Investigator-initiated Research Grant Research Articles

Prevalence of exocrine pancreatic insufficiency at 12 months after acute pancreatitis: a prospective, multicentre, longitudinal cohort study

Exocrine Pancreatic insufficiency (EPI) occurs following acute pancreatitis (AP) at variably reported rates and with unclear recovery timeline. The aim of this study was to establish the prevalence and predictors of EPI at 12 months after AP in a prospective cohort. In this prospective, multicentre, longitudinal cohort study, adult participants (≥18 years) admitted to the hospital with an AP attack (defined by Revised Atlanta Classification) were enrolled in a United States multi-centre longitudinal cohort (Sites: The Ohio State University, University of Pittsburgh, and Johns Hopkins University). Patients were excluded if they had pancreatic cancer, chronic pancreatitis, or malabsorptive disease (including previously diagnosed EPI). Participant data was obtained by interview and by review of the electronic medical record. EPI was assessed by stool fecal elastase (FE-1) levels collected at baseline, 3 months, and 12 months (primary endpoint). EPI was defined by FE-1 <200μg/g; severe FE-1 level ≤100μg/g; mild FE-1 101-200μg/g. Multivariable logistic regression was used to identify predictors of EPI at 12 months. This study is registered with ClinicalTrials.gov, NCT03063398. EPI was observed in 29 (34.1%) of the 85 participants [44 (51.8%) male, mean age 54.7±14.1 years] who provided stool samples at 12 months. For the study overall, participants were recruited between June 22, 2017 and October 18, 2021. A total of 5794 individuals were screened, 311 of whom were eligible for the study. 112 participants provided stool samples at baseline, 79 completed stool samples at 3 months, and 85 completed samples at 12 months. 64 participants included samples at all 3 timepoints. In univariable analysis, factors significantly associated with EPI at 12 months included recurrent (versus index) AP, pre-existing diabetes, alcohol, and idiopathic etiologies, and increasing severity of AP. In multivariable analysis, the odds of having EPI at 12 months increased 4-fold with idiopathic AP etiology (Odds Ratio 4.095, 95% Confidence Interval [CI] 1.418, 11.826), and 3-fold with moderately severe or severe AP (Odds Ratio 3.166, 95% CI 1.156, 8.670), and baseline diabetes mellitus (Odds Ratio 3.217, 95% CI 1.113, 9.298). Even individuals with an index mild attack of AP (n=39) developed severe EPI at 12 months (prevalence 12.8%). EPI as diagnosed by FE-1 is present in over one third of prospectively assessed patients at 12 months post-AP. Since EPI develops in patients with mild AP, investigations are needed to understand the mechanisms of injury and identify methods for tailored screening. This study was supported by an Investigator Initiated Research Grant from AbbVie, Inc.

Pneumococcal serotypes and risk factors in adult community acquired pneumonia 2018–20: a multicentre UK cohort study

BackgroundHigher-valency pneumococcal vaccines are anticipated. We aimed to describe serotype distribution and risk factors for vaccine-serotype community-acquired pneumonia (CAP) in the two years pre-SARS-CoV-2 pandemic. MethodsWe conducted a prospective cohort study of adults hospitalised with CAP at three UK sites between 2018 and 2020. Pneumococcal serotypes were identified using a 24-valent urinary-antigen assay and blood cultures. Risk factors associated with vaccine-type pneumonia caused by serotypes in the 13-, 15- and 20-valent pneumococcal conjugate vaccines (PCV13, PCV15, PCV20) and 23-valent pneumococcal polysaccharide vaccine (PPV23) were determined from multivariable analysis. FindingsOf 1921 adults hospitalised with CAP, 781 (40·7%, 95% confidence intervals (CI) 38·5-42·9%) had pneumococcal pneumonia. A single PCV13-serotype was detected in 242 (31·0%, 95% CI 27·8-34·3%) pneumococcal CAP patients, mostly serotype 3 (171/242, 70·7%, 95% CI 64·5-76·0%). The additional two PCV15-serotypes were detected in 31 patients (4%, 95% CI 2·8-5·6%), and PCV20-non13-serotypes in 192 (24·6%), with serotype 8 most prevalent (123/192, 64·1%, 95% CI 57·1-70·5%). Compared to PCV13-serotype CAP, people with PCV20-non13 CAP were younger (median age 62 versus 72 years, p<0·001) and less likely to be male (44% versus 61%, p=0·01). PPV23-non13-serotypes were found in 252 (32·3%, 95% CI 29·1-35·6%) pneumococcal CAP patients. InterpretationDespite mature infant pneumococcal programmes, the burden of PCV13-serotype pneumonia remains high in older adults, mainly due to serotype 3. PCV20-non13-serotype pneumonia is more likely in younger people with fewer pneumococcal risk factors. FundingUnrestricted investigator-initiated research grant from Pfizer; support from National Institute for Health Research (NIHR) Biomedical Research Centre, Nottingham.

Nephrologists’ Perspectives on Home Dialysis Utilization: A National Survey From Israel

Nephrologists’ Perspectives on Home Dialysis Utilization: A National Survey From Israel

Characterization of atrial substrate to predict AF ablation success

Abstract Funding Acknowledgements Type of funding sources: Private company. Main funding source(s): The study has been financially supported by an investigator-initiated research grant by Biosense Webster (Study ID – IIS-532) (MRM) Background Left atrial (LA) substrate may have mechanistic relevance for ablation of atrial fibrillation (AF). We sought to analyze the relationship between low-voltage zones (LVZ), transition-zones (TrZ) and AF recurrence in patients undergoing pulmonary vein isolation (PVI). Methods We conducted a prospective multicenter study on consecutive patients undergoing PVI-only approach. LVZ and TrZ (0.5-1mV) were analyzed offline on high-density electroanatomical maps collected prior to PVI. Results 262 patients (61±11 years, 31% female) with paroxysmal (130 pts) or persistent (132 pts) AF were included. After 28 months of follow-up, 73 (28%) patients experienced recurrence. An extension of more than 5% LVZ in paroxysmal AF and more than 15% in persistent AF were associated with recurrence (HR=4.4 [2.0-9.8], p&amp;lt;0.001 and HR=1.9 [1.1-3.7], p=0.045, respectively). Significant linear association was found between LVZ and TrZ and between LVZ and left atrial volume index (LAVI) (both p&amp;lt;0.001). One-third of patients had significantly increased LAVI without LVZ. Eight percent of the patients had LVZ despite normal LAVI. Older age, female sex, oncological history and increased AF recurrence characterized this latter subgroup. Conclusions In patients undergoing first PVI, the impact of LVZ on outcomes occurs with lower burden in paroxysmal than persistent AF suggesting that not all LVZs have equal prognostic implications. A proportional area of moderately decreased voltages accompanies LVZ, suggesting a continuous fibrotic substrate instead of the dichotomous division of healthy or diseased tissue. LAVI generally correlates with LVZ but a small subgroup of patients may present with disproportionate atrial remodeling, despite normal LAVI.

Risk assessment in pulmonary arterial hypertension: A step towards clinical implementation based on the 2022 ESC/ERS pulmonary hypertension guidelines.

Risk assessment in pulmonary arterial hypertension: A step towards clinical implementation based on the 2022 ESC/ERS pulmonary hypertension guidelines.

Single-cell characterization of anti-LAG-3 and anti-PD-1 combination treatment in patients with melanoma.

BackgroundRelatlimab plus nivolumab (anti-lymphocyte-activation gene 3 plus anti-programmed death 1 [anti-LAG-3+anti-PD-1]) has been approved by the FDA as a first-line therapy for stage III/IV melanoma, but its detailed effect on the immune system is unknown.MethodsWe evaluated blood samples from 40 immunotherapy-naive or prior immunotherapy-refractory patients with metastatic melanoma treated with anti-LAG-3+anti-PD-1 in a phase I trial using single-cell RNA and T cell receptor sequencing (scRNA+TCRαβ-Seq) combined with other multiomics profiling.ResultsThe highest LAG3 expression was noted in NK cells, Tregs, and CD8+ T cells, and these cell populations underwent the most significant changes during the treatment. Adaptive NK cells were enriched in responders and underwent profound transcriptomic changes during the therapy, resulting in an active phenotype. LAG3+ Tregs expanded, but based on the transcriptome profile, became metabolically silent during the treatment. Last, higher baseline TCR clonality was observed in responding patients, and their expanding CD8+ T cell clones gained a more cytotoxic and NK-like phenotype.ConclusionAnti-LAG-3+anti-PD-1 therapy has profound effects on NK cells and Tregs in addition to CD8+ T cells.Trial registrationClinicalTrials.gov (NCT01968109)FundingCancer Foundation Finland, Sigrid Juselius Foundation, Signe and Ane Gyllenberg Foundation, Relander Foundation, State funding for university-level health research in Finland, a Helsinki Institute of Life Sciences Fellow grant, Academy of Finland (grant numbers 314442, 311081, 335432, and 335436), and an investigator-initiated research grant from BMS.

A Real-World Population Pharmacokinetic (PK) Study of Two Recombinant Factor VIII (rFVIII) Concentrates in Boys with Severe Hemophilia a without Inhibitors

Introduction To personalize long-term prophylaxis in boys with hemophilia A with a severe bleeding phenotype, the individual's pharmacokinetic (PK) profile must be established. Traditional FVIII PK assessment has required a 2-3-day washout, which can place boys at risk of bleeding, and up to 11 post-infusion blood samples collected over a 48h period (Lee et al., ISTH guidelines, 2001). Population PK models with Bayesian forecasting are currently available that permit the use of a no-washout PK protocol with sparse sampling, which is clinically practical and less demanding for patients and their families. Our previous experience with a no-washout, single-clinic visit, reverse 2-sampling time point (24 and 3h) PK protocol established that this practical, patient-friendly PK protocol was sufficiently accurate for generating clinically useful individual PK profiles in patients receiving a standard half-life (SHL) FVIII concentrate [antihemophilic factor (recombinant) plasma/albumin-free method (Advate®)] for long-term prophylaxis (Blanchette et al., Thromb Haemost, 2021). Aim To determine the accuracy of a clinically practical single-clinic visit, reverse 2-sampling time point population PK protocol for generating individual PK profiles [clearance (Cl) and terminal half-life (t1/2)] in boys with severe hemophilia A without inhibitors receiving either an SHL [antihemophilic factor (recombinant) BAY 81-8973 (Kovaltry®)] or an extended half-life (EHL) FVIII concentrate [antihemophilic factor (recombinant) PEGylated BAY 94-9027 (Jivi®)] for long-term prophylaxis. Methods In this multicenter observational study, participants had their first infusion given at home. Of a total of 14 boys with hemophilia A without inhibitors receiving long-term prophylaxis, 5 receiving a SHL completed a single clinic visit, reverse 2-point (24 and 3h) and a multiple clinic visit 6-point (baseline, 1, 3, 8, 24 and 48h) PK sampling protocol; and 4 boys completed a SHL single clinic visit reverse 2-point (48 and 3h) and a 2 clinic visit reverse 3-point (48, 3 and 24h) PK sampling protocol. 5 boys receiving EHL completed single clinic visit, reverse 2-point (72 and 3h) and 2-clinic visit 3-point (72, 3 and 48h) PK sampling protocols and they had multiple spot samplings (n=12) at various post-infusion times to evaluate the precision of their predicted PK profiles based on their 2-point PK sampling protocol. One-stage (OS) and chromogenic (CHR) FVIII:C and von Willebrand factor antigen (VWF:Ag) assays were performed in a central reference coagulation laboratory in Kingston, Ontario. PK parameters (Cl and t1/2) were estimated using the WAPPS-Hemo population PK program. The median of the % difference between the 2-sampling time point PK protocol compared to the 6- and 3- sampling time point PK protocols is reported. Results 14 boys with hemophilia A (FVIII:C <2%; median age: 14.5 yrs, range: 5-19 yrs) participated in the study. The 2-point PK protocol for both SHL and EHL showed a higher Cl and lower t1/2 when compared to either a 6-sampling time point (for SHL) or a 3-sampling time point (for either SHL or EHL) PK assessment (Table 1). The difference was greatest for the 2-point (24 and 3h) vs the 6-point (Table 1). In the case of the 2-point (48 and 3h for SHL and 72 and 3h for EHL) vs 3-point (an additional 24h time point for SHL and 48h for EHL) PK parameter estimates, the 2-point protocol gave values that were all within 6% of those obtained with the 3-sampling time point PK (Table 1). The OS and CHR assays gave similar estimations for Cl and t1/2 with the exception of t1/2 when comparing the 6-point to the 2-point PK protocol (Table 1). Evaluation of the 2-sampling time point PK protocol through spot sampling showed approximately 66% and 81% of FVIII:C values falling within the 95% prediction limits for the OS and CHR assays, respectively (n=12 for EHL OS; n=11 for EHL CHR). There was a strong association between the observed FVIII:C levels from the spot sampling and their predicted values from the 2-point PK for EHL (R2=94% and 71% for the OS and CHR assays, respectively) (Fig. 1). Conclusion The reverse 2-point, single clinic visit, PK protocol (24/48 or 72h and 3h) is a practical approach to generate PK parameters that provide clinically useful information for guiding personalized prophylaxis regimens for boys receiving SHL or EHL for long-term prophylaxis. Funding Supported by Bayer (Investigator-Initiated Research grant) Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Can oxymetazoline simulate the outcomes of septoplasty and inferior turbinate reduction surgery?

Inferior turbinate hypertrophy (ITH), with or without nasal septum deviation, is among the most common surgically correctable etiologies of nasal obstruction.1 The current challenge associated with surgical decision is twofold: 1) there are significant variabilities in individual nasal anamtomies as well as in surgical techniques; 2) there are few objective measures to identify which patients would benefit from surgery.2, 3 A patient's responsiveness to oxymetazoline has been often used as a proxy for surgical candidacy.3 Oxymetazoline is a selective α1 adrenergic receptor agonist and α2 adrenergic receptor partial agonist, which causes vasoconstriction and results in nasal decongestion since the soft tissue of the turbinates is rich in venous sinusoids and seromucinous glands. Yet despite the ubiquitous use of this bedside test, there are limited data that objectively compare the effect of oxymetazoline versus surgery on nasal morphology and aerodynamics, and whether such an approach could be used to predict patient outcomes. This study uses computational fluid dynamics (CFD) modeling to examine the changes in nasal aerodynamics and resistance in one patient after administration of oxymetazoline nasal spray as well as after inferior turbinate reduction surgery, to preliminarily investigate whether the changes in these factors are similar between the two and can corroborate the degree of symptomatic improvement. The patient is a 39-year-old male with moderate bilateral ITH and septal deviation resulting in nasal obstructive symptoms refractory to topical intranasal steroids. He denied history of chronic rhinosinusitis, allergies, head trauma, or autoimmune/connective tissue disorders. The patient completed the NOSE, SNOT-22, and Visual Analog Scales (VAS) for nasal obstruction (0: completely clear, 10: completely obstructed) immediately before his baseline computed tomography (CT) scan. To rule out placebo effect, a single-blinded sham test was performed with saline solution prior to oxymetazoline administration. Saline was topically applied via nasal spray followed by a 30 min rest and reassessment of symptoms (VAS and NOSE score). After the sham test, topical oxymetazoline spray was applied with symptom reassessment after a 30 min rest. A second CT scan then immediately followed. The patient ultimately underwent bilateral inferior turbinate reduction as well as minor septoplasty to remove a septal spur, with postoperative assessment after 8 weeks. Three-dimensional CFD models were constructed using the described method5 based on cone beam CT scans (3D Accuitomo 170, J. Morita USA, Inc.) at three time points: baseline, 30 min after oxymetazoline, and 8 weeks after surgery. Airflow patterns and velocity changes throughout the nasal airway were simulated under quasi-steady restful breathing conditions (15 Pa pressure drop between the nostrils and the nasal pharynx at a room air temperature of 20°C) using CFD software (ANSYS Fluent 19.2, Ansys, Inc, Canonsburg, PA). The numerical method and meshing protocol applied in this study have been previously validated against experimental measurements.4 The patient reported significant symptomatic improvement after both oxymetazoline and surgery. The NOSE score decreased from 80 at baseline and 80 after the sham test to 35 after oxymetazoline spray and 30 at 8 weeks after surgery. Likewise, VAS ratings of nasal obstruction decreased from 7 at baseline, to 6 after the sham test, 3 after oxymetazoline spray, and 2 after surgery. The SNOT-22 score decreased from 39 at baseline, to 9 at the post-surgery visit. Despite similar symptomatic outcomes, the aerodynamic effect of oxymetazoline was distinctly different and more pronounced than that of surgery. Post-oxymetazoline, nasal resistance was reduced by 56%, while average airflow velocity increased by 128% from baseline. Post-surgery, nasal resistance only reduced by 17%, while average airflow velocity increased by 21%. Peak mucosal heat flux increased 122% post-oxymetazoline versus 27% post-surgery as compared to baseline (Figure 1). Morphologically, oxymetazoline can affect the full length of inferior, middle, and superior turbinates, whereas the effect of surgery is limited to the surgical sites (Figure 2). The high velocity airflow is centered around the inferior portion of the middle turbinate post-oxymetazoline, while distributed towards the inferior turbinate post-surgery (Figure 2). One additional benefit of surgery may be the balancing of airflow between the two nasal cavities. At baseline, the patient's right nasal cavity had 4.55 times higher resistance than the left side. This reduced to 1.35 times after oxymetazoline administration and was nearly even (0.96) after surgery. This airflow-balancing effect may contribute to the marked improvement in airflow sensation post-surgery despite significantly better aerodynamic improvement post-oxymetazoline. This finding necessitates further study to confirm. Oxymetazoline and nasal airway surgery have comparable outcomes in relieving nasal obstructive symptoms. However, they appear to impact nasal morphology and aerodynamics very differently. Additional studies are warranted to rigorously test whether the responsiveness to oxymetazoline is a reliable predictor of satisfactory surgical outcomes. This study was supported by an investigator-initiated research grant by Bayer Health USA, Inc., to K.Z. The authors have no conflicts of interest to report.

Patient self-screening stations for atrial fibrillation in general practice waiting rooms: process evaluation

Abstract Background Our previous work has identified factors relevant to general practitioner (GP)-led screening for atrial fibrillation (AF) in Australian general practices, with GPs indicating significant time constraints. AF SELF SMART (Atrial fibrillation self-screening, management and guideline recommended therapy) allows for opportunistic patient self-screening using purpose-built screening stations located in GP waiting rooms (figure 1). It utilises a single-lead ECG, with results automatically imported into the patient medical record for review during the GP consultation. AF SELF SMART may increase screening rates, but acceptability by practice staff is unknown. Purpose Determine staff perspectives on opportunistic self-screening in practice waiting rooms, utilising AF SELF SMART. Method 14 semi-structured interviews have been conducted with practice staff (GPs, receptionists and practice managers) across 3 practices participating in the AF SELF SMART pilot, with thematic analysis of results. Results Several themes were identified. All staff acknowledged the importance of increasing screening for AF in the practice. GPs in particular placed a high value on AF screening for stroke prevention. GPs valued the increased information and accuracy provided by AF SELF SMART, as previously they checked patients for AF using manual methods, either routinely or as clinically indicated. There were differential impacts on workflow. GPs reported some small increase in workload but these were seen as being acceptable given the benefits of the program. Receptionists and Practice Managers reported significant interruptions to normal workflow associated with assisting patients. Receptionists routinely offered patients help with screening instead of patients screening independently. Staff perceived that patients were either unable to negotiate the self-screening process by themselves, or did not want to try. Given the increase in workload associated with assisting patients, and as screening was not receptionists' main priority, not all patients were offered self-screening during busy periods. Patient refusal was also identified as a factor limiting uptake. Conclusion While AF self-screening may increase screening rates, further process improvements are required to reduce impact on reception staff, and enhance the usability of the self-screening station for patients. Such improvements may increase acceptability and ongoing sustainability at a practice level. Funding Acknowledgement Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Investigator initiated research grant from Bristol-Myers Squibb/Pfizer Alliance Figure 1. Self-screening station

Pneumococcal vaccine uptake and vaccine effectiveness in older adults with invasive pneumococcal disease in Germany: A retrospective cohort study.

BackgroundInvasive pneumococcal disease (IPD) in people ≥60 years old is on the rise in Germany. There has been a recommendation for pneumococcal vaccination in this age group since 1998.MethodsWe determined the vaccination status of people ≥60 years old with IPD in Germany. We assessed vaccine effectiveness (VE) of the recommended 23-valent polysaccharide vaccine (PPV23) against IPD using the indirect cohort method.ResultsThe rate of pneumococcal vaccination in older adults with IPD is low, 26%, with only 16% of people receiving a pneumococcal vaccine within five years of the IPD episode. Age- and gender- adjusted vaccine effectiveness (VE) for PPV23 was 37% (95% confidence interval 12% - 55%). For people vaccinated with PPV23 less than two years prior to IPD, VE was -20% (-131% - 34%), between two and four years prior to IPD, VE was 56% (20% - 76%), and 47% (17% - 63%) for those vaccinated ≥5 five years ago. Excluding serotype 3, overall VE for the remaining serotypes in PPV23 was 63% (49% - 74%). For people receiving PPV23 within the past two years, VE against all serotypes except 3 was 49% (12% - 71%); for people vaccinated between two and four years prior to IPD 66% (37% - 82%); for those vaccinated ≥five years ago, 69% (50% - 81%). VE of PPV23 against serotype 3 IPD only was -110% (-198% - -47%).ConclusionsTo reduce IPD in older adults in Germany, we must increase the rate of pneumococcal vaccine uptake. For 22/23 serotypes, PPV23 was effective. Serotype 3 remains a major problem.FundingThis work was supported by an investigator-initiated research grant from Pfizer.

The Saqmolo’ Project: Protocol for a Randomized Controlled Trial Examining the Impact of Daily Complementary Feeding of Eggs on Infant Development and Growth in Guatemala

Abstract Objectives Studies in Ecuador and Malawi have demonstrated mixed effects of interventions involving daily complementary feeding of eggs on child growth. For example, in Malawi, the egg intervention had no overall effect on child development. There is a need to test the effects of egg interventions on child growth and development in other settings with high prevalence of stunting and in the context of other nutritional interventions. The Saqmolo’ (i.e.,“egg” in the Mayan language, Kaqchiquel) study aims to evaluate the impact of adding 1 egg per day to local standard nutrition care (LSNC) on child development, in rural Maya infants from Guatemala. Methods In a community-based, individually randomized, controlled comparative effectiveness trial among rural indigenous Maya children (n = 1200), starting at 6–9 months at baseline, we will compare the impact of adding one egg per day to LSNC with LSNC alone. LSNC includes: growth monitoring, medical care, deworming medication, multiple micronutrient powders for point of use food fortification, and individualized complementary and responsive feeding education for caregivers. Intervention and control groups will be visited once per month during 6-months and adherence will be monitored during the visits and through phone calls for the first 2 months in both groups at the same frequency. The primary outcome is differences in child global development (measured by Caregiver Reported Child Development Instruments –CREDI-and the Guide for Monitoring Child Development GMCD); secondary outcomes include: growth (z-scores for weight for age, length for age, weight for length, and head circumference for age), and diet quality (using the World Health Organization's infant and young child feeding indicators). Results N/A (submitting study protocol abstract). Conclusions This study will provide new evidence on the potential effect of increased egg accessibility in high prevalence stunting areas along with integrated nutrition care on child development. The results may help to inform public health decision-making regarding resource allocation for effective nutrition interventions during the complementary feeding period in Guatemala. Funding Sources This work was supported by the Academy of Nutrition and Dietetics Foundation via an investigator-initiated research grant from the Egg Nutrition Center.

Comparing Effectiveness of First-Line Antiretroviral Therapy between Peri-Urban and Rural Clinics in KwaZulu-Natal, South Africa

Background: Viral suppression (VS) is the hallmark of successful antiretroviral therapy (ART) programs. We sought to compare clinic retention, virologic outcomes, drug resistance, and mortality between peri-urban and rural settings in South Africa after first-line ART. Methods: ADReSS was a prospective study where 1,000 ART-naive people with HIV were enrolled, 500 at each site (one urban and one rural), between July 2014 and September 2016 and observed until July 2018. Participants were managed per local standard of care. Endpoints assessed included clinic retention, virologic suppression (VS), virologic failure (VF), genotypic drug resistance, and mortality. VS was defined as a viral load (VL) £1000 copies/mL. Time to event analyses were stratified (by site, median age, and gender). Kaplan-Meier (KM) curves were calculated and graphed with log-rank modelling to compare curves. Findings: Based on 2,741 patient-years of follow-up, retention and mortality did not differ between sites. Among all 1,000 participants, 73·9%, 83·9%, and 87·7% had achieved VS by six, 12, and 24 months, respectively, which was observed earlier in the peri-urban site. At both sites, men 32 years had the lowest with just 7·1% (p=0·018). Of all participants achieving VS, only 63 (8·7%) subsequently developed VF. This rate did not differ by site but was greater for men <32 years at both sites (p=0·015). Among 55 genotypes, 42 (76·4%) had at least one resistance mutation which did not differ by site. K103N (59%) and M184V (52%) were the most common mutations, followed by V106M and K65R (31% each). Overall, death was infrequent (<4%). Interpretation: No significant differences in treatment outcomes between urban and rural sites were observed. In both settings, young men were especially vulnerable to clinic attrition and VF. More effective adherence support for this important demographic group is needed to achieve UNAIDS targets. Funding Information: National Institute of Allergy and Infectious Diseases of the National Institutes of Heath and Emory CFAR. Declaration of Interests: V.C.M. has received investigator-initiated research grants (to the institution) and consultation fees (both unrelated to the current work) from Eli Lilly, Bayer, Gilead Sciences and ViiV. D.R.K. has received consulting honoraria (unrelated to the current work) and/or research grants (to the institution) from Gilead, GlaxoSmithKline, Merck and ViiV. MYS received consulting fees unrelated to the current work from MSD, J&J, CIPLA, and Gilead. All other authors report no potential conflicts. Ethics Approval Statement: Ethics approval from the Biomedical Research Ethics Committee of the University of KwaZulu-Natal, the Emory University and Mass General Brigham Institutional Review Boards was obtained prior to the start of the study. Signed informed consent was obtained.

POS0383 EFFECTS OF TOFACITINIB THERAPY ON ARGININE AND METHIONINE METABOLITES IN ASSOCIATION WITH VASCULAR PATHOPHYSIOLOGY IN RHEUMATOID ARTHRITIS: A METABOLOMIC APPROACH

Background:Rheumatoid arthritis (RA) has been associated with increased cardiovascular (CV) risk and metabolic changes.Objectives:We wished to determine how the Janus kinase (JAK) inhibitor tofacitinib influences vascular pathophysiology and metabolites of the arginine and methionine-homocysteine pathways.Methods:Thirty RA patients with active disease were treated with either 5 mg bid or 10 mg bid tofacitinib and evaluated at baseline and after 6 and 12 months. We determined DAS28, CRP, IgM rheumatoid factor (RF) and anti-cyclic citrullinated peptide (aCCP) levels. We assessed brachial artery flow-mediated vasodilation (FMD), carotid intima-media thickness (IMT) and pulse-wave velocity (PWV) by ultrasound. We also determined plasma L-arginine, L-citrulline, L-ornithine, inducible nitric oxide synthase (iNOS), asymmetric (ADMA) and symmetric dimethylarginine (SDMA), L-N-monomethyl-arginine (L-NMMA), cysteine, homocysteine, and methionine levels.Results:Twenty-six patients completed the study. Tofacitinib treatment maintained FMD and PWV. Ten mg bid tofacitinib significantly increased L-arginine, L-ornithine, iNOS and methionine levels after 12 months. Tofacitinib transiently increased L-citrulline and L-NMMA and decreased homocysteine levels after 12 months. Based on L-citrulline, L-ornithine, ADMA and SDMA levels, L-arginine remained highly available for endothelial NO production. Multivariate analysis indicated variable correlations of L-arginine, L-citrulline, ADMA, L-NMMA, homocysteine and methionine with DAS28, CRP, ESR and RF but not with aCCP. Regarding vascular pathophysiology, only PWV and methionine correlated with each other after 12 months.Conclusion:Tofacitinib suppressed systemic inflammation in RA yielding stabilization of vascular function. It may exert CV protective effects in RA, at least in part, by shifting L-arginine metabolism to high arginine availability and decreasing homocysteine levels.Acknowledgements:This research was supported by the European Union and the State of Hungary and co-financed by the European Social Fund in the framework of TAMOP-4.2.4.A/2-11/1-2012-0001 ‘National Excellence Program ’(Z.S.); by the European Union grant GINOP-2.3.2-15-2016-00015 (Z.S.) and by the WI188341 investigator-initiated research (IIR) grant obtained from Pfizer US (Z.S.).Disclosure of Interests:Boglárka Soós: None declared, Attila Hamar: None declared, Anita Pusztai: None declared, Monika Czókolyová: None declared, Edit Végh: None declared, Szilvia Szamosi Speakers bureau: Roche, Zsófia Pethö: None declared, Katalin Gulyás: None declared, György Kerekes: None declared, Éva Szekanecz: None declared, Sándor Szántó Speakers bureau: Abbvie, MSD, Novartis, Consultant of: Abbvie, Novartis, Gabriella Szücs Speakers bureau: Actelion, Roche, Sager, Boehringer, Consultant of: Boehringer, Actelion, Sager, Uwe Christians: None declared, Jelena Klawitter: None declared, Tamas Seres: None declared, Zoltán Szekanecz Speakers bureau: Pfizer, Abbvie, Roche, Lilly, Novartis, Boehringer, Consultant of: Pfizer, Abbvie, Novartis, Grant/research support from: Pfizer

Impact Evaluation of Typhoid Conjugate Vaccine Against Culture-Confirmed Typhoid in Extensively Drug-Resistant Outbreak Setting of Hyderabad, Pakistan

Background: We aim to report the effectiveness and impact evaluation of typhoid conjugate vaccine (TCV) against Salmonella Typhi (S.Typhi) among 6 months to 10 years old children in an outbreak setting of extensively drug resistant (XDR) Typhoid in Pakistan. Methods: A cohort and nested case-cohort studies conducted from March 01, 2018 to December 31, 2019. All households located in Qasimabad and Latifabad sub-districts were registered through electronic registry at baseline and age eligible children were offered free vaccination. Typhoid surveillance was established. 1058 randomly selected vaccinated cohort was followed till December 31, 2019 for additional S.Typhi cases. Besides, a case-cohort of 20,090 children were surveyed during Oct-Dec 2019 for any missed cases of S.Typhi. TCV vaccination status was available from baseline registry. Incidence rate ratio (IRR) and vaccine effectiveness (VE) against S.Typhi was calculated using 1-IRR. Findings: A total 23,407 children, 13436 (57·4%) were vaccinated, 12214 (52·2%) were male, and 10168 (43·4%) were 6-59 months old. 5378 (23%) children had suspected S.Typhi, among whom 775 (14·4%) were culture confirmed and 361/526 (68·6%) were XDR. The VE (95% CI) against suspected (regardless of cultures), culture confirmed and XDR S.Typhi, was 55% (52% to 57%), 95% (93% to 96%), and 97% (94% to 98%), respectively. The adjusted hazard ratio (aHR) of contracting culture confirmed S.Typhi among vaccinated children was 0·053; 95% CI 0·039 to 0·071; p <0·001). Interpretation: TCV is effective against culture confirmed S.Typhi among children aged 6 months to 10 years in an outbreak setting in Pakistan, and is able with only moderate deployment to curtail major XDR typhoid outbreak in a dense populous setting. The vaccine is effective against typhoid irrespective of AMR. Funding Statement: The study was funded through Bill & Melinda Gates Foundation with grant number OPP1176356. Declaration of Interests: Naor Bar-Zeev has obtained investigator-initiated research grants from Glaxo-Smith-Kline Biologicals, Takeda Pharmaceuticals, Merck Sharp & Dohme and the Serum Institute of India, all unrelated to this work. He has no other conflicts to declare. All other authors have nothing to declare. Ethics Approval Statement: This study was approved by the ethical review committee (ERC) of Aga Khan University Karachi and National Bioethics Committee (NBC) of Pakistan. Written informed consents were obtained from one of the parents/legal guardians.

Renal Clearance of FGF23 and its Fragments in Humans

Background: Relative abundance of fibroblast growth factor-23 (FGF23) measured by the C-terminal (cFGF23, which measures both intact FGF23 & c-terminal fragments) vs intact (iFGF23, measures only intact hormone) assays varies by kidney function in humans. Differential kidney clearance may explain this. Methods: We measured cFGF23 and iFGF23 in the aorta and bilateral renal veins of 162 patients with essential hypertension undergoing renal angiography. Using multivariable linear regression models, we examined factors associated with aorta to renal vein reduction of FGF23 using both assays. Similar, parameters and urine concentrations were measured in 6 Wistar rats. Results: Mean age was 54±12 years, 54% percent were women, and mean creatinine clearance was 72±48 ml/min/100g. The human kidney reduces the concentrations of both cFGF23 (16±12%) and iFGF23 (21±16%) compared to aorta, but reduction was higher for iFGF23. Greater kidney creatinine and PTH reduction were each independently associated with greater reductions of both cFGF23 and iFGF23. The relative kidney reduction of iFGF23 and cFGF23 appeared stable and consistent across the range of creatinine clearance. Kidney clearance was similar, and urine concentrations of both assays were low in the rat models, suggesting kidney metabolism of both cFGF23 and iFGF23. Conclusions: Renal reduction of iFGF23 is higher than that of creatinine and cFGF23.FGF23 is likely metabolized and cleared through the human kidney tubules, above and beyond glomerular filtration. Kidney clearance of FGF23 does not explain differences in C-terminal and intact moieties across the range of kidney function. Funding: This work was supported by National Institute of Diabetes and Digestive Kidney Diseases (NIDDK) Grants R01DK119528 and K24DK110427 (J.H.I). P30 DK079328, R01 DK091392, R01 DK092461 and R01 DK119528 (O.W.M). Veterans Health Administration IK2-CX002195 (SS). Declaration of Interest: Dr. Ix is principal investigator of an investigator-initiated research grant from Baxter International, serves as a data safety monitoring board member for Sanifit International, and has served on advisory boards for Alpha Young, AstraZeneca, Ardelyx Inc., and Jnana Inc. Dr. Moe has served on advisory boards and received compensations in the last 5 years for Allena, Alnylam, Ardelyx, Applied Therapeutics, Dicerna, Janssen, Genzyme-Sanofi, and Tricida. Remaining authors have declared no conflicts of interest. Ethical Approval: The human renal angiography studies were approved by the medical ethical committee of the Maastricht University Hospital. Animal studies were performed in accordance with the National Institutes for Health’s Guide for Care and Use of Laboratory Animals, and the experimental protocols had gained approval by the VA San Diego Health Care Systems and conducted under their guidelines.

Reply to Vitamin D Supplements: Is Bone Loss by HR-pQCT Really Negative?

Reply to Vitamin D Supplements: Is Bone Loss by HR-pQCT Really Negative?

Genotype Analysis of Adolescents with Heavy Menstrual Bleeding and Low Von Willebrand Activity - Report of a Multi-Center Study

Introduction: Low von Willebrand factor (VWF) activity is prevalent in adolescents with heavy menstrual bleeding (HMB). There is a need to better genetically characterize these patients and improve our understanding of the pathophysiology of their bleeding risk. Methods: One of the main objectives of this multi-center, single arm, observational cohort study was to genotype adolescent females with HMB and low VWF (≥ 30 and ≤ 50 IU/dL) by means of whole exome sequencing (WES), to identify variants throughout the exome that may modulate risk for bleeding. Post-menarchal females &amp;lt; 21 years with HMB (defined as PBAC score &amp;gt;100) and low VWF were eligible for the study. All patients were enrolled by participating centers where blood samples were collected. Exome data for 86 cases and 900 unrelated pediatric (&amp;lt;21 years) controls taken from a genetic study on Chiari 1 Malformation (CM1) were aligned and sorted, and variants called using the Sentieon software package. Annotation including allele frequencies, function, amino acid change and Clinvar rating among others was obtained using ANNOVAR. Variants were retained if there was a genotype call rate of &amp;gt;0.8, GQ&amp;gt;20, AB between 0.3-0.7 and min DP&amp;gt;8. Case/control analyses included common and rare SNP associations, gene burden analysis of both rare nonsynonymous variants and ClinVar 'pathogenic' variants, and gene-set burden analyses. Variants were considered rare if they had a minor allele frequency of &amp;lt;1% in the Genome Aggregation Database (gnomAD). Count differences between cases/controls were determined by Fisher's Exact test. Results: Of the 113 subjects enrolled, 86 had sufficient blood samples collected for WES. The median age was 16.2 years (range: 11.5-19.6). 36% of cases showed variants in VWF vs. 26% of controls (p=0.14). After multiple test correction, WES revealed a significant common variant association in FERMT2 with an LD block with a frequency of 24% in cases and 6% in controls (p=7.5x10-7). Rare variant analysis showed a significant association with an intronic variant in ABCA13 (p=1.6x10-7). Among the gene burden analysis using rare nonsynonymous variants, 2 genes of interest passed multiple test correction: IL12B and DTNBP1. When using ClinVar 'pathogenic' variants as the input for the gene burden analysis, 4 genes of interest passed multiple test correction: HBM, MYLK, RUNX1 and CD36. Gene-set burden analysis revealed 5 significant pathways of interest, including platelet degranulation, platelet alpha granule lumen and erythrocyte differentiation. We then focused a subset of known risk genes and compared the number of missense, nonsense and ClinVar 'pathogenic' variants between cases and controls. GP6, and MTHFR had significantly more missense variants in controls vs. cases (p=0.003 and 0.01, respectively), and F13B approached significance, with more missense variants in controls than cases (p=0.07). Conclusion: We found VWF variants in 36% of subjects, in accordance with previous reports. We found novel SNP associations with variants in FERMT2 and ABCA13.FERMT2 encodes for the integrin, Kindlin 2, which has been shown to be critical for supporting vascular integrity. Several other relevant genes passed multiple test correction in gene burden analyses, including genes known to cause Hermansky-Pudlak syndrome (DTNBP1), familial platelet disorder (RUNX1), platelet glycoprotein IV deficiency (CD36) and aortic aneurysm (MYLK). This association with platelet disorders was strengthened by our gene-set burden results, which implicate several platelet-related pathways. These data suggest that while a subset of HMB patients may have their bleeding explained by variants in VWF, there is a role for other hemostasis, platelet biology and vascular integrity related gene variants which can contribute to the variation in bleeding severity in adolescents with low-VWF related HMB. Study supported by an investigator-initiated research grant from Shire US Inc., now part of Takeda Disclosures O'Brien: Bristol Myers Squibb: Consultancy, Membership on an entity's Board of Directors or advisory committees. Mullins:Takeda, Bayer: Other: Advisory Board. Sidonio:Takeda: Research Funding. Ragni:Sangamo: Consultancy, Research Funding; Takeda: Research Funding; Bioverativ: Consultancy, Research Funding; Spark: Consultancy, Research Funding; BioMarin: Consultancy, Research Funding; Alnylam/Sanofi, ATHN, BioMarin, Bioverativ, Sangamo, Spark: Research Funding; Alnylam/Sanofi, BioMarin, Bioverativ, Spark: Consultancy; Alnylam Pharmaceuticals Inc., Baxalta/Takeda, BioMarin, Bioverativ, and Spark Therapeutics: Membership on an entity's Board of Directors or advisory committees; American Thrombosis Hemostasis Network: Other: Committee work; Baxalta/Takeda, CSL Behring, Genentech, a member of the Roche Group, OPKO Biologics, and Vascular Medicine Institute: Research Funding. Kulkarni:Sanofi/ Bioverativ, Bayer, Biomarin, Shire/Takeda, Novo Nordisk, Freeline: Other: clinical trial research grants ; Bioverativ/Sanofi, BPL, Genentech, Kedrion, Novo Nordisk, Octapharma, Pfizer, Takeda, Catalyst Bioscience Bayer: Membership on an entity's Board of Directors or advisory committees. Srivaths:Shire US Inc., now part of Takeda: Research Funding.

Reduced Hepatitis C Incidence Associated with Rapid Treatment Scale-Up in Australian Prisons: Treatment-as-Prevention in the SToP-C Study

Background: Limited empirical evidence exists for hepatitis C virus (HCV) treatment-as-prevention. The Surveillance and Treatment of Prisoners with hepatitis C (SToP-C) study assessed HCV treatment-as-prevention in four Australian prisons. Methods: Prisoners in two maximum- (male) and two medium-security prisons (one male, one female) were enrolled from late-2014 to 2019. Following HCV testing, participants were monitored for risk behaviors and HCV, among three sub-populations: 1) uninfected (HCV antibody negative); 2) previously infected (HCV antibody positive, HCV RNA negative); 3) infected (HCV antibody and HCV RNA positive). Uninfected and previously infected (at-risk) participants were followed every 3-6 months for HCV primary infection and re-infection, respectively. Infected participants were assessed for treatment, initially standard of care treatment (by prison health services), followed by direct-acting antiviral (DAA) treatment scale-up from mid-2017 (12 weeks sofosbuvir/velpatasvir, through SToP-C). HCV incidence was compared between pre- and post-treatment scale-up periods. Findings: Of 3,691 participants, 719 (19%) had detectable HCV RNA and 2,965 were at-risk of primary infection (n=2,240) or re-infection (n=725) at baseline. DAA treatment was initiated in 349/499 eligible participants during scale-up. Among at-risk population with longitudinal follow-up (n=1,643; median age 33 years; 82% male), 31% reported injecting drug use in prison. HCV incidence declined by 48%, from 8.31 to 4.35/100 person-years between pre- and post-treatment scale-up periods [Incidence Rate Ratio (IRR): 0.52, 95%CI: 0.36, 0.78]. The incidence of primary infection declined from 6.64 to 2.85/100 person-years (IRR: 0.43, 95%CI: 0.25, 0.74), while incidence of re-infection declined from 12.36 to 7.27/100 person-years (IRR: 0.59, 95%CI: 0.35, 1.00). Adjusted analysis indicated 50% reduction in HCV risk between pre- and post-treatment scale-up periods (adjusted Hazard Ratio: 0.50, 95% CI: 0.33, 0.76). Interpretation: DAA treatment scale-up was associated with reduced HCV incidence in prison, indicative of HCV treatment-as-prevention. The findings support broad DAA treatment scale-up among incarcerated populations. Trial Registration: Clinicaltrials.gov Identifier: NCT02064049. Funding Statement: The SToP-C study was funded by an Australian National Health and Medical Research Council (NHMRC) Partnership Project Grant (APP1092547), including support from Gilead Sciences. Declaration of Interests: GJD is a consultant/advisor and has received research grants from Gilead, Abbvie, Merck, Bristol-Myers Squibb, and Cepheid. ARL a consultant/adviser and has received investigator-initiated research grants from Gilead, Merck, and Bristol-Myers Squibb. JG a consultant/advisor and has received research grants from Gilead, Abbvie, Merck, and Cepheid. PV has received investigator-initiated untied grants from Gilead and honorarium from Gilead and Merck. NKM has received unrestricted research grants from Gilead and Merck. JGMc is a stockholder and ex-employee of Gilead Sciences. DMB is a stockholder and employee of Gilead Sciences. None of the other authors has commercial relationships that might pose a conflict of interest in connection with this study. Ethics Approval Statement: All participants provided written informed consent before study procedures. The study protocol was approved by New South Wales Justice Health and Forensic Mental Health Network Human Research Ethics Committee (HREC/14/JH/7), Aboriginal Health and Medical Research Council Human Research Ethics Committee (1047/14 and 1253/17) and New South Wales Corrective Services Ethics Committee. The study was conducted according to the Declaration of Helsinki and International Conference on Harmonization Good Clinical Practice (ICH/GCP) guidelines.

Aggressive Colonization Screening and Infection Control Measures in Containment of NDM-5 Carbapenemase-Producing CRE

Background: In April 2019, Nebraska Public Health Laboratory identified an NDM-producing Enterobacter cloacae from a urine sample from a rehabilitation inpatient who had recently received care in a specialized unit (unit A) of an acute-care hospital (ACH-A). After additional infections occurred at ACH-A, we conducted a public health investigation to contain spread. Methods: A case was defined as isolation of NDM-producing carbapenem-resistant Enterobacteriaceae (CRE) from a patient with history of admission to ACH-A in 2019. We conducted clinical culture surveillance, and we offered colonization screening for carbapenemase-producing organisms to all patients admitted to unit A since February 2019. We assessed healthcare facility infection control practices in ACH-A and epidemiologically linked facilities by visits from the ICAP (Infection Control Assessment and Promotion) Program. The recent medical histories of case patients were reviewed. Isolates were evaluated by whole-genome sequencing (WGS). Results: Through June 2019, 7 cases were identified from 6 case patients: 4 from clinical cultures and 3 from 258 colonization screens including 1 prior unit A patient detected as an outpatient (Fig. 1). Organisms isolated were Klebsiella pneumoniae (n = 5), E. cloacae (n = 1), and Citrobacter freundii (n = 1); 1 patient had both NDM-producing K. pneumoniae and C. freundii. Also, 5 case patients had overlapping stays in unit A during February–May 2019 (Fig. 2); common exposures in unit A included rooms in close proximity, inhabiting the same room at different times and shared caregivers. One case-patient was not admitted to unit A but shared caregivers, equipment, and devices (including a colonoscope) with other case patients while admitted to other ACH-A units. No case patients reported travel outside the United States. Screening at epidemiologically linked facilities and clinical culture surveillance showed no evidence of transmission beyond ACH-A. Infection control assessments at ACH-A revealed deficiencies in hand hygiene, contact precautions adherence, and incomplete cleaning of shared equipment within and used to transport to/from a treatment room in unit A. Following implementation of recommended infection control interventions, no further cases were identified. Finally, 5 K. pneumoniae of ST-273 were related by WGS including carriage of NDM-5 and IncX3 plasmid supporting transmission of this strain. Further analysis is required to relate IncX3 plasmid carriage and potential transmission to other organisms and sequence types identified in this study. Conclusions: We identified a multiorganism outbreak of NDM-5–producing CRE in an ACH specialty care unit. Transmission was controlled through improved infection control practices and extensive colonization screening to identify asymptomatic case-patients. Multiple species with NDM-5 were identified, highlighting the potential role of genotype-based surveillance.Funding: NoneDisclosures: Muhammad Salman Ashraf reports that he is the principal investigator for a study funded by an investigator-initiated research grant.

Dynamic changes in paediatric invasive pneumococcal disease after sequential switches of conjugate vaccine in Belgium: a national retrospective observational study

Ten-valent and 13-valent pneumococcal conjugate vaccines (PCVs) have shown important benefits by decreasing invasive pneumococcal disease caused by vaccine serotypes. Belgium had an uncommon situation with sequential use of PCV7, PCV13, and PCV10 in the childhood vaccination programmes between 2007 and 2018. We aimed to analyse the changes in incidence of invasive pneumococcal disease and serotype distribution in children throughout this period. Streptococcus pneumoniae isolates were obtained from patients with invasive pneumococcal disease in Belgium between 2007 and 2018 by the national laboratory-based surveillance. Paediatric invasive pneumococcal disease incidence, serotype distribution, and antimicrobial susceptibility were analysed in periods during which PCV7 (2009-10), PCV13 (2013-14), both PCV13 and PCV10 (2015-16), and PCV10 (2017-18) were used. Incidence rates and trends were compared. Vaccination status was collected. For a subset of serotype 19A isolates, multilocus sequence type was identified. After a decrease in PCV7 serotype invasive pneumococcal disease was observed during the PCV7 period, total paediatric invasive pneumococcal disease incidence significantly declined during the PCV13 period (-2·6% monthly, p<0·0001). During the PCV13-PCV10 period (2015-16), the lowest mean in paediatric invasive pneumococcal disease incidence was achieved, but the incidence increased again during the PCV10 period (2017-18), especially in children younger than 2 years (+1·7% monthly; p=0·028). This increase was mainly due to a significant rise in serotype 19A invasive pneumococcal disease incidence in the PCV10 period compared with the PCV13 period (p<0·0001), making serotype 19A the predominant serotype in paediatric invasive pneumococcal disease in the PCV10 period. Genetic diversity within the 2017-18 serotype 19A collection was seen, with two predominant clones, ST416 and ST994, that were infrequently observed before PCV10 introduction. In 2018, among children younger than 5 years with invasive pneumococcal disease who were correctly vaccinated, 37% (37 of 100) had PCV13 serotype invasive pneumococcal disease, all caused by serotype 19A and serotype 3. After a significant decrease during the PCV13 period, paediatric invasive pneumococcal disease incidence increased again during the PCV10 period. This observation mainly resulted from a significant increase of serotype 19A cases. During the PCV10 period, dominant serotype 19A clones differed from those detected during previous vaccine periods. Whether changes in epidemiology resulted from the vaccine switch or also from natural evolution remains to be further elucidated. The Belgian National Reference is funded by the Belgian National Institute for Health and Disability Insurance and the whole genome sequencing by an investigator-initiated research grant from Pfizer.