Adalimumab or Etanercept as first line biologic therapy in Enthesitis related arthritis (ERA) - a drug-survival single centre study spanning 10 years

Objectives: To analyse and compare drug-survival of adalimumab and etanercept (and their biosimilars) in biologic-naïve patients with ERA (Enthesitis-Related Arthritis). // Methods: In this retrospective observational study, conventional statistics and machine-learning were applied to compare drug-survival (adalimumab, etanercept and their biosimilars initiated: 2009–2019) in ERA and identify determinants. The primary outcome was discontinuation of treatment due to primary- or secondary-failure and adverse drug-reactions. // Results: During the observation period, 99 of 188 patients with ERA on first-line TNF inhibitors (etanercept-n=108, adalimumab-n=80) discontinued their treatment (median survival-time 3.9years, 95%CI 2.6-4.9years). Adalimumab was associated with longer drug-survival compared to etanercept especially after an initial positive response, with the median time to treatment discontinuation 4.9years (95% CI 3.9–5.7) for adalimumab, compared to 2years (95%CI 1.4–4.0) for etanercept (HR of treatment-discontinuation-0.49, 95%CI 0.32–-0.75, p=0.001). Adjusted by propensity-score, adalimumab-methotrexate combination was associated with longer drug survival, compared to adalimumab-monotherapy (HR-0.41, 95%CI 0.20–0.85), etanercept-monotherapy (HR-0.28, 95%CI 0.15–0.53), and etanercept-methotrexate combination (HR-0.39, 95%CI 0.21–0.73). The presence of HLA-B27 was associated with longer drug-survival (HR-0.50, 95%CI 0.29–0.87) following an initial positive response. Higher-CRP at baseline was associated with higher rate of primary-failure (HR-1.68, 95%CI 1.08–2.62). Axial-ERA (sacroiliitis±spinal-involvement) was associated with poorer drug-survival for both primary- and secondary-failure (overall HR-2.03, 95%CI 1.22–3.40). Adjusted by propensity-score, shorter drug-survival was observed in patients with baseline-CRP≥12.15 mg/L, but only in the context of axial-ERA, not in peripheral-ERA (no sacroiliitis/spinal-involvement) (HR-2.28, 95%CI 1.13–-3.64). // Conclusion: Following an initial positive primary response, continuing methotrexate with adalimumab was associated with the longest drug-survival compared to adalimumab-monotherapy or etanercept-based regimens. Axial-ERA was associated with a poorer drug-survival. A CRP >12.15 in patients with axial-ERA was associated with a higher rate of primary-failure. Further prospective studies are required to confirm these findings

Developing and evaluating JIApp: Acceptability and usability of a smartphone app system to improve self-management in young people with juvenile idiopathic arthritis

Background: Flare-ups in juvenile idiopathic arthritis (JIA) are characterized by joint pain and swelling and often accompanied with fatigue, negative emotions, and reduced participation in activities. To minimize the impact of JIA on the physical and psychosocial development and well-being of young people (YP), it is essential to regularly monitor disease activity and side effects, as well as to support self-management such as adherence to treatment plans and engagement in general health-promoting behaviors. Smartphone technology has the potential to engage YP with their health care through convenient self-monitoring and easy access to information. In addition, having a more accurate summary of self-reported fluctuations in symptoms, behaviors, and psychosocial problems can help both YP and health care professionals (HCPs) better understand the patient’s condition, identify barriers to self-management, and assess treatment effectiveness and additional health care needs. No comprehensive smartphone app has yet been developed in collaboration with YP with JIA, their parents, and HCPs involved in their care. Objectives: The objective of this study was to design, develop, and evaluate the acceptability and usability of JIApp, a self-management smartphone app system for YP with JIA and HCPs. Methods: We used a qualitative, user-centered design approach involving YP, parents, and HCPs from the rheumatology team. The study was conducted in three phases: (1) phase I focused on developing consensus on the features, content, and design of the app; (2) phase II was used for further refining and evaluating the app prototype; and (3) phase III focused on usability testing of the app. The interview transcripts were analyzed using qualitative content analysis. Results: A total of 29 YP (aged 10-23, median age 17) with JIA, 7 parents, and 21 HCPs were interviewed. Major themes identified as the ones that helped inform app development in phase I were: (1) remote monitoring of symptoms, well-being, and activities; (2) treatment adherence; and (3) education and support. During phase II, three more themes emerged that informed further refinement of the app prototype. These included (4) adapting a reward system to motivate end users for using the app; (5) design of the app interface; and (6) clinical practice integration. The usability testing during phase III demonstrated high rates of overall satisfaction and further affirmed the content validity of the app. Conclusions: We present the development and evaluation of a smartphone app to encourage self-management and engagement with health care for YP with JIA. The app was found to have high levels of acceptability and usability among YP and HCPs and has the potential to improve health care and outcomes for this age group. Future feasibility testing in a prospective study will firmly establish the reliability, efficacy, and cost-effectiveness of such an app intervention for patients with arthritis

Development of a benchmarking toolkit for adolescent and young adult rheumatology services (BeTAR)

Background: Young people (YP; 12–24 years old) with rheumatic diseases face many challenges associated with chronic illness in addition to the physiological and psychosocial changes of adolescence. Timely access to developmentally appropriate multidisciplinary care is key to successfully managing rheumatic diseases, but gaps in the care of this vulnerable age group still exist. This study aimed to develop a benchmarking toolkit to enable comparative evaluation of YP rheumatology services in order to promote best practice and reduce variations in service delivery. Methods: A staged and consultative method was used across a broad group of stakeholders in the UK (YP, parents/other carers, and healthcare professionals, HCPs) to develop this toolkit, with reference to pre-existing standards of YP-friendly healthcare. Eighty-seven YP (median age 19 years, range 12–24 years) and 26 rheumatology HCPs with 1–34 years of experience caring for YP have participated. Results: Thirty quality criteria were identified, which were grouped into four main domains: assessment and treatment, information and involvement, accessibility and environment, and continuity of care. Two toolkit versions, one to be completed by HCPs and one to be completed by patients, were developed. These were further refined by relevant groups and face validity was confirmed. Conclusions: A toolkit has been developed to systematically evaluate and benchmark YP rheumatology services, which is key in setting standards of care, identifying targets for improvement and facilitating research. Engagement from YP, clinical teams, and commissioners with this tool should facilitate investigation of variability in levels of care and drive quality improvement

BHPR research: qualitative1. Complex reasoning determines patients' perception of outcome following foot surgery in rheumatoid arhtritis

Background: Foot surgery is common in patients with RA but research into surgical outcomes is limited and conceptually flawed as current outcome measures lack face validity: to date no one has asked patients what is important to them. This study aimed to determine which factors are important to patients when evaluating the success of foot surgery in RA Methods: Semi structured interviews of RA patients who had undergone foot surgery were conducted and transcribed verbatim. Thematic analysis of interviews was conducted to explore issues that were important to patients. Results: 11 RA patients (9 ♂, mean age 59, dis dur = 22yrs, mean of 3 yrs post op) with mixed experiences of foot surgery were interviewed. Patients interpreted outcome in respect to a multitude of factors, frequently positive change in one aspect contrasted with negative opinions about another. Overall, four major themes emerged. Function: Functional ability & participation in valued activities were very important to patients. Walking ability was a key concern but patients interpreted levels of activity in light of other aspects of their disease, reflecting on change in functional ability more than overall level. Positive feelings of improved mobility were often moderated by negative self perception ("I mean, I still walk like a waddling duck”). Appearance: Appearance was important to almost all patients but perhaps the most complex theme of all. Physical appearance, foot shape, and footwear were closely interlinked, yet patients saw these as distinct separate concepts. Patients need to legitimize these feelings was clear and they frequently entered into a defensive repertoire ("it's not cosmetic surgery; it's something that's more important than that, you know?”). Clinician opinion: Surgeons' post operative evaluation of the procedure was very influential. The impact of this appraisal continued to affect patients' lasting impression irrespective of how the outcome compared to their initial goals ("when he'd done it ... he said that hasn't worked as good as he'd wanted to ... but the pain has gone”). Pain: Whilst pain was important to almost all patients, it appeared to be less important than the other themes. Pain was predominately raised when it influenced other themes, such as function; many still felt the need to legitimize their foot pain in order for health professionals to take it seriously ("in the end I went to my GP because it had happened a few times and I went to an orthopaedic surgeon who was quite dismissive of it, it was like what are you complaining about”). Conclusions: Patients interpret the outcome of foot surgery using a multitude of interrelated factors, particularly functional ability, appearance and surgeons' appraisal of the procedure. While pain was often noted, this appeared less important than other factors in the overall outcome of the surgery. Future research into foot surgery should incorporate the complexity of how patients determine their outcome Disclosure statement: All authors have declared no conflicts of interes

Role of Graphic Integer Sequence in the Determination of Graph Integrity

Networks have an important role in our daily lives. The effectiveness of the network decreases with the breaking down of some vertices or links. Therefore, a less vulnerable communication network is required for greater stability. Vulnerability is the measure of resistance of the network after failure of communication links. In this article, a graph has been taken for modeling a network and integrity as a measure of vulnerability. The approach is to estimate the integrity or upper bound of integrity of at least one connected graph or network constructed from the given graphic integer sequence. Experiments have been done with random graphs, complex networks and also a comparison between two parameters, namely the vertex connectivity and graph integrity as a measure of the network vulnerability have been carried out by removing vertices randomly from various complex networks. A comparison with the existing method shows that the algorithm proposed in this article provides a much better integrity measurement

COVED: A Hardware Accelerated Soft Computing Enabled Intelligent Value Chain Based Diagnostic Automation for nCOVID-19 Estimation and Identification

Purpose: COVID-19, a global pandemic, first appeared in the city of Wuhan, China, and has since spread differently across geographical borders, classes, and genders from various age groups, sometimes mutating its DNA strands in the process. The sheer magnitude of the pandemic's spread is putting a strain on hospitals and medical facilities. The need of the hour is to deploy IoT devices and robots to monitor patients' body vitals as well as their other pathological data to further control the spread. There has not been a more compelling need to use digital advances to remotely provide quality healthcare via computing devices and AI-powered medical aids. Method: This research developed a deployable Internet of Things (IoT) based infrastructure for the early and simple detection and isolation of suspected coronavirus patients, which was accomplished via the use of ensemble deep transfer learning. The proposed Internet of Things framework combines 4 different deep learning models: DenseNet201, VGG16, InceptionResNetV2, and ResNet152V2. Utilizing the deep ensemble model, the medical modalities are used to obtain chest high-resolution computed tomography (HRCT) images and diagnose the infection. Results: Over the HRCT image dataset, the developed deep ensemble model is collated to different state-of-the-art transfer learning (TL) models. The comparative investigation demonstrated that the suggested approach can aid radiologists inefficiently and swiftly diagnosing probable coronavirus patients. Conclusion: For the first time, our group has developed an AI-enabled Decision Support System to automate the entire process flow from estimation to detection of COVID-19 subjects as part of an Intelligent Value Chain algorithm. The screening is expected to eliminate the false negatives and asymptomatic ones out of the equation and hence the affected individuals could be identified in a total process time of 15 minutes to 1 hour. A Complete Deployable System with AI Influenced Prediction is described here for the first time. Not only did the authors suggest a Multiple Hypothesis based Decision Fusion Algorithm for forecasting the outcome, but they also did the predictive analytics. For simple confined isolation or hospitalization, this complete Predictive System was encased within an IoT ecosystem

Unconstrained vision guided UAV based safe helicopter landing

In this paper, we have addressed the problem of automated detection of safe zone(s) for helicopter landing in hazardous environments from videos captured by an Unmanned Aerial Vehicle (UAV). The unconstrained motion of the video capturing drone (the UAV in our case) makes the problem further difficult. The solution pipeline consists of natural landmark detection and tracking, stereo-pair generation using constrained graph clustering, digital terrain map construction and safe landing zone detection. The main methodological contribution lies in mathematically formulating epipolar constraint and then using it in a Minimum Spanning Tree (MST) based graph clustering approach. We have also made publicly available AHL (Autonomous Helicopter Landing) dataset, a new aerial video dataset captured by a drone, with annotated ground-truths. Experimental comparisons with other competing clustering methods i) in terms of Dunn Index and Davies Bouldin Index as well as ii) for frame-level safe zone detection in terms of F-measure and confusion matrix clearly demonstrate the effectiveness of the proposed formulation.</p