Risk of post-extraction bleeding with direct oral anticoagulant compared with warfarin: Retrospective cohort study using large scale claims data in Japan

INTRODUCTION

Comparative safety of direct oral anticoagulants vs. warfarin in patients undergoing tooth extraction remains unclear. We compared the incidence of post-extraction bleeding between patients taking warfarin and those taking direct oral anticoagulants (DOACs) using administrative claims data.

MATERIALS AND METHODS

We identified outpatients on anticoagulant therapy who underwent permanent tooth extraction between 2015 and 2020 and categorized them into the warfarin and DOAC groups based on medication prescribed within six months prior to tooth extraction. We used the overlap propensity score weighting method to balance the baseline characteristics between the groups and compared the incidence of post-extraction bleeding within seven days after tooth extraction.

RESULTS

Among 5253 eligible patients, those in the DOAC group (n = 3696) were older and less frequently prescribed antiplatelets than those in the warfarin group (n = 1557). The distribution of tooth extraction type and number of teeth extracted in a single procedure did not differ between the groups. The unadjusted incidences of post-extraction bleeding in the warfarin and DOAC groups were 35 (2.2 %) and 71 (1.9 %), respectively. Moreover, the overlap weighting analysis showed that the adjusted odds ratio of post-extraction bleeding in the DOAC group in comparison with that in the warfarin group was 0.84 (95 % confidence interval, 0.54-1.31).

CONCLUSION

The incidence of post-extraction bleeding in patients taking DOACs was comparable to that in patients taking warfarin. The findings suggest that dentists and physicians should exercise the same degree of caution when extracting teeth in patients on DOACs and those on warfarin in terms of post-extraction bleeding.

Age-related reference intervals for ambulatory electrocardiographic parameters in healthy individuals

Background

The advent of novel monitoring technologies has dramatically increased the use of ambulatory electrocardiography (AECG) devices. However, few studies have conducted detailed large-scale investigations on the incidence of arrhythmias over 24 h, especially ectopy, in healthy individuals over a wide age range.

Objectives

This study aimed to investigate the incidence of arrhythmias detected using AECG and associated factors, in healthy individuals, over a wide age range.

Methods

In this cross-sectional study, we performed AECG on 365 healthy volunteers (median [interquartile range]: 48 [36, 67], 20-89 years, 165 men) under free-running conditions for 24 h. Ultrasonic echocardiography and heart rate variability analysis were performed to explore the factors associated with the incidence of arrhythmias.

Results

The 97.5th percentile of single ventricular ectopy (VE) was 149/day, 254/day, and 1,682/day in the 20-39-, 40-59- and 60-89-year age groups, respectively; that of single supraventricular ectopy (SVE) was 131/day, 232/day, and 1,063/day, respectively. Multivariate analysis revealed that aging was the only independent significant factor influencing the frequency of VE (β = 0.207, P = 0.001). Age (β = 0.642, P < 0.001), body mass index (BMI) (β = -0.112, P = 0.009), and the root mean square of successive differences in RR intervals (β = 0.097, P = 0.035) were factors significantly associated with SVE frequency.

Conclusions

Age-specific reference intervals of VE and SVE in a large population of healthy participants over a wide age range were generated. VE and SVE increased with age; SVE was influenced by BMI and the aging-induced decrease in parasympathetic tone activity.

Iodine-containing ointment-induced hypothyroidism in a patient with anorexia nervosa and sacral decubitus ulcer: a case report with literature review

We present a case of a 58-year-old woman with anorexia nervosa and a sacral decubitus ulcer who developed hypothyroidism because of an iodine-containing ointment. Considering the absence of autoimmune thyroid diseases, the development of hypothyroidism after the use of an iodine-containing ointment, and the recovery of thyroid function after the discontinuation of the ointment, we presumed that her hypothyroidism was induced by the iodine-containing ointment. Although the hypothyroidism improved after discontinuing the iodine-containing ointment, she developed aspiration pneumonia and required long-term hospitalization. Many patients with autoimmune thyroid diseases develop hypothyroidism after excessive iodine intake. However, anorexia nervosa may have exacerbated the iodine-induced hypothyroidism in our patient. To the best of our knowledge, no previous study has reported a case of hypothyroidism caused by iodine-containing ointment in a patient with anorexia nervosa. Hence, physicians must pay careful attention to a patient's background factors to ensure the early diagnosis of hypothyroidism due to iodine-containing ointments.

Clinical characteristics and outcomes of pheochromocytoma crisis: a literature review of 200 cases

PURPOSE

Pheochromocytoma crisis is a life-threatening endocrine emergency that requires prompt diagnosis and treatment. Because of its rarity, sudden onset, and lack of internationally uniform and validated diagnostic criteria, pheochromocytoma crisis remains to be fully clarified. Therefore, we aimed to describe the clinical characteristics and outcomes of pheochromocytoma crisis through a literature review.

METHODS

We performed a systematic literature search of PubMed/MEDLINE database, Igaku-Chuo-Zasshi (Japanese database), and Google Scholar to identify case reports of pheochromocytoma crisis published until February 5, 2021. Information was extracted and analyzed from the literature that reported adequate individual patient data of pheochromocytoma crisis in English or Japanese. Cases were also termed as pheochromocytoma multisystem crisis (PMC) if patients had signs of hyperthermia, multiple organ failure, encephalopathy, and labile blood pressure.

RESULTS

In the 200 cases of pheochromocytoma crisis identified from 187 articles, the mean patient age was 43.8 ± 15.5 years. The most common symptom was headache (39.5%). The heart was the most commonly damaged organ resulting from a complication of a pheochromocytoma crisis (99.0%), followed by the lungs (44.0%) and the kidney (21.5%). PMC accounted for 19.0% of all pheochromocytoma crisis cases. After excluding 12 cases with unknown survival statuses, the mortality rate was 13.8% (26/188 cases). Multivariable logistic regression analysis revealed that nausea and vomiting were significantly associated with a higher mortality rate.

CONCLUSION

Pheochromocytoma can present with different symptomatology, affecting different organ systems. Clinicians should be aware that patients with nausea or vomiting are at a higher risk of death because of pheochromocytoma crisis.

Oral Gonadotropin-Releasing Hormone Antagonist Relugolix Has the Same Effect as Gonadotropin-Releasing Hormone Agonist Injections in Terms of Preparation for Transcervical Resection Myomectomy

For preparing the optimal condition in transcervical resection (TCR) surgery, gonadotropin-releasing hormone (GnRH) agonist has been utilized. Recently, an oral GnRH antagonist (relugolix) is available and acts directly on GnRH receptor, avoiding flare up and reducing blood E2 levels rapidly. We retrospectively compared the oral GnRH antagonist (n = 14) effect to that of subcutaneous GnRH agonist (n = 19) for the pretreatment of endometrium in TCR myomectomy. Endometrial thickening was determined by intraoperative videos. The color tone of the endometrium in the normal part was assessed by digital image processing. The median duration of the first GnRH agonist injection and the surgery was 67 days (21-136 days), which is significantly longer than that of the oral GnRH antagonist group, 18.5 days (7-157 days P < 0.01). Both the GnRH agonist and antagonist groups did not exhibit prominence in the endometrium. The GnRH antagonist group showed the same degree of whiteness in the normal endometrium as the GnRH agonist group. The oral GnRH antagonist administration could rapidly atrophy the endometrium and create an optimal surgical field for TCR in a short period.

Infrared Plasmonic Metamaterials Based on Transparent Nanoparticle Films of In2O3:Sn for Solar-Thermal Shielding Applications

Three-dimensional nanoparticle (NP) assemblies show interesting optical responses that differ from naturally occurring materials, such as metals, oxides, and semiconductors. In this study, we investigate the optical response of thin films comprising Sn:In₂O₃ NPs (ITO NP films) based on the correlation between complex permittivity and infrared (IR) reflectance for solar-thermal shielding applications. IR ellipsometry measurements are conducted to clarify the presence of Lorentz resonances in plasmonic metamaterials. The Lorentz resonances are correlated to the electric field strength at interparticle gaps by varying the Sn dopant concentration, as confirmed using finite-difference time-domain (FDTD) simulations. High solar-thermal shielding performance was obtained owing to selective near-IR reflection based on strong Lorentz resonances as the ITO NP films were electrically polarizable but magnetically inactive. Thermal shielding efficiency was demonstrated via a comparison of the air temperature change in a simulated box used as a model house. Additionally, we demonstrate the significance of NP packing density on the enhancement of the near-IR reflectance. The role of interparticle spacing for high near-IR reflectance was revealed by comparing effective medium approximation analyses and FDTD simulations. This relationship was also demonstrated by the reduction of solar-thermal shielding performance when using aggregated ITO NPs. Our work confirmed that the control of complex permittivity in plasmonic metamaterials must be considered in the structural design of transparent and reflective materials for solar-thermal shielding applications.

Influence of Uterine Cavity Breach in Laparoscopic Myomectomy on the Risk of Obstetric Complications

Objectives

Prepregnancy myomectomy is effective for the treatment of infertility or prevention of obstetric complications and is usually performed with laparoscopy. However, pregnancies following myomectomy have risks of obstetric complications, especially in cases with uterine cavity breaches, but the evidence remains unclear. We investigated how uterine cavity breach in laparoscopic myomectomy influenced the occurrence of obstetric complications.

Patients and Methods

One hundred and eighty women who underwent a cesarean section from 2014 to 2020 in pregnancies following laparoscopic myomectomy were included. They were divided into two groups: 25 women in the uterine cavity breach group and 155 in the nonbreach group. Obstetric complications, including placenta accreta spectrum (PAS), uterine rupture, placental malposition, abruption placenta, preterm delivery, threatened premature labor, premature rupture of membranes, and massive intrapartum hemorrhage, were assessed.

Results

Multivariate analysis revealed that the frequency of PAS in the breach group (24.0%) was statistically significantly higher than in the nonbreach group (5.2%, P < 0.05).

Conclusion

This study demonstrated that women who experienced uterine cavity breach in laparoscopic myomectomy had an increased risk of PAS in subsequent pregnancies.

Vascular endothelial factor C and D in patients with heart failure with preserved, mildly reduced, and reduced ejection fraction: the PREHOSP-CHF study

Background

The lymphatic system has been suggested to play an important role in cardiovascular diseases including heart failure (HF). Vascular endothelial growth factor C (VEGF-C) and D (VEGF-D) are key regulators of lymphangiogenesis, and we recently reported the association of low VEGF-C with the risk of all-cause death and high VEGF-D with the risk of HF hospitalization in patients with HF.

Purpose

To investigate the association of VEGF-C and VEGF-D with prognosis in patients with HF with preserved ejection fraction (EF) (HFpEF: EF≥50%), mildly reduced EF (HFmrEF: EF, 40–49%), and reduced EF (HFrEF: EF&lt;40%).

Methods

The PREHOSP-CHF study is a multicenter prospective cohort study to determine the predictive value of angiogenesis-related biomarkers in HF. A total of 1,024 patients (mean age 75.5±12.6 years; 58.7% male) admitted to acute decompensated HF were included in the analyses. Serum levels of VEGF-C and VEGF-D, as well as N-terminal pro B-type natriuretic peptide (NT-proBNP), high sensitivity cardiac troponin-I (hs-cTnI), high sensitivity C reactive protein, were measured at the time of discharge. Patients were followed-up over two years.

Results

The numbers of HFpEF, HFmrEF, and HFrEF were 429 (41.9%), 186 (18.2%), and 409 (39.9%), respectively. HFpEF patients were older, more likely to be female, and had more hypertension, atrial fibrillation, and anemia, but less coronary artery disease. NT-proBNP and hs-cTnI levels increased with decreasing EF. VEGF-C levels decreased with increasing EF (median [interquartile range]: HFpEF, 4508 [3318–5919] pg/ml; HFmrEF, 4719 [3663–6203] pg/ml; HFrEF, 5023 [3804–6382] pg/ml), whereas VEGF-D levels were comparable among the three EF groups (HFpEF, 404.6 [293.1–560.3] pg/ml; HFmrEF, 386.0 [298.5–556.3] pg/ml; HFrEF, 414.2 [296.1–557.3] pg/ml). In multivariate stepwise logistic regression analyses, anemia and high NT-proBNP were independently associated with low VEGF-C levels, and high NT-proBNP was independently associated with high VEGF-D levels, across all the EF groups. During the follow-up, incidences of all-cause death and HF hospitalizations were similar among the three EF groups (log-rank P=0.6 for all-cause death, and log-rank P=0.3 for HF hospitalization). On multivariate Cox proportional hazard analyses including established risk factors and cardiovascular biomarkers, VEGF-C levels tended to be inversely associated with the incidence of all-cause death in patients with HFpEF and HFrEF (Figure). On the contrary, VEGF-D levels were significantly and positively associated with the incidence of HF hospitalization in patients with HFpEF, and tended to be positively associated with it in patients with HFmrEF and HFrEF (Figure).

Conclusions

Low VEGF-C was associated with the risk of all-cause death in patients with HFpEF and HFrEF, while high VEGF-D was associated with the risk of HF hospitalization especially in HFpEF.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): Grant-in-Aid for Clinical Research from the National Hospital Organization

Comparative Effectiveness of BNT162b2 and mRNA-1273 Booster Dose After BNT162b2 Primary Vaccination Against the Omicron Variants: A Retrospective Cohort Study Using Large-Scale Population-Based Registries in Japan

BACKGROUND

Direct comparative effectiveness of booster doses of BNT162b2 and mRNA-1273 after BNT162b2 primary vaccination is unknown.

METHODS

We investigated comparative effectiveness of BNT162b2 and mRNA-1273 booster dose using data from registry systems for vaccination and coronavirus disease 2019 (COVID-19) infection in a local city in Japan. We followed participants aged ≥16 years who completed the BNT162b2 primary vaccination between 22 November 2021, and 15 April 2022. We collected information on age, sex, vaccination status, vaccine type, and infection status. Age was categorized as 16-44, 45-64, 65-84, and ≥85 years. Vaccine effectiveness for mRNA-1273 and no booster vaccination against BNT162b2 was estimated using age-stratified Cox regression adjusted for age, sex, and days since the second vaccination. The estimated hazard ratios for mRNA-1273 and no booster vaccinations were integrated separately using random effects meta-analyses.

RESULTS

During the study period, we identified 62 586 (40.4%), 51 490 (33.2%), and 40 849 (26.4%) participants who received BNT162b2, mRNA-1273, and no booster dose, respectively. The median age was 69, 71, and 47 years for BNT162b2, mRNA-1273, and no booster dose, respectively. The integrated hazard ratio with reference to BNT162b2 was 1.72 for no booster vaccination and 0.62 for mRNA-1273. The comparative effectiveness of mRNA-1273 was similar across age categories.

CONCLUSIONS

Both homologous and heterologous vaccinations are effective against Omicron variants. In the head-to-head comparison, the effect was stronger in people who received heterologous vaccination than in those who received homologous vaccination. These findings may help improve logistics and decision making in future vaccination programs.

Subacute Thyroiditis after COVID-19: A Literature Review

Subacute thyroiditis (SAT), potentially caused by severe acute respiratory syndrome coronavirus 2 infection, has been reported as a complication of COVID-19 since 2020. The clinical characteristics and outcomes of SAT after COVID-19 remain incompletely defined. Therefore, we aimed to collect and survey case reports of SAT after COVID-19. We performed a systematic search of PubMed/MEDLINE, Web of Science, and Google Scholar. The keywords and MeSH terms used for the searches were "subacute thyroiditis" and "COVID-19." A total of 38 patients from 26 case reports, case series, and letters on SAT associated with COVID-19 were included and analyzed. The most frequent SAT symptom was neck pain (27 cases), followed by fever (22 cases). Of the 25 cases with information on the duration between onset of COVID-19 symptoms and onset of SAT symptoms, the shortest was simultaneous occurrence, and the longest was 4 months. In most cases, patients developed SAT at several days or weeks after the onset of COVID-19. All patients with SAT recovered with no severe complications or sequelae. Clinicians should be aware of the possibility of SAT development in patients with neck pain and fever following COVID-19. Further research is necessary to determine the relationship between SAT and COVID-19.

Rapid progression of marginal zone B-cell lymphoma after COVID-19 vaccination (BNT162b2): A case report

B-cell lymphomas are neoplastic diseases occasionally associated with chronic inflammation. mRNA vaccines for coronavirus disease 2019 (COVID-19) induce inflammatory responses, which often lead to fever and lymphadenopathies indistinguishable from lymphomas. Although both lymphadenopathies and lymphomas can be influential, the correlation between them is unclear. Herein, we present the first case of marginal zone B-cell lymphoma following mRNA COVID-19 vaccination. An 80-year-old Japanese woman presented with a right temporal mass that appeared the morning after she was administered her first mRNA COVID-19 vaccination (BNT162b2). The mass gradually decreased in size but persisted over 6 weeks after her first vaccination (3 weeks after her second vaccination). At her first visit to our hospital, ultrasound revealed the size of the mass to be 28.5 × 5.7 mm, and computed tomography revealed multiple lymphadenopathies in the right parotid, submandibular, jugular, and supraclavicular regions. Initially, we suspected head-and-neck benign lymphadenopathy as a side effect of vaccination. Nine weeks later, the number of swollen submandibular and parotid glands increased, and the lymph nodes further enlarged. Finally, the right temporal mass was diagnosed as marginal zone B-cell lymphoma based on immunohistochemical and flow cytometry findings of biopsy specimens. Our findings suggest that although 4–6 weeks of observation for lymph node inflammation after the second vaccination is recommended, malignancy should also be considered in the differential diagnosis of lymphadenopathy following vaccination.

Fulminant elderly adult-onset Still disease effectively treated with tocilizumab and methotrexate: A case report

RATIONALE

Adult-onset Still disease (AOSD) is a rare inflammatory disease of unknown etiology. AOSD is common in young or middle-aged adults; however, in recent years, there have been increasing reports of elderly AOSD. Differentiating AOSD from diseases such as infections and malignancies is difficult. Moreover, rare fulminant AOSD cases with resistance to corticosteroids and immunosuppressive drugs have been reported.

PATIENT CONCERNS

An 80-year-old woman presented with flaccid fever, generalized arthralgia, and erythema of the anterior chest for 2 weeks. On day 5 of hospitalization, the patient developed pleural effusion with hypoxemia and her vital signs indicated rapid progression to shock. During the clinical course, the levels of inflammatory markers, including maximum level of ferritin and white blood cells (WBCs) were elevated (252,796 ng/mL and 86,500/μV, respectively) with disseminated intravascular coagulation syndrome (DIC) and macrophage activation syndrome (MAS).

DIAGNOSIS

The patient was diagnosed with elderly AOSD as per the Yamaguchi criteria for AOSD. The state of disease was extremely severe with rapid progression and was, thus, categorized as a fulminant form of elderly AOSD.

INTERVENTIONS

The patient was treated with prednisolone (PSL) pulse therapy (1000 mg/d) twice and plasma exchange in the intensive care unit for the primary disease and shock. Although she recovered from shock, she developed DIC and MAS. Methotrexate (MTX; 10 mg/d) improved the DIC and MAS. However, severe pleuritis recurred and the patient developed pericarditis; her primary disease was poorly controlled. Finally, tocilizumab (TCZ) was introduced using interleukin-18 (IL-18) as a surrogate marker. The IL-18 level was measured repeatedly following admission, with the peak level (170,000 pg/mL) recorded on the 75th day of hospitalization, immediately prior to introducing TCZ.

OUTCOMES

The combined use of MTX, TCZ, and PSL was effective in suppressing elderly AOSD, which was unsuccessfully controlled with MTX and PSL. Frequent monitoring of IL-18 levels proved useful for differentiating elderly AOSD from other diseases.

LESSONS

A fulminant form of elderly AOSD was treated with a combination of MTX, TCZ, and PSL. Repeated monitoring of IL-18 levels can be useful for decision-making in treating elderly AOSD.

Bilateral inguinal bladder hernias

Inguinal hernia may contain the bladder as one of its contents, while bilateral inguinal bladder herniation is rare. Urinary obstruction and obesity are associated with increased abdominal pressure and are risk factors of bladder herniation. Clinicians should be aware of the bladder hernia in elderly with chronic dysuria and obesity.

Clinicians should be aware of the bladder hernia in elderly with chronic dysuria and obesity.

AB0343 LONG-TERM TOCILIZUMAB TREATMENT IN PATIENTS WITH RHEUMATOID ARTHRITIS IN DAILY CLINICAL PRACTICE

Background

Tocilizumab (TCZ) is a humanized anti-IL-6 receptor monoclonal antibody that improves the signs and symptoms of rheumatoid arthritis (RA). In previous clinical trials, long-term outcomes have been increasingly evaluated in daily clinical practice. We report the five-year outcomes of TCZ treatment at our institute.

Objectives

This retrospective study determined the long-term trends in TCZ use in clinical practice.

Methods

Data from the Toyohashi RA database (TRAD) were used. The TRAD is single-center retrospective data. Last observation carried forward was used as a complementary method for missing data. Participants were 59 RA patients in whom TCZ therapy was started at our institute from September 2009 to May 2016. Subsequent items, baseline patient characteristics, disease activity, treatment continuation rates of TCZ using the Kaplan-Meier method, reasons for stopping TCZ, concomitant use of methotrexate (MTX) and prednisolone (PSL) were investigated.

Results

Baseline characteristics at the start of TCZ treatment were 17 men and 42 women with a mean age of 58.6 years (30–81). The mean RA duration was 8.7 years (0–31). The mean SDAI score was 27.9 ± 11.6; the mean DAS28-CRP was 5.0 ± 1.0. CRP was 4.1 ± 3.0 mg/dl and MMP-3 388.3 ± 311.5 ng/ml. Methotrexate (MTX) was administered in 37 patients (62.7%, mean 6.0 mg, mean MTX dose administered in cases, 9.6 mg/week). Prednisolone (PSL) was administered in 37 patients (62.7%, mean 3.6 mg; the mean PSL dose administered in cases 5.7 mg/day).

Regarding disease activity, the mean SDAI was 27.9 at baseline; 12.3 at three months; 8.1 at one year; 7.3 at two years; 6.5 at three years; 46.7 at four years; 5.6 at five years, and 5.2 at final observation. The SDAI significantly improved after two years compared to baseline. Remission and low disease activity also significantly improved at one year and gradually improved after one year (Figure 1). The remission rate at the final observation was 55.2%, with an SDAI ≦3.3.

TCZ continuation rates were 86.9% at one year, 78.7％ at three years, and 68.9% at five years (Figure 2). TCZ was discontinued due to adverse events in 11 cases (18%), and inadequate efficacy occurred in 9 (14.8%). The adverse events were respiratory infection (5), purulent arthritis (1), infectious endocarditis (1), subarachnoid hemorrhage (1), breast cancer (1), pruritis (1), and skin ulcer (1). Other reasons for discontinuation were dialysis (2), suspension of hospital visits (2), kidney transplant (1), and financial difficulties (1). Concomitant use from baseline to final observation declined from 62.7% to 15.3% for MTX and from 62.7% to 23.7% for PSL.

Conclusion

Long-term treatment with TCZ was acceptable. We found that with TCZ therapy, the remission and low disease activity rates significantly improved at one year and continued to improve after one year. Treatment persistence was high, but careful monitoring for infection is necessary.

Disclosure of Interests

None declared

AB0368 EFFECTS OF SWITCHING FROM ETANERCEPT ORIGINATOR TO ETANERCEPT BIOSIMILAR ON DISEASE ACTIVITY, PHYSICAL FUNCTION, AND PATIENT-REPORTED OUTCOME REGARDING A SELF-INJECTION DEVICE IN PATIENTS WITH WELL-CONTROLLED RHEUMATOID ARTHRITIS

Background

Although biological drugs have dramatically changed and improved the outcome of patients with rheumatoid arthritis (RA), a lot of unresolved problems still exist. Although comorbidity by which enough treatment drugs cannot be prescribed or RA patients refractory to biological agents are representatives, financial difficulty is another representative. There are RA patients who hesitate biological treatment or treatment with Janus-kinase inhibitor due to financial difficulty. Although biosimilar disease-modifying anti-rheumatic drugs (DMARDs) are promising treatment options for such patients, real-world clinical experiences are still lacking in respect to exchanging from biological originator DMARDs to biosimilar DMARDs.

Objectives

This retrospective study investigated the effects of switching from etanercept originator (ETN-OR) to ETN biosimilar (ETN-BS: LBEC0101 developed by LG Chem) on disease activity, physical function, and patient reported outcome (PRO) regarding a self-injection device in patients with well-controlled RA.

Methods

Data from the Toyohashi RA Database (TRAD) was used, which is a collection of single-center retrospective data. We retrospectively investigated disease activity, modified health assessment questionnaire (mHAQ), and patient characteristics in 42 RA patients that switched from ETN-OR to ETN-BS at least 6 months prior. Patients were also requested to answer the Toyohashi Self-Injection Assessment Questionnaire (T-SAQ), originally designed to assess PRO. T-SAQ consisted of 18 questions about self-injection device such as burden, learning, pain, convenience, handling and so on. Best was 0 and worst was 4 in each question and mean score of 18 questions was called total T-SAQ score.　

Results

All the patients were female. The mean age, RA duration, and ETN-OR treatment duration were 63.1 years, 18.3 years, and 3107 days, respectively. Mean disease activity and mean mHAQ after switching were as follows (baseline-3 months-6): DAS28-CRP (1.86-2.00-2.03), SDAI (4.3-5.0-5.3), and mHAQ (0.43-0.44-0.46). SDAI after 6 months was significantly elevated compare to baseline. Among each parameter, tender joints count at 3 months and patients’ global assessment at 6 months after switching are significantly increased compared to baseline (Table 1). Other parameters such as swollen joint counts, physician global assessment and CRP were not significantly changed. Total T-SAQ scores before and after switching were 1.3 and 1.1 (p < 0.01), respectively. Ease of use, mental tension, and pain were especially improved after switching to ETN-BS.

Conclusion

Switching from ETN-OR to ETN-BS worsened disease activity in well-controlled RA patients in our real-world clinical practice due to not objective findings, but subjective complaints by RA patient. We thought that nocebo effect was one of the reasons to explain the results. On the other hand, the PRO regarding the injection device was improved. This improvement may be due to Finer needle of ETN-BS (ETN-OR: 27G, ETN-OR: 29G).

Disclosure of Interests

None declared

AB1016 ROMOSOZUMAB AS A TREATMENT FOR OSTEOPOROSIS: PREDICTORS OF EFFICACY AT 12 MONTHS

Background

Romosozumab (ROMO) is an antisclerostin antibody that is used in the treatment of severe osteoporosis (OP). In March 2019, ROMO was approved for use in Japan for treating severe OP in clinical practice, causing an increase in its prescription in our institute. Although efficacy data for ROMO have been presented in clinical trials, there is a lack of real-world data. In our experience, ROMO treatment results in significant bone mineral density (BMD) gain in some patients, but not all. Therefore, understanding the predictors that enhance the efficacy of ROMO treatments to achieve BMD gain is essential.

Objectives

This study investigated the efficacy of a 12-month ROMO treatment in patients with OP and explored the efficacy predictors of increased BMD.

Methods

Our study included 52 patients with OP, who were started on ROMO treatment between June 2019 and August 2020. The following information was collected: 1) baseline characteristics, 2) time-course of BMD (lumbar spine [LS] and total hip [TH]) and bone turnover markers (BTM; bone-specific alkaline phosphatase [BAP], type I procollagen-N-propeptide [P1NP], type I procollagen-N-propeptide[NTX], and tartrate-resistant acid phosphatase-5b [TRACP-5b]), 3) multiple regression analysis results following Spearman’s correlation analysis of increased BMD values (%) at 12 months and BL characteristics, including BTM change (%) at one month, to investigate the efficacy predictors of ROMO.

Results

1) The mean age of the participants was 72.9 years (48 female and four male). Of the 52 understudied patients, 78.8% had past insufficiency fractures, whereas 21.2% had been treated with concomitant prednisolone. Furthermore, 21 patients had primary OP, 20 had rheumatoid arthritis, nine had glucocorticoid-induced OP, and two had other conditions. Pretreatments for OP were bisphosphonate (33 patients), vitamin D (6), none (5), selective estrogen receptor modulator (4), and denosumab (3).

2) Both mean LS- and TH-BMD significantly increased in the patients for whom ROMO administration was continued for 12 months. The average percentage changes of LS- and TH-BMD were 7.1% and 1.6% at six months and 11.7% and 3.0% at 12 months, respectively (Figure 1). However, BAP and P1NP increased steeply at one month, followed by a gradual decrease. As observed, the average percentage changes of BAP and P1NP were +70.1% and +166.8% at one month, +50.3% and +91.7% at six months, and +24.4% and +41.5% at 12 months, respectively. The results also showed that TRACP-5b decreased from one to 12 months, with the average percentage changes being −22.9% at one month, −13.8% at six months, and −17.7% at 12 months. Moreover, NTX, a bone-resorptive marker, was slightly increased during ROMO treatment.

3) Multiple regression analysis results revealed that the baseline BAP and percentage calcium changes at 12 months were significant factors positively correlated with the percentage change of LS-BMD at 12 months. As observed, the baseline T-score of LS-BMD was a significant factor negatively correlated with the percentage change of LS-BMD at 12 months. The standardized partial regression coefficient values were +0.68, +0.26, and −0.40, respectively. Moreover, the multiple regression analysis results revealed no significant factor that was correlated with the percentage changes of TH-BMD at 12 months.

Figure 1.

Conclusion

ROMO treatments rapidly increased BMD, especially LS-BMD, and changed BTM after one month. Baseline BAP were correlated with increased LS-BMD but not with TH-BMD. The factors correlated with increased BMD may differ between LS-BMD and TH-BMD.

Disclosure of Interests

None declared

POS1143 FIVE-YEAR TREATMENT OUTCOME OF DENOSUMAB ON OSTEOPOROSIS IN PATIENTS WITH RHEUMATOID ARTHRITIS, IN CLINICAL PRACTICE

Background

Osteoporosis (OP) is a frequent complication identified in patients with rheumatoid arthritis (RA). Effective treatment must be provided to treat OP in RA (RAOP). Denosumab (DMB) is a promising drug, currently being used for the treatment of RAOP. Although DMB was determined to be effective in a long-term FREEDOM extension trial [1] for treating postmenopausal OP, its efficacy in the treatment of RAOP in real-world is not be fully evaluated.

Objectives

This retrospective study assessed the five-year treatment outcome of DMB in Japanese patients with RAOP.

Methods

Data from the Toyohashi RA Database (TRAD) was used, which is a collection of single-center retrospective data. Our study included 65 female patients with RAOP for whom DMB treatment was initiated between October 2013 and May 2016. The following information was collected: 1) baseline characteristics, 2) DMB continuation rates using the Kaplan–Meier method and reasons for stopping DMB, 3) fracture occurrence during DMB treatment, and 4) time-course of bone mineral density (BMD) [lumbar spine (LS) and total hip (TH)] and bone turnover markers (BTM) [bone-specific alkaline phosphatase (BAP), type I procollagen-N-propeptide (P1NP), type I procollagen-N-propeptide (NTX), and tartrate-resistant acid phosphatase-5b (TRACP-5b)] in 38 patients who underwent DMB treatment over a period of five years.

Results

1) The mean age and RA duration were 69.4 years (46–86) and 17.2 years (1–49), respectively. Prednisolone and biologics were administered in 21 (32.3%) and 20 (30.8%) patients, respectively. Twenty-seven patients (41.5%) had a history of fragility fractures, and 24 patients (36.9%) had a history of vertebral fractures. Pretreatment drugs for OP were as follows: bisphosphonate in 22 patients; teriparatide, 17; none, 16; activated vitamin D, 7; and selective estrogen receptor modulator, 3.

2) Continuation rates of DMB were 96.9% at one year, 95.4% at two years, 85.8% at three years, 79.4% at four years, and 71.1% at five years. DMB treatment was terminated in 24 patients due to lack of efficacy in nine patients, death in seven patients (unknown reason in four, pneumonia in two, and senile decay in one), adverse events except death in five patients (worsening of dementia in two, brain hemorrhage in one, necrosis of jaw in one, and pneumonia in one), and other reasons in three patients.

3) Nine patients (13.8%) experienced fractures during DMB treatment; vertebral and non-vertebral fractures occurred in three and four patients, respectively. Two cases of fractures remained undefined.

4) Both mean LS-BMD and TH-BMD significantly increased in 38 patients for whom DMB administration was continued for five years. Average percent changes of LS-BMD and TH-BMD were 3.9% and 3.0% at six months, 5.5% and 3.8% at one year, 7.6% and 4.1% at two years, 9.8% and 5.7% at three years, 10.8% and 6.5% at four years, and 12.9% and 6.8% at five years (Figure 1). Four BTMs, BAP, P1NP, NTX, and TRACP-5b, significantly decreased from six months to five years when compared to baseline values, with average changes at 5 years equaling −38.4%, −37.8%, −23.8%, and −24.6%, respectively.

Conclusion

DMB treatment of RAOP proved effective and reasonably safe, and it increased BMD by a percentage similar to that observed in the FREEDOM extension trial. However, DMB administration was ceased in 13.8% of cases due to fractures and lack of efficacy. Although DMB is recommended for the treatment of RAOP, future evaluations should be conducted to predict its efficacy and determine alternative treatment strategies.

References

[1]Bone HG et al. Lancet Diabetes Endocrinol. 2017.

Disclosure of Interests

None declared

A Combined Human in Silico and CRISPR/Cas9-Mediated in Vivo Zebrafish Based Approach to Provide Phenotypic Data for Supporting Early Target Validation

The clinical heterogeneity of heart failure has challenged our understanding of the underlying genetic mechanisms of this disease. In this respect, large-scale patient DNA sequencing studies have become an invaluable strategy for identifying potential genetic contributing factors. The complex aetiology of heart failure, however, also means that in vivo models are vital to understand the links between genetic perturbations and functional impacts as part of the process for validating potential new drug targets. Traditional approaches (e.g., genetically-modified mice) are optimal for assessing small numbers of genes, but less practical when multiple genes are identified. The zebrafish, in contrast, offers great potential for higher throughput in vivo gene functional assessment to aid target prioritisation, by providing more confidence in target relevance and facilitating gene selection for definitive loss of function studies undertaken in mice. Here we used whole-exome sequencing and bioinformatics on human patient data to identify 3 genes (API5, HSPB7, and LMO2) suggestively associated with heart failure that were also predicted to play a broader role in disease aetiology. The role of these genes in cardiovascular system development and function was then further investigated using in vivo CRISPR/Cas9-mediated gene mutation analysis in zebrafish. We observed multiple impacts in F0 knockout zebrafish embryos (crispants) following effective somatic mutation, including changes in ventricle size, pericardial oedema, and chamber malformation. In the case of lmo2, there was also a significant impact on cardiovascular function as well as an expected reduction in erythropoiesis. The data generated from both the human in silico and zebrafish in vivo assessments undertaken supports further investigation of the potential roles of API5, HSPB7, and LMO2 in human cardiovascular disease. The data presented also supports the use of human in silico genetic variant analysis, in combination with zebrafish crispant phenotyping, as a powerful approach for assessing gene function as part of an integrated multi-level drug target validation strategy.

Influence of laparoscopic surgery for endometriosis and its recurrence on perinatal outcomes

Purpose

It is unknown whether surgery for endometriosis or recurrence of endometriosis affects obstetric outcomes.

Methods

A total of 208 pregnant women with a history of endometriosis were analyzed. Patients who had endometriomas >3 cm and no history of laparoscopic surgery for endometriosis were defined as non‐surgery group (n = 60), while those who had a history of surgery for endometriosis (n = 148) were defined as surgery group. We investigated the obstetric outcomes in 208 patients according to with or without postoperative recurrence of endometriosis and the time from surgery to pregnancy.

Results

Among 177 cases of on‐going pregnancy, in surgery group, there were lower prevalence of placenta previa compared with non‐surgery group (8.5% vs. 23.4%; p = 0.020). Subgroup analysis revealed a decreased prevalence of placenta previa in postoperative non‐recurrence group (6.0%: p = 0.007) compared with non‐surgery (23.4%) and postoperative recurrence group (28.6%). Placenta previa was more prevalent in the patients who got pregnant more than 2 years after surgery (20.0%) than the patients who got pregnant within 2 years (2.4%: p = 0.002). Multivariate analysis revealed that the surgery was associated with a reduction in placenta previa (OR: 0.32, 95% CI [0.11–0.90]; p = 0.032).

Conclusions

Pregnancy within two years after laparoscopic surgery for endometriosis may reduce placenta previa.