). In-vitro LIPUS testing systems have been developed and typically include polystyrene cell culture plates (CCP) placed directly on top of the ultrasound transducer in the acoustic near-field (NF). This configuration introduces several undesirable acoustic artifacts, making the establishment of dose-response relationships difficult, and is not relevant for targeting deep tissues such as the IVD, which may require far-field (FF) exposure from low frequency sources. The objective of this study was to design and validate an in-vitro LIPUS system for stimulating ECM synthesis in IVD-cells while mimicking attributes of a deep delivery system by delivering uniform, FF acoustic energy while minimizing reflections and standing waves within target wells, and unwanted temperature elevation within target samples. Acoustic field simulations and hydrophone measurements demonstrated that by directing LIPUS energy at 0.5, 1.0, or 1.5 MHz operating frequency, with an acoustic standoff in the FF (125–350 mm), at 6-well CCP targets including an alginate ring spacer, uniform intensity distributions can be delivered. A custom FF LIPUS system was fabricated and demonstrated reduced acoustic intensity field heterogeneity within CCP-wells by up to 93% compared to common NF configurations. When bovine IVD cells were exposed to LIPUS (1.5 MHz, 200 μs pulse, 1 kHz pulse frequency, and ISPTA = 120 mW cm−2) using the FF system, sample heating was minimal (+0.81 °C) and collagen content was increased by 2.6-fold compared to the control and was equivalent to BMP-7 growth factor treatment. The results of this study demonstrate that FF LIPUS exposure increases collagen content in IVD cells and suggest that LIPUS is a potential noninvasive therapeutic for stimulating repair of tissues deep within the body such as the IVD.
A Gaussian Process Model of Human Electrocorticographic Data
Authors: Owen Lucy L W , Muntianu Tudor A , Heusser Andrew C , Daly Patrick M , Scangos Katherine W , Manning Jeremy R
Published: April 2020

We present a model-based method for inferring full-brain neural activity at millimeter-scale spatial resolutions and millisecond-scale temporal resolutions using standard human intracranial recordings. Our approach makes the simplifying assumptions that different people’s brains exhibit similar correlational structure, and that activity and correlation patterns vary smoothly over space. One can then ask, for an arbitrary individual’s brain: given recordings from a limited set of locations in that individual’s brain, along with the observed spatial correlations learned from other people’s recordings, how much can be inferred about ongoing activity at other locations throughout that individual’s brain? We show that our approach generalizes across people and tasks, thereby providing a person- and task-general means of inferring high spatiotemporal resolution full-brain neural dynamics from standard low-density intracranial recordings.
Wi-ESP—A tool for CSI-based Device-Free Wi-Fi Sensing (DFWS)
Authors: Atif Muhammad , Muralidharan Shapna , Ko Heedong , Yoo Byounghyun
Published: April 2020

Recent progress in Device-Free Wi-Fi Sensing (DFWS) has established the use of wireless signals like Wi-Fi not only to communicate but also as a tool to enable device-free sensing. As an emerging technique, DFWS has many capable applications such as sensing activity and gesture and fall detection, monitoring elderly, surveillance, and many more applications while waiving out the necessity to mount devices on the object. A wide range of applications can use the channel state information (CSI) from commercial Wi-Fi devices pervasively for ubiquitous sensing. Existing CSI tools, such as the Intel 5300 network interface controller tool or the Atheros 9390 tool, have limitations when deployed in large-scale systems due to their high deployment costs and limitations in the resolution of CSI measurements. Due to these shortcomings, DFWS applications need an alternative CSI tool in order to perform efficiently. In this paper, we present ESP32-based Wi-ESP as a CSI gathering tool that can report detailed CSI measurements based on 802.11n standards. The proposed Wi-ESP tool works as a complete device by collecting the CSI measurements as well as processing further for DFWS applications. Wi-ESP can work as standalone device, unlike other CSI tools, and can offer large-scale deployment to many DFWS applications. In this paper, we have explored the options of Wi-ESP as a tool for CSI measurements and processing and propose it as a tool for DFWS.
From Monetary to Fiscal to Political Union: A Progression to Integration or a Recipe for Failure?
Authors: D’Antoni Massimo
Published: April 2020

In this paper, we discuss the limits of the architecture of the euro from an economic point of view. We first highlight how the choice to create a monetary union was not supported by the accepted theory of optimal currency areas, and how its institutional set-up responded to a special and questionable view of the functioning of the economy, which recognized only a limited role to active macroeconomic policies. We continue by reconstructing the reasons for the emergence of the 2010–2011 debt crisis that can be traced back to the dynamics triggered by the single currency itself, and we highlight the role played by structural differences between various models of capitalism. Finally, we argue that the proposals currently on the table are by no means sufficient to correct the flaws in the European monetary architecture. The prospects are therefore pessimistic about the possibility of monetary union evolving towards a fiscal and political union.
The Term Structures of Expected Loss and Gain Uncertainty*
Authors: Feunou Bruno , Aliouchkin Ricardo Lopez , Tédongap Roméo , Xu Lai
Published: April 2020

We document that the term structures of risk-neutral expected loss and gain uncertainty on S&P 500 returns are upward sloping on average. These shapes mainly reflect the higher premium required by investors to hedge downside risk and the belief that potential gains will increase in the long run. The term structures exhibit substantial time-series variation with large negative slopes during crisis periods. Through the lens of a flexible Jump-Diffusion framework, we evaluate the ability of existing reduced-form option pricing models to replicate these term structures. We stress that three ingredients are particularly important: (i) the inclusion of jumps; (ii) disentangling the price of negative jump risk from its positive analog in the stochastic discount factor specification; and (iii) specifying three latent factors.
Functional networks of co-expressed genes to explore iron homeostasis processes in the pathogenic yeast Candida glabrata
Authors: Denecker Thomas , Zhou Li Youfang , Fairhead Cécile , Budin Karine , Camadro Jean-Michel , Bolotin-Fukuhara Monique , Angoulvant Adela , Lelandais Gaëlle
Published: April 2020

Candida glabrata is a cause of life-threatening invasive infections especially in elderly and immunocompromised patients. Part of human digestive and urogenital microbiota, C. glabrata faces varying iron availability, low during infection or high in digestive and urogenital tracts. To maintain its homeostasis, C. glabrata must get enough iron for essential cellular processes and resist toxic iron excess. The response of this pathogen to both depletion and lethal excess of iron at 30°C have been described in the literature using different strains and iron sources. However, adaptation to iron variations at 37°C, the human body temperature and to gentle overload, is poorly known. In this study, we performed transcriptomic experiments at 30°C and 37°C with low and high but sub-lethal ferrous concentrations. We identified iron responsive genes and clarified the potential effect of temperature on iron homeostasis. Our exploration of the datasets was facilitated by the inference of functional networks of co-expressed genes, which can be accessed through a web interface. Relying on stringent selection and independently of existing knowledge, we characterized a list of 214 genes as key elements of C. glabrata iron homeostasis and interesting candidates for medical applications.
EP06 Successful treatment of alopecia universalis with rituximab therapy
Authors: Oke Anuoluwapo R , Young-Min Steven
Published: April 2020

Background

Alopecia universalis (AU) is a severe subtype of alopecia areata (AA), in which there is non-scarring hair loss affecting the whole body. The pathogenesis involves, increased MHC class I expression in hair follicles, loss of hair follicle immune privilege and autoimmune-mediated damage to pigmented hair. There is no cure for alopecia areata, and though mild cases may have a good chance of either spontaneous or treatment-induced recovery, the prognosis of complete hair loss is poor with less than 10% recovery. Treatment remains a challenge with no reliably effective therapy and in the absence of well-evaluated trials, isolated case reports can influence practice. Here, we present the first report of AU being successfully treated with rituximab with remarkably sustained improvement at 6 years follow up. This case is also the first report of AU developing in adult dermatomyositis (DM) and we speculate upon the implications for the aetiopathogenesis of both conditions.

Methods

A 55-year-old lady, presented with proximal limb weakness, lethargy, a non-itchy rash, pleurisy and breathlessness. The serum creatinine kinase (3369 u/L) and anti-Jo-1 antibodies were elevated consistent with antisynthetase syndrome and a diagnosis of dermatomyositis was made. There was an initial response to corticosteroids and cyclophosphamide. She then relapsed and was treated with IV rituximab. Seventeen months after her initial presentation, she developed widespread hair loss sparing only white hairs (making Telogen Effluvium unlikely), combined with a concurrent relapse of her dermatomyositis. A diagnosis of alopecia universalis (AU) was made. A further course of IV rituximab therapy administered at this stage led to an excellent response in both her dermatomyositis and AU. At three months review, both the AU and the dermatomyositis had entered remission and this has been sustained 6 years on.

Results

Please refer to the conclusion section.

Conclusion

Disease activity in dermatomyositis has been linked with the expression of type I Interferon IFN and this may induce MHC class I expression that is identified on muscle biopsy. It may be that similar type I IFN action on hair follicles may have triggered the development of AU in our case. Whilst this is the first report of AU occurring with adult dermatomyositis, there has been a report of AU occurring in juvenile dermatomyositis. There are also other reports of other combinations of autoimmune conditions occurring with both DM & AU. This case also demonstrates that rituximab, an anti-CD 20 B cell therapy, maybe a useful treatment option in alopecia areata and universalis. This has not been reported elsewhere. Despite postulation that AU is a mainly T cell-driven disease, this case demonstrates that B cells may play a role, in much the same way that we now recognise the importance of B cell involvement in RA.

Disclosures

A.R. Oke None. S. Young-Min None.
EP09 Bamboo nodes in a patient with mixed connective tissue disease
Authors: Christidis Dimitrios C , Lloyd Mark
Published: April 2020

Background

Vocal cord lesions related to autoimmune diseases have been described as early as 1959, when Scarpelli et.al described a case of a woman with systemic lupus erythematosus (SLE) presented with laryngeal oedema. Pathological examination of the tissue revealed inflammatory cells and the lesions were labeled as “inflammatory nodules”. Since then numerous case reports were published describing patients with rheumatic diseases and abnormal vocal cords with Hosako et al. in 1993 proposing the term “bamboo nodes”.

Methods

A 27 year old female, lifelong nonsmoker, developed a husky voice which persisted through the day. She had no odynophagia or dysphagia and occasionally suffered from heartburn.She reported feeling fatigue and described a non-blanching purpuric rash affecting her lower limbs. She was referred to rheumatology and also to ear, nose and throat (ENT) specialist for further assessments including laryngeal endoscopy and autoimmune screen.

Results

The video laryngeal endoscopy revealed an area of linear thickening of the left mid-vocal fold. There was no evidence of reflux or muscle tension. Immunological test's revealed positive antinuclear, ribonuclear and Sm antibodies, with normal serum complement. The erythrocyte sedimentation rate was raised with normal C-reactive protein and there was a polyclonal increase of immunoglobulins. A diagnosis of mixed connective tissue disease with bamboo nodes was made. Her treatment consisted of local corticosteroid injections into the vocal cords with prednisolone 5mg (Solu-DecortinR) and systemic corticosteroids followed by hydroxychoroquine 5mg/kg and azathioprine 2mg/kg. Patient improved clinically but still requires speech therapy as adjunctive to the pharmacological treatment.

Conclusion

Bamboo nodes are a rare manifestation of autoimmune diseases and currently there is no gold standard on how to manage them. This case highlights the need of close collaboration between ENT, rheumatology and speech&language therapy.

Disclosures

D.C. Christidis None. M. Lloyd None.
EP14 Association between initial csDMARD strategy and disease activity at 6 months in patients with new onset rheumatoid arthritis
Authors: Wood Sarah , Hyrich Kimme , Verstappen Suzanne , Steinke Douglas
Published: April 2020

Background

Until 2018, NICE guidance recommended the use of a combination of disease-modifying anti-rheumatic drugs (DMARDs), including methotrexate (MTX), in the initial management of people with rheumatoid arthritis (RA). In 2018 the guideline was updated to recommend monotherapy with MTX due to uncertainties in the evidence for combination therapy. However, it remains a requirement for progression onto any biologic that the patient should have persistent high disease activity and/or have intolerance to, a minimum of two DMARDs. The aim of this study was to understand the association between initial treatment strategy and EULAR response at 6 months.

Methods

This analysis included patients recruited to the longitudinal observational Rheumatoid Arthritis Medication Study (RAMS) in the UK who were DMARD naïve and had symptoms for less than 1 year. Patients were defined as either starting MTX monotherapy or MTX in combination with another DMARD (6 weeks either side of MTX start date) and categorised into EULAR non responders or moderate/ good responders after 6 months. A logistic regression model was applied to test the association between initial treatment strategy and EULAR response at 6 months, adjusting for confounders.

Results

A total of 948 participants were included in the analysis. MTX monotherapy was prescribed in 72% (n = 678) of patients and combination therapy was prescribed in 28% (n = 270) of patients, the majority of whom received MTX plus hydroxychloroquine (HCQ) (n = 236, 87%). There was no significant difference between the MTX monotherapy and combination therapy groups in EULAR response at 6-months (adjusted odds ratio [aOR] 0.77, 95% CI 0.53 to 1.14).

Conclusion

In this large UK observational study investigating the effect of treatment strategy within the first 6 weeks of presentation and treatment response at 6 months, there was no significant difference between combination DMARD therapy and MTX monotherapy on EULAR response. Most patients received MTX in combination with HCQ, for which little evidence exists.

Disclosures

S. Wood None. K. Hyrich Consultancies; ABBVIE. Grants/research support; BMS, PFIZER, UCB. S. Verstappen None. D. Steinke None.
EP15 Switching to biosimilar adalimumab: a real world study
Authors: Begum Julie , Nisar Muhammad K
Published: April 2020

Background

Since the introduction of anti-TNF biosimilars in routine clinical practice, there has been a drive to implement the switch program for all biosimilars at the point of availability. Our Trust was aligned to NHS England strategy which required adoption of biosimilar within three months for new patients and one year for switchers. This could help deliver significant savings to the NHS whilst achieving similar clinical outcomes. We report our early experience of introducing adalimumab biosimilar (Imraldi®).

Methods

A list of all patients prescribed adlimumab was extracted through our database. A ‘switch’ letter was drafted and sent to all patients including Imraldi information sheet. Patients were given the opportunity to contact nurse helpline as needed. We reviewed all relevant records and collected data on any adverse events and disease outcome on either side of the switch.

Results

198 patients were identified established on adalimumab. All had switched by October 2019 to Imraldi. Mean age of switchers was 48 (range 16-83 years). Gender distribution was equal (99 each). 35 (17%) were Asian, two Afro-Caribbean, four other and the remaining 157 (80%) were White Caucasian. 54 (27%) had RA, 81 (41%) PsA, 57 (29%) AS and six had JIA. Co-prescribed DMARDs included methotrexate (n = 53, 27%), sulfasalazine (n = 15, 7.5%), hydroxychloroquine (n = 14, 7%) and leflunomide in two individuals. 83 (42%) participants were prescribed adalimumab monotherapy. Prior to switch, median DAS28 for RA group was 2.28 (0.57 - 6.29). Median BASDAI and spinal VAS for AS cohort was 3.3 (0.8 - 8.8) and 3.0 (0 - 9) respectively. Tender and swollen joint components for PsARC were median three (0-8 tender, 0-6 swollen) in PsA group. Only 30% of the patients had been reviewed face-to-face following the switch. Their respective median disease activity indices were not significantly different from pre-switch assessments. Eleven patients had complained of adverse events including injection site reaction (n = 7) and loss of disease control (n = 6). Six of these decided against further biosimilar and requested to return to the originator. No obvious precipitating factors were identified.

Conclusion

Our experience of switching adalimumab patients has been reasonably successful. All were happy to switch after receiving a letter and having the opportunity to contact if necessary. Substantial annual cost savings of over £300,000 have been projected for this financial year. At group level there were no major differences in disease outcomes and 90% reported no issues. However, just under 10% of those reviewed have decided to return to the originator within three months of switch with loss of efficacy and thereby confidence in the drug. We support the routine switching from originator to biosimilar adalimumab however close monitoring is required certainly in the first few weeks of dose administration.

Disclosures

J. Begum None. M.K. Nisar None.
EP42 Delaying diagnosis: inflammatory back pain and the other features of suspected spondyloarthritis have been rarely featured in musculoskeletal health professions literature
Authors: McCrum Carol
Published: April 2020

Background

The diagnostic delays commonly experienced by many people with spondyloarthritis (SpA), particularly axial spondyloarthritis, is a global concern. Early diagnosis is important since earlier intervention supports better outcomes, responses to treatment and reductions in the many personal impacts. Although core knowledge within Rheumatology, research indicates that the key feature of inflammatory back pain and the signs, symptoms and risk factors for axial and peripheral SpA are under-recognised in primary care. This study investigated the prevalence within musculoskeletal health professional literature (physiotherapy, osteopathy, chiropractic) of the terminology, clinical features and risk factors that appear in recommended criteria to support suspicion of axial and peripheral SpA and referral to rheumatology.

Methods

A systematic search and bibliometric analysis was undertaken across databases and musculoskeletal professional literature sources until 30 September 2019 (see Table 1) . The search was applied to all text, without limits except English language where enabled. Occurrences of terms were identified and the literature sources graded as 'core', 'peripheral', 'minimally accessed', or 'beyond scope' of musculoskeletal health professions to reflect likely professional exposure to the sources.

Results

Only 22 journal articles were found with any of the searched terms within core musculoskeletal profession journals. Prevalence included 'inflammatory back pain' (2 articles), 'axial spondyloarthritis' (2 articles), 'spondyloarthropathy ' (12 articles), 'reactive arthritis (3 articles), 'oligoarthritis' (1 article), psoriasis (2 articles). Prevalence was significantly more predominant in peripheral journal specialties; rheumatology (5,967) including 'inflammatory back pain' (424 articles); orthopaedics, sports medicine, spine and pain (257 articles) and medicine/general practice (44).

Conclusion

This review highlights the significant lack of profile in musculoskeletal literature of inflammatory back pain as a clinical presentation, or other features that are key in suspecting axial and peripheral spondyloarthritis. This scarcity may contribute to limited awareness, knowledge and confidence of musculoskeletal health professions with screening for spondyloarthritis and a factor in delayed diagnosis. The findings suggest the importance of raising the profile of the features of suspected spondyloarthritis, inflammatory back pain and the other risk factors for axial and peripheral spondyloarthritis within global core musculoskeletal literature to support screening for SpA to become routine in musculoskeletal clinical practice.

Disclosures: C. McCrum: Honoraria; Novartis.
O02 Is vitamin D testing essential in elderly patients with a hip fracture?
Authors: Mehta Serena N , Omar Mohd K , Sapkota Hem
Published: April 2020

Background

Elderly patients with hip fractures are likely to be vitamin D deficient. As per some studies, a vitamin D level above 75nmol/L is considered to be sufficient for this cohort. The majority of these patients will require treatment for their osteoporosis. Prior to treatment, vitamin D levels need to be sufficient, however there is often a delay to obtain vitamin D test results and this can postpone the initiation of osteoporosis management. In this retrospective study, we hypothesised whether empirical, high dose vitamin D treatment can be given to patients with hip fractures, regardless of their vitamin D level, who are not currently on vitamin D supplementation.

Methods

We obtained a list of 917 patients with a hip fracture, aged over 50, from the Trust National Hip Fracture Database from January 2017 to December 2018. We accessed patients’ electronic hospital and GP records to collect patient demographics, vitamin D levels, and medication history.

Results

The mean age in this study was 82.7 years, and 69.8% were female. Vitamin D levels were available for 666 patients. Of this, 69.9% of patients had a below adequate level (50 nmol/L) and 88.4% of patients had a below sufficient level (75 nmol/L) of vitamin D. Electronic records for vitamin D supplementation were only available for 434 patients. Of this, 300 patients (69.1%) were not on any form of vitamin D supplementation. In this cohort, only 7 patients had a vitamin D level above sufficient levels (75 nmol/L). Upon contacting these 7 patients; 3 were taking some form of vitamin D supplementation, 3 died and no information was available for 1.

Conclusion

Our study demonstrates all patients with a hip fracture, who are not taking any form of vitamin D supplementation will have subtherapeutic vitamin D levels. Thus, patients presenting with a hip fracture, can be treated empirically with high dose vitamin D treatment, without prior vitamin D testing. This would reduce the number of vitamin D tests conducted by 69.1% which will enable patients to receive prompt osteoporosis treatment and will reduce costs.

Disclosures

S.N. Mehta None. M.K. Omar None. H. Sapkota None.
O22 Assessing the role of tendon T cell interactions in the development of chronicity in PsA
Authors: Garcia-Melchor Emma , Cafaro Giacomo , Sood Shatakshi , Crowe Lindsay A. N , McLean Michael , McInnes Iain B , Akbar Moeed , Millar Neal L
Published: April 2020

Background

Mechanical stress or damage is a well-known inducer of inflammation in both psoriasis and psoriatic arthritis (PsA). The occurrence of microtrauma at enthesial sites, areas subjected to high mechanic stress, could explain the development of local inflammation (enthesitis) that further extends to the synovial tissue through what it is known synovio-entheseal complex. Current treatment strategies mainly target the immune compartment, however there is growing evidence for the role of the stroma in the development of chronic inflammation. Increasing attention has focused on the interaction between the stroma and immune system and its role in the initiation/development of tissue inflammatory chronicity. Our hypothesis is that stromal cells in the tendon or tenocytes, once activated, are able to recruit and activate T cells into the tendon, which in turn may have an effect on the stroma, altogether leading to chronicity.

Methods

We assessed the effect of damage on healthy tenocytes after stimulation with conditioned media from tendon explants or IL-1β by qPCR and ELISA. A transwell membrane system was used to test the impact of conditioned media from tenocytes on T cell migration. T cells and tenocytes were co-cultured with or without the presence of a transwell membrane to quantify T cell activation (CD69 by FACS and IFN-γ by ELISA). Changes in gene expression on tenocytes after co-culture with activated T cells were analysed by qPCR.

Results

In the presence of damage, tenocytes upregulated inflammatory cytokines (IL-1β, IL-6), chemokines (IL-8, CCL2, CCL5, CXCL10) and adhesion molecules (ICAM-1). Of interest, we observed an upregulation of CCL20, both at transcript and protein level. Conditioned media from tenocytes induced T cell migration, especially after stimulation. Co-culture of tenocytes and T cells resulted in contact dependant activation of T cells. These activated T cells also had an effect on tenocytes, further upregulating the production of inflammatory mediators.

Conclusion

These results support the role of the tendon stromal compartment in the recruitment and activation of T cells, creating a feedback loop that could be involved in the maintenance of the inflammatory process and the development of chronicity in the context of PsA. Moreover, the production of CCL20 by tenocytes after damage could explain the preferential recruitment of Th17 or gamma delta T cells into the tendon. We are further investigating the mechanisms that govern this relationship that could be targeted therapeutically in the future.

Disclosures

E. Garcia-Melchor None. G. Cafaro None. S. Sood None. L.A.N. Crowe None. M. McLean None. I.B. McInnes None. M. Akbar None. N.L. Millar None.
O26 Non-serious infections in patients with RA: results from the British Society for Rheumatology Biologics Register for Rheumatoid Arthritis
Authors: Bechman Katie , Halai Kapil , Norton Sam , Cope Andrew P , Hyrich Kimme L , Galloway James B
Published: April 2020

Background

Patients with rheumatoid arthritis (RA) are at an increased risk of infection. Most attention has been given to serious infections, but these are the tip of the iceberg. Non-serious infections (NSI) are far more frequent, and although not life-threatening, have potential to impact treatment outcomes (drug survival) and quality of life. Our objective was to describe frequency of NSI and compare incidence of NSI by biologic drug within the British Society for Rheumatology Biologics Register (BSRBR-RA).

Methods

The BSRBR-RA is a prospective observational cohort study. NSI was identified as not requiring hospitalisation, intravenous therapy or leading to disability or death. Infections were captured from clinician questionnaires and patient diaries. Individuals were considered ‘at risk’ from the date of commencing biologic treatment for 3 years. Drug exposure was defined by agent; TNF inhibitor, IL-6 inhibitor, anti-CD20 or csDMARD only. To account for a high frequency of events, a multiple-failure Cox model was used. Multivariable adjustment included age, gender, DAS28-ESR, HAQ-DI, disease duration, smoking, steroid usage, year recruited to BSRBR-RA, line of biologic therapy and cumulative infection number.

Results

There were 17,304 NSI in 10,099 patients, with an event rate of 27.0 per year (95% CI 26.6 to 27.4). Increasing age, female gender, comorbidity burden, corticosteroid therapy, DAS28 and HAQ-DI were associated with an increased risk of NSI. The rate of NSI was numerically lowest with csDMARDs. Compared to TNFi, IL-6 inhibitor had a higher risk of NSI, whilst the csDMARD cohort had a lower risk. Between the TNFi agents, adalimumab had a higher risk than etanercept (Table 1).

Conclusion

These results confirm that NSI is a frequent occurrence for patients, which historically has received little attention in research literature. The data suggest biologics increase the risk of NSI, especially IL-6 inhibition. Whilst unmeasured confounding must be considered, the magnitude of effects are large and it seems likely that a causal link between targeted immunosuppression and NSI risk exists. Further research is needed to understand the impact of NSI on clinical outcomes including drug survival and quality of life.

Disclosures

K. Bechman: None. K. Halai: None. S. Norton: None. A.P. Cope: None. K.L. Hyrich: Honoraria; AbbVie paid to the institution and grant income from Pfizer and Bristol-Myers Squibb for activities outside of this work. J.B. Galloway: Honoraria; for speaking or attending conferences from AbbVie, Bristol-Myers Squibb, Celgene, Janssen, Pfizer and Union Chimique Belge.