POS0891 REUMA.pt/MYOSITIS – THE PORTUGUESE REGISTRY OF INFLAMMATORY MYOPATHIES

Background

The idiopathic inflammatory myopathies (IMM) module of the Rheumatic Diseases Portuguese Register (Reuma.pt/Myositis) is a tool used to systematically evaluate IIM patients.

Objectives

To clinically characterise the Reuma.pt/Myositis cohort.

Methods

Multicentre open cohort study, including IIM patients registered in Reuma.pt up to January 2022. Data collected included demographic, clinical, and treatment data and patient-reported outcomes. Data were presented as frequencies and median (interquartile range) for categorical and continuous variables, respectively.

Results

280 patients were included, 71.4% female, 89.4% Caucasian, with a median age at diagnosis and disease duration of 48.9 (33.6-59.3) and 5.3 (3.0-9.8) years, respectively. Patients were classified as having definite (N=57/118, 48.3%; N=35/224, 15.6%), likely (N=23/118, 19.5%; N=50/224, 22.3%), or possible (N=2/118, 1.7%; N=46/224, 20.5%) IIM by 2017 EULAR/ACR and Bohan-Peter criteria, respectively. Disease subtypes included dermatomyositis (DM, N=122/280, 43.6%), polymyositis (N=59/280, 21.1%), myositis in overlap syndromes (N=41/280, 14.6%), clinically amyopathic DM (N=17/280, 6.1%), nonspecific myositis (N=13/280, 4.6%), mixed connective tissue disease (N=12/280, 4.3%), immune-mediated necrotizing myositis (N=9/280, 3.2%), and inclusion bodies myopathy (N=7/280, 2.5%). Over the course of the disease, the most common symptoms were proximal muscle weakness (N=180/215, 83.7%), arthralgia (N=127/249, 52.9%), erythema (N=63/166, 38.0%), fatigue (N=47/127, 37.0%), Raynaud’s phenomenon (N=76/234, 32.5%), and dysphagia (N=33/121, 27.3%), and the most common clinical signs were Gottron’s sign (N=75/184, 40.8%), heliotrope rash (N=101/252, 40.1%), Gottron’s papules (N=93/237, 39.2%), and arthritis (N=38/98, 38.8%). Organ involvement included lung (N=78/230, 33.9%), oesophageal (N=40/221, 18.1%), and heart (N=11/229, 4.8%) involvements. Most patients expressed myositis-specific (MSA, N=158/242, 65.3%) and/or myositis-associated (MAA, 112/242, 46.3%) antibodies. The most frequent antibodies were anti-SSA/SSB (N=70/231, 30.3%), anti-Jo1 (N=56/236, 23.7%), and anti-Mi2 (N=31/212, 14.6%). Most patients had a myopathic pattern on electromyogram (N=101/138, 73.2%), muscle oedema in magnetic resonance (N=33/62, 53.2%), and high CK (N=154/200, 55.0%) and aldolase levels (N=74/135, 54.8%) at diagnosis, with median highest CK levels of 1308 (518-3172) and aldolase of 42 (12-121) mg/dL. Neoplasia was found in 11/127 patients (8.7%), most commonly breast (N=3/11, 27.3%), non-melanoma skin (N=2/11, 18.2%), and colorectal (N=2/11, 18.2%) cancer (Table 1). Most patients with cancer-associated myositis had DM (N=8/11, 72.7%) and expressed MSA (N=6/11) and/or MAA (N=3/11). The most used drugs over the course of disease were glucocorticoids (N=201/280, 71.8%), methotrexate (N=117/280, 41.8%), hydroxychloroquine (N=87/280, 31.1%), azathioprine (N=85/280, 30.4%), mycophenolate mofetil (N=56/280, 20.0%), intravenous immunoglobulin (N=55/280, 19.6%), and rituximab (N=45/280, 16.1%). At the last follow-up, there was a median MMT8 of 150 (142-150), modified DAS skin of 0 (0-1), global VAS of 10 (0-50) mm, and HAQ of 0.125 (0.000-1.125).

Table 1.

Autoantibodies in cancer-associated myositis

CancerIIMAutoantibodiesBreastDM (3)Mi2, SRP (+ SSA/SSB), Pm/SclSkin (non-melanoma)Clinically amyopathic DM, PMJo1, SAE1 (+SSA/SSB)ColorectalDM (2)Mi2 (2)KidneyDM-LungDM-LymphomaInclusion bodies myopathy-UnknownDM-

Conclusion

Reuma.pt/Myositis adequately captures the main features of inflammatory myopathies’ patients, depicting in this first report a heterogeneous population, with frequent muscle, joint, skin and lung involvements. Of interest, most patients reached low disease activity at the last follow-up appointment.

Disclosure of Interests

None declared

Portuguese recommendations for the use of biological and targeted synthetic disease-modifying antirheumatic drugs in patients with rheumatoid arthritis - 2020 update

OBJECTIVE

To update the recommendations for the treatment of rheumatoid arthritis (RA) with biological and targeted synthetic disease-modifying antirheumatic drugs (bDMARDs and tsDMARDs), endorsed by the Portuguese Society of Rheumatology (SPR).

METHODS

These treatment recommendations were formulated by Portuguese rheumatologists taking into account previous recommendations, new literature evidence and consensus opinion. At a national meeting, in a virtual format, three of the ten previous recommendations were re-addressed and discussed after a more focused literature review. A first draft of the updated recommendations was elaborated by a team of SPR rheumatologists from the SPR rheumatoid arthritis study group, GEAR. The resulting document circulated among all SPR rheumatologists for discussion and input. The level of agreement with each of all the recommendations was anonymously voted online by all SPR rheumatologists.

RESULTS

These recommendations cover general aspects such as shared decision, treatment objectives, systematic assessment of disease activity and burden and its registry in Reuma.pt. Consensus was also achieved regarding specific aspects such as initiation of bDMARDs and tsDMARDs, assessment of treatment response, switching and definition of persistent remission.

CONCLUSION

These recommendations may be used for guidance of treatment with bDMARDs and tsDMARDs in patients with RA. As more evidence becomes available and more therapies are licensed, these recommendations will be updated.

AB0747 MATERNAL AND FETAL OUTCOMES IN PREGNANT WOMEN WITH JUVENILE IDIOPATHIC ARTHRITIS: A SYSTEMATIC LITERATURE REVIEW

Background:

Juvenile idiopathic arthritis (JIA), one of the most common chronic diseases in children, can be classified in seven different categories according to its onset presentation. Concerns about pregnancy outcomes play a secondary role in disease approach. However, recent data showed an increased risk of pre-term birth in women with JIA instead the small patient samples analysed.

Objectives:

In this review, our aim is to describe the current available knowledge on JIA adverse, maternal and fetal, outcomes.

Methods:

A systematic literature review was conducted since January of 2000 until December 2020, by searching the PubMed and Embase bibliographic databases. The search was limited to articles in English language, presenting a comparator group (healthy individuals or patients without known auto-immune rheumatic diseases) and at least one clinical outcome of interest. Two independent reviewers screened the titles and abstracts followed by a full-text review to assess papers regarding their eligibility.

Results:

Ten observational studies out of 1560 references, fulfilled the inclusion criteria, of which, 9 were retrospective and 1 prospective. A total of 6.214 women with JIA (with 6.811 pregnancies) and 18.659.513 healthy controls (with 21.339.194 pregnancies) were included in this review.

Concerning maternal outcomes, delivery by caesarian section (CS) was more frequent among JIA women (in 4 out of 6 studies). Pre-eclampsia was referred in 3 out of 6 studies and a higher risk of vaginal bleeding and placenta previa in one additional study. No study found an increased risk for gestational diabetes or hypertension in pregnant women with JIA.

Regarding fetal outcomes, 8 studies revealed significantly increased of pre-term birth (only in first births in one study) but one study didn’t show any increased risk. Two studies showed a higher risk of small gestational age (SGA) and in another 2, increased risk for low birth weight (LBW). No evidence of increased risk of major congenital malformations.

Conclusion:

This systematic review suggests an increased risk for pre-eclampsia, preterm birth, delivery by CS, SGA and LBW, among pregnant women with JIA. Conclusions should be carefully interpreted, giving the heterogeneity of studied populations regarding demography, disease type, disease activity, and prescribed medication.

Disclosure of Interests:

None declared

What if HCM Risk-SCD was assessed with CMR maximum LV wall thickness measurements?

Funding Acknowledgements

Type of funding sources: None.

Introduction

The HCM Risk-SCD estimates the risk of sudden cardiac death at 5 years in patients (pts) with hypertrophic cardiomyopathy (HCM). According to ESC Guidelines, in pts with a 5-year risk of SCD <4%, an implantable cardioverter defibrillator (ICD) is generally not indicated, in pts with a risk of 4 to less than 6%, an ICD may be considered and in pts with a 5-year risk ≥6%, an ICD should be considered. The association between the degree of LVH and sudden cardiac death (SCD) has been based on measurements of maximum LVWT by echocardiography which is part of HCM Risk-SCD score. However, cardiac magnetic resonance (CMR) has shown a superior resolution in characterization of cardiac structures, with additional role in SCD risk stratification. Whether measurements of LVWT by echocardiography and CMR are interchangeable has been brought to question.

Purpose

  We sought to evaluate the incidence of discrepant measurements of maximal LVWT between echocardiography and CMR and determine its implication in HCM Risk-SCD score and ICD indication.

Methods

Unicentric, retrospective analysis of pts submitted to CMR who had HCM as definitive diagnosis, between 1/2013 and 9/2019. CMR and echocardiographic measures were compared, as well as HCM Risk-SCD score calculated with these values (maximum LVWT was the only variable that differed between measures). Subsequently, pts were divided in three groups according to HCM Risk-SCD score: pts with a 5-year risk of SCD <4% (G1), risk of 4 to less than 6% (G2) and risk ≥6% (G3).

Results

Out of the 781 CMR studies evaluated, 59 pts were found to have HCM (7.6%) with mean age of 62 ± 11 years and female predominance (50.8%). 12 pts had obstructive phenotype (20.3%). Mean LVWT was 20.0 ± 4.6mm when measured by CMR and 18.8 ± 4.6mm by echo; when comparing the measures by echo with CMR, there was a positive correlation between them (p < 0.001; r 0.719). Mean HCM Risk-SCD was 2.80 ± 1.51% when measured by CMR and 2.69 ± 1.53% by echo; there was a positive correlation between these measures too (p < 0.001; r 0.963). Maximum LV thickness evaluated by CMR showed a positive correlation (p = 0.006, r 0.384) with the HCM risk-score assessed by CMR. Only 1 pt changed risk group with CMR measurement of maximum LVWT (from G1 to G2). Conclusion: In this cohort, there was a positive, linear relationship between maximum LVWT and HCM Risk-SCD score measured by CMR and echocardiogram. Only 1 pt changed risk stratification group (5-year risk of SCD <4% to 4 to less than 6%).  Although CMR measurements, when interpreted correctly, are more precise compared with echocardiography, in this cohort there was no impact on the patient"s future clinical orientation regarding ICD implantation.

FRI0462 PREDICTIVE FACTORS OF RELAPSE AFTER METHOTREXATE DISCONTINUATION IN JIA PATIENTS WITH INACTIVE DISEASE

Background:

Methotrexate (MTX) is the most widely used conventional synthetic disease-modifying antirheumatic drug (csDMARD) in the treatment of juvenile idiopathic arthritis (JIA).1,2When remission is achieved, questions remain about discontinuing MTX. There is some evidence that a longer period of inactive disease before MTX withdrawal is associated with lower likelihood of relapse, while both rheumatoid factor (RF) positive polyarthritis and extended oligoarthritis categories are associated with higher probability of disease relapse.2,3

Objectives:

To identify predictive factors of relapse after discontinuation of MTX in JIA patients with inactive disease.

Methods:

Prospective multicentre cohort study in patients diagnosed with JIA, according to the ILAR classification, using real world data from the Portuguese national register database, Reuma.pt (Fig 1).4We evaluated patients who have reached JADAS27 inactive disease (≤1 and no active extra-articular manifestations) and discontinued MTX before the age of 18 years-old.5Relapse was defined as recurrence (>1 or extra-articular manifestations) or restarting a DMARD.5To identify differences of relapse risk, univariate analyses were performed. Persistence in remission was estimated using the Kaplan-Meier method. Subsequently, Cox regression analyses were performed to identify predictors of relapse.

Results:

119 JIA patients discontinued MTX due to inactive disease (Fig 1). 69.7% were females and 60.6% had oligoarticular JIA. Sociodemographic and clinical characteristics are shown in Table 1. Relapse has occurred in 32.8%. Table 2 shows the disease characteristics at MTX initiation and discontinuation and at relapse or last visit.

In univariate analysis, relapse was associated with the use of NSAIDs at the time of MTX discontinuation (p=.027) and with a period of less than two years in inactive disease before MTX suspension (p=.040). We found no association with gender, race, immunology (RF, antinuclear and cyclic citrullinated peptide antibodies), MTX dose, discontinuation modality (tapering and spacing the doses or just tapering the dose), extra-articular manifestations, previous corticotherapy, family history, body mass index, JADAS, CHAQ index, inflammatory parameters, tender and swollen joint counts at MTX initiation or discontinuation nor with age at remission or at MTX suspension. Median persistence in inactive disease was significantly higher in patients with more than two years in remission before MTX discontinuation (p=.034) and in those who did not use NSAIDs at time of MTX discontinuation (p=.026) (Fig 2).

After adjustment for age at diagnosis, MTX tapering and JIA category, use of NSAIDs at the time of discontinuation (HR, 1.98 95%CI 1.03-3.82) and less than two years in remission (HR, 3.12 95%CI 1.35-7.13) remained associated with relapse.

Conclusion:

In this large cohort we found that the use of NSAIDs at the time of MTX discontinuation was associated with two times the likelihood of relapse. Like in other studies we also showed that the time in remission before MTX discontinuation is the main predictor of relapse. We found no association between the JIA category and the risk of relapse.

References:

[1]Hügle B 2016

[2]Klotsche J 2018

[3]Guzman J 2014

[4]Canhão H 2011

[6]Consolaro A 2014

Disclosure of Interests:

Soraia Azevedo: None declared, José Tavares-Costa: None declared, Ana Teresa Melo: None declared, Raquel Freitas: None declared, Marta Cabral: None declared, Marta Conde: None declared, Francisca Aguiar: None declared, Agna Neto: None declared, Ana Filipa Mourão: None declared, Filipa Oliveira-Ramos: None declared, Maria Jose Santos Speakers bureau: Novartis and Pfizer, Daniela Peixoto: None declared

AB0688 GAIT PATTERN DIFFERENCES BETWEEN PATIENTS WITH RADIOGRAPHIC AND NON-RADIOGRAPHIC AXIAL SPONDYLOARTHRITIS, THE MyoSpA STUDY

Background:

Axial spondyloarthritis (axSpA) is a chronic inflammatory disease classified as radiographic (r-axSpA) or non-radiographic (nr-axSpA). Defining the gait patterns associated with these two groups can improve its detection and promote early intervention. In normal walking, body segments move around the joints as struts of an inverted pendulum. The resultant cyclic rotations contribute to the forward translation of the body, while minimizing muscle work and maintaining stability. Recent literature describes a decline in this pendulum-like mechanism associated with aging and some neurological diseases (Parkinson and multiple sclerosis).

Objectives:

The aim was to compare the 3D gait kinematics of patients with r-axSpA and nr-axSpA.

Methods:

A cross-sectional study was conducted on 54 participants (18-50 years old), 27 patients with axSpA (according to ASAS criteria, with less than 10 years since symptoms onset) and 27 healthy controls, matched by gender, age and level of physical activity. A sub-analysis was performed involving the whole group of patients classified as r-axSpA (n=14) and nr-axSpA (n=6). Subjects movement was reconstructed using a 3D full-body kinematic model (Kinetikos, Coimbra, Portugal) fed by 15 inertial sensors placed in the head, arms, trunk, pelvis, thighs, shanks and feet. 3D gait kinematics was characterised based on variables that analyse the body movement as a whole (e.g. center of mass displacement, speed), conventional spatiotemporal parameters (e.g. stance/swing time, step length) and joints kinematics time-normalized to 101 points, comprising the gait cycle from 0 to 100%. Nonparametric statistical tests were used.

Results:

In the r-axSpA group, 71,4% were male, with a mean age of 34.43±7.84 years and a BASDAI of 2.84±2.39, whereas in the nr-axSpA, 50% were male, with a mean age of 41.83±6.27 years and a BASDAI of 2.99±0.58. A statistically significant difference was observed in the displacement of the center of mass (with respect to the pelvis local coordinate system) along the anteroposterior axis between the two studied groups (H = 4.96, p = 0.03), with a mean rank displacement of 8.6 for r-axSpA and 15.00 for nr-axSpa, corresponding to a reduction in displacement of 38% (mean 0.00986 vs 0.01579m), in the r-axSpa group.

Conclusion:

Our preliminary results in r-axSpA subjects show a reduction of the pendulum mechanism. Although no significant segmental (kinematics) changes were observed, the sum of all studied variables result in a clear different gait pattern between the two groups. The observed decline can be an early sign of the inefficiency of the r-axSpA group to minimise the cost of transport of the center of mass during walking (i.e. increased instability). This study shows the potential of gait analysis to identify subjects who may benefit from early physiotherapy intervention.

Disclosure of Interests:

Nuno Gonçalves: None declared, Lúcia Domingues: None declared, Atlas Mashayekhi Sardoo: None declared, Lucian Radu: None declared, Santiago Rodrigues-Manica Speakers bureau: Jansse, MSD, Novartis, Agna Neto: None declared, Rita Torres: None declared, José Marona: None declared, Jaime Branco Speakers bureau: Vitoria, César Mendes: None declared, Ricardo Matias: None declared, Fernando Pimentel dos Santos Speakers bureau: Novartis, Pfizer, Biogen, Vitoria,

THU0021 IDENTIFICATION OF MUSCLE ASSOCIATED KEY GENES TO SUPPORT AXIAL SPONDYLOARTHRITIS DIAGNOSIS BY TRANSCRIPTOMIC APPROACH, THE MYOSPA STUDY

Background:

Early diagnosis of axial Spondyloarthritis (axSpA) represents a major clinical challenge nowadays. Increasing evidence has determined that early diagnosis, prompt treatment initiation and early achievement of remission are the best predictors of long-term clinical, functional and radiographic outcomes. New tools to support the diagnosis are needed.

Objectives:

This study aims to identify differentially expressed genes that may improve the current clinical diagnosis approach for early axSpA.

Methods:

A cross-sectional study was conducted on 50 participants, 25 patients with axSpA (according to ASAS criteria) and 25 Healthy Controls, matched by gender, age and levels of physical activity. Peripheral blood samples were collected and RNA-Seq technology was performed. Normalization of raw data, and identification of differentially expressed genes was obtained using edgeR and limma-voom R packages. Gene Set Enrichment Analysis (GSEA) and Functional Enrichment analysis using Gene ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) annotations were also performed. A number of Differently Expressed Genes were highlighted.

Results:

311 genes were identified as being significantly differentially expressed between patients and controls. In details, 129 downregulated (7 genes have fold change more than 1) and 182 upregulated genes (3 genes have fold change more than 1) are highlighted. These genes are mostly involved in Myogenesis, Innate Immune Signalling and JAK/STAT pathways. Several genes with functions of skeletal muscle development and muscle contraction were identified.

Conclusion:

The evidence disclosed that regulation of muscle development and contraction may be also engaged in physiopathology mechanisms of axSpA. These new cues open new perspectives for diagnosis and therapeutic approaches in axSpA.

Acknowledgments:

To all patients and healthy people who participate in MyoSpA study

Disclosure of Interests:

Atlas Mashayekhi Sardoo: None declared, Daniel Sobral: None declared, Lucia Domingues: None declared, Santiago Rodrigues-Manica Speakers bureau: Jansse, MSD, Novartis, Rita Pinheiro Torres: None declared, Agna Neto: None declared, Patricia Alves: None declared, Julia Costa: None declared, Ana Rita Grosso: None declared, Jaime Branco Speakers bureau: Vitoria, Fernando Pimentel dos Santos Speakers bureau: Novartis, Pfizer, Biogen, Vitoria,

P767 Imagiologic features and Prevalence of Cardiac Lesions detected in Transesophageal Echocardiography

INTRODUCTION

Echocardiography plays a central role in the detection of intracardiac lesions, with transesophageal echocardiography (TEE) acquiring an outstanding role due to its increased sensitivity, improving diagnosis and evaluation of complications.

PURPOSE

To characterize clinically and echocardiographically the type of intracardiac masses mostly identified on TEE, in order to reflect about its prevalence, exam indication and echocardiographic criteria for correct diagnosis.

METHODS

Unicentric, retrospective observational analysis of TEE examinations performed between 01/2014 and 05/2019. Data collected from TEE registers and patient process assessment. Cardiac findings were classified according to its echocardiographic features as vegetations, thrombi or suspected tumoral masses.

RESULTS

144 TEE examinations revealed the presence of intracavitary lesions, with 62% of them (89 exams) having imagiologic features suggestive of vegetations, with polypoid highly mobile lesions attached to valve leaflets, often leading to valvular insufficiency. More than one valve was affected in 21% and about 30% were prosthetic valves. Potential serious complications such as perforation and abscess formation were present in 13% and 7%, respectively.

35 examinations disclosed the presence of thrombi, 66% located on the left atrial appendage and 17% on the left atrium (LA). In 4 cases they were attached to prosthetic valves and 10 of the patients had not been anticoagulated previously. Some doubtful diagnosis were lately confirmed after disappearance of the lesion with anticoagulation therapy.

Diagnosis of tumoral masses was made in 11%, some of them waiting for histologic confirmation. 50% had features resembling pappilary fibroelastomas (PF) (38% of the aortic valve, 25% of the mitral valve, 1 of the pulmonary valve and 1 the left ventricle pathologically confirmed), such as a filiform highly mobile pedunculated structure attached to a valve leaflet. Heterogeneous masses suggestive of myxomas were identified in 35%, 80% located on the LA.

The most frequent reason for performing a TEE examination was a previous embolic event, a doubtful image on transthoracic echocardiogram or before electrical cardioversion.

Except for PF which were increasingly detected by echocardiography, the prevalence of thrombi or vegetations remained similar across the years.

Most presumptive diagnosis made by TEE were confirmed based on clinical evolution or histology.

CONCLUSIONS

In this cohort, most TEE examinations revealed the presence of vegetations, a major criterion for establishing the diagnosis of infective endocarditis.

TEE enables more accurate evaluation of the lesions and although histologic confirmation is frequently necessary, some imagiologic features allow for a presumptive diagnosis which is often correct.

This analysis also reflects the prevalence of cardiac lesions and the increased awareness of some conditions, such as PF.

P1346 Not all chest pains are scary: a case report of an important - but often forgotten - diagnosis

INTRODUCTION

Epipericardial fat necrosis (EFN) is an uncommon self-limiting benign condition that curses with chest pain. The first case was reported in 1957 and since than only few cases were reported. Recently, new imaging modalities have increased its diagnosis.

CASE REPORT

An otherwise healthy 42 years-old man presented with severe left-sided pleuritic chest pain, non-radiating, with 4 days duration, mildly relieved by an analgesic. No other symptoms nor history of infection. Physical examination, chest x-ray (CXR), ECG, routine laboratory testing, d-dimer and troponin measurements were unrevealing. Chest CT with contrast showed an increased density of anterior pericardial fat with nodular appearance consistent with EFN. The transthoracic echocardiogram was normal. For better characterization, a cardiac MRI was performed, and confirmed a small nodular lesion (10x17mm) with regular contours, externally to the pericardium, in relation to the apex of the right ventricle and the anterior thoracic wall (hypersignal on T1 and T2, loss of signal in fat saturation sequences, no contrast capture during the first pass nor late enhancement). The mass was delimited from the remaining pericardiac fat by a regular halo. Combined antiinflamatory therapy was started with favourable evolution. Cardiac surgery concluded that there was no need to perform a biopsy of the lesion unless there was recurrence of the symptoms. At 3 and 6-month follow-up, chest pain had resolved (no recurrence) - CT was performed for comparison and still showed a slight densification of the anterior mediastinum’s fat.

DISCUSSION

EFN is an often-overlooked etiology of chest pain in patients with a negative cardiopulmonary workup. The aetiology of EFN is still unknown but appears to be similar to other analogous conditions such as epiploic appendagitis and fat necrosis in the omentum or breast. It’s not expectable that patients with EFN have a higher risk of coronary heart disease. Onset is usually acute but can persist up to a year. Increased heart rate and diaphoresis may be found. ECG and lab tests are usually normal. CXR often shows a paracardiac opacity, occasionally with an associated pleural effusion. CT typically shows a fatty lesion anterior to the pericardium, in the epipericardial fat, with stranding of surrounding soft tissue. In most cases the adjacent pericardium is also thickened. CT enables prompt diagnosis in most cases, preventing further invasive procedures. No evidence-based treatment guidelines are available due to the rarity and benign behaviour of the disease. Treatment is usually conservative with analgesics and non-steroidal anti-inflammatory drugs. Follow-up imaging is recommended to confirm resolution and exclude neoplastic diseases such as liposarcoma. It is important to be familiar with its features since the clinical and radiologic characteristics suggest a presumptive diagnosis, thereby avoiding more aggressive techniques.

Abstract P1346 Figure. MRI - small nodular lesion

P228 Mitral valve aneurysm in the context of post-infective endocarditis in hypertrophic cardiomyopathy: an issue of inflammation or pressure gradients?

Mitral valve aneurysms (MVA) are uncommon and usually develop acutely in the setting of infective endocarditis (IE).

We present a case report of a patient with a ruptured aneurysm of the mitral valve (MV) leaflet and obstructive hypertrophic cardiomyopathy (HCM), previously treated for IE. Echocardiography is essential for diagnosis, highlighting the importance of imaging for early identification and timely intervention.

CASE REPORT

68-year-old male patient with type 2 diabetes mellitus and dyslipidemia was admitted to hospital with a 3-week history of malaise, fever and recent left-sided abdominal pain. No past relevant history.

Physical examination revealed a grade II/VI systolic heart murmur at the cardiac apex, fever, abdominal tenderness in the left upper quadrant and purpuric lesions in the inferior limbs.

Neutrophilia, CPR 211mg/L. Positive blood cultures for Staphylococcus aureus methicillin-sensitive. Spleen embolization, with no abcess on abdominal CT.

Transthoracic (TTE) and transesophageal echocardiography (TEE) disclosed a highly mobile polypoid mass in the atrial side of the anterior MV leaflet, septal left ventricular hypertrophy and systolic anterior motion (SAM) of the MV. Mild mitral regurgitation (MR). No evidence of abcess, aneurysm or valve perforation.

The diagnosis of IE was established and the patient completed 42 days of Flucloxaciline. Favorable clinical evolution, residual lesions on the MV.

TTE and TEE were repeated on follow-up. Besides HCM and SAM of the MV, an aneurysm of the anterior leaflet of the MV was identified and two regurgitant jets: one due to incomplete coaptation of the leaflets; other through the perforated aneurysm. Mild global MR.

A strategy of close follow-up was adopted. Beta blocker dose was increased. Maintenance of the characteristics of the aneurysm.

DISCUSSION

MVA are rare, with perforation and significant MR development as the most serious complications.

They mostly develop in the acute setting of IE of the aortic valve (AV), due to the "jet lesion" from the regurgitant jet or direct extension of the infection. In this case, MVA developed as a late complication of IE of the MV.

Previous infection and inflammation lead to increased susceptibility of the valve leaflet, with possible persistent chronic inflammation. In the setting of obstructive HCM, the lesioned endothelium is exposed to significant intraventricular pressure gradients, which have probably raised its propensity to bulge towards the atrium, resulting in aneurysm formation and perforation.

Optimal approach to MVA has not been defined. If the setting of perforation with severe MR, surgery must be performed in order to avoid a fatal outcome. In small aneurysms with mild MR, a conservative approach seems reasonable.

The purpose of this case is to highlight potential complications of IE, which should be actively investigated, with echocardiography playing a central role in the diagnosis and follow-up.

Portuguese Recommendations for the use of biological therapies in patients with rheumatoid arthritis- 2016 update

OBJECTIVE

To update the recommendations for the treatment of Rheumatoid Arthritis (RA) with biological therapies, endorsed by the Portuguese Society of Rheumatology (SPR).

METHODS

These treatment recommendations were formulated by Portuguese rheumatologists based on literature evidence and consensus opinion. At a national meeting the 10 recommendations were discussed and updated. The document resulting from this meeting circulated to all Portuguese rheumatologists, who anonymously voted online on the level of agreement with the recommendations.

RESULTS

These recommendations cover general aspects as shared decision, prospective registry in Reuma.pt, assessment of activity and RA impact and treatment objective. Consensus was also achieved regarding specific aspects as initiation of biologic therapy, assessment of response, switching and definition of persistent remission.

CONCLUSION

These recommendations may be used for guidance of treatment with biological therapies in patients with RA. As more evidence becomes available and more therapies are licensed, these recommendations will be updated.

Portuguese recommendations for the use of methotrexate in rheumatic diseases - 2016 update

BACKGROUND

Methotrexate (MTX) is the first-line drug in the treatment of rheumatoid arthritis (RA) and the most commonly prescribed disease modifying anti-rheumatic drug. Moreover, it is also used as an adjuvant drug in patients under biologic therapies, enhancing the efficacy of biologic agents.

OBJECTIVES

To review the literature and update the Portuguese recommendations for the use of MTX in rheumatic diseases first published in 2009.

METHODS

The first Portuguese guidelines for the use of MTX in rheumatic diseases were published in 2009 and were integrated in the multinational 3E Initiative (Evidence Expertise Exchange) project. The Portuguese rheumatologists based on literature evidence and consensus opinion formulated 13 recommendations. At a national meeting, the recommendations included in this document were further discussed and updated. The document resulting from this meeting circulated to all Portuguese rheumatologists, who anonymously voted online on the level of agreement with the updated recommendations.

RESULTS

Results presented in this article are mainly in accordance with previous guidelines, with some new information regarding hepatitis B infection during MTX treatment, pulmonary toxicity monitoring, hepatotoxicity management, association with hematologic neoplasms, combination therapy and tuberculosis screening during treatment.

CONCLUSION

The present recommendations combine scientific evidence with expert opinion and attained desirable agreement among Portuguese rheumatologists. The regular update of these recommendations is essential in order to keep them a valid and useful tool in daily practice.

PORTUGUESE RECOMMENDATIONS FOR THE USE OF BIOLOGICAL THERAPIES IN PATIENTS WITH PSORIATIC ARTHRITIS--2015 UPDATE

OBJECTIVE

To update recommendations for the treatment of psoriatic arthritis with biological therapies, endorsed by the Portuguese Society of Rheumatology (SPR).

METHODS

These treatment recommendations were formulated by Portuguese rheumatologists based on literature evidence and consensus opinion. At a national meeting the 16 recommendations included in this document were discussed and updated. The level of agreement among Portuguese Rheumatologists was assessed using an online survey. A draft of the full text of the recommendations was then circulated and suggestions were incorporated. A final version was again circulated before publication.

RESULTS

A consensus was achieved regarding the initiation, assessment of response and switching biological therapies in patients with psoriatic arthritis (PsA). Specific recommendations were developed for several disease domains: peripheral arthritis, axial disease, enthesitis and dactylitis.

CONCLUSION

These recommendations may be used for guidance in deciding which patients with PsA should be treated with biological therapies. They cover a rapidly evolving area of therapeutic intervention. As more evidence becomes available and more biological therapies are licensed, these recommendations will have to be updated.

The Portuguese Society of Rheumatology position paper on the use of biosimilars

Biotechnological drugs have become a fundamental resource for the treatment of rheumatic patients. Patent expiry of some of these drugs created the opportunity for biopharmaceutical manufacturers to develop biosimilar drugs intended to be as efficacious as the originator product but with a lower cost to healthcare systems. Due to the complex manufacturing process and highly intricate structure of biologicals, a biosimilar can never be an exact copy of its reference product. Consequently, regulatory authorities issued strict preclinical and clinical guidelines to ensure safety and efficacy equivalence and, in September 2013, the biosimilar of infliximab was the first biosimilar monoclonal antibody to be authorized for use in the European Union. The current document is a position statement of the "Sociedade Portuguesa de Reumatologia" (Portuguese Society of Rheumatology) on the use of biosimilar drugs in rheumatic diseases. Two systematic literature reviews were performed, one concerning clinical trials and the other one concerning international position papers on biosimilars. The results were presented and discussed in a national meeting and a final position document was discussed, written and approved by Portuguese rheumatologists. Briefly, this position statement is contrary to automatic substitution of the originator by the biosimilar, defends either a different INN or the prescription by brand name, supports that switching between biosimilars and the originator molecule should be done after at least 6 months of treatment and based on the attending physician decision and after adequate patient information, recommends the registration of all biosimilar treated patients in Reuma.pt for efficacy, safety and immunogenicity surveillance, following the strategy already ongoing for originators, and opposes to extrapolation of indications approved to the originator to completely different diseases and/or age groups without adequate pre-clinical, safety or efficacy data.

A protection system for the JET ITER-like wall based on imaging diagnostics

The new JET ITER-like wall (made of beryllium and tungsten) is more fragile than the former carbon fiber composite wall and requires active protection to prevent excessive heat loads on the plasma facing components (PFC). Analog CCD cameras operating in the near infrared wavelength are used to measure surface temperature of the PFCs. Region of interest (ROI) analysis is performed in real time and the maximum temperature measured in each ROI is sent to the vessel thermal map. The protection of the ITER-like wall system started in October 2011 and has already successfully led to a safe landing of the plasma when hot spots were observed on the Be main chamber PFCs. Divertor protection is more of a challenge due to dust deposits that often generate false hot spots. In this contribution we describe the camera, data capture and real time processing systems. We discuss the calibration strategy for the temperature measurements with cross validation with thermal IR cameras and bi-color pyrometers. Most importantly, we demonstrate that a protection system based on CCD cameras can work and show examples of hot spot detections that stop the plasma pulse. The limits of such a design and the associated constraints on the operations are also presented.

[Portuguese recommendations for pain management by pharmocotherapy in inflammatory arthritis]

OBJECTIVES

To develop Portuguese evidence-based recommendations for pain management by pharmocotherapy in inflammatory arthritis.

METHODS

The Portuguese project was integrated in the multinational 3E Initiative (Evidence, Expertise, Exchange) 2010 where a total of 453 rheumatologists from 17 countries have participated. The clinical questions concerning pain were formulated and the Portuguese group added 2 more questions. A systematic literature search was performed in Medline, Embase, Cochrane Library and 2008-2009 EULAR and ACR abstracts. The selected articles were systematically reviewed and the evidence was defined according to the Oxford Levels of Evidence. In each country a group of experts joined to discuss their national recommendations. In Portugal, the national meeting was held in October 2010, where 33 rheumatologists discussed and voted by Delphi method the national recommendations. Finally, the agreement among the rheumatologists and the potential impact on their clinical practice was assessed.

RESULTS

Thirteen national recommendations were formulated: pain measure scores; analgesic combination therapy; pharmacotherapy in preconception, pregnancy and lactation periods; pharmacotherapy according to comorbilities; safety of NSAIDs and/or paracetamol with methotrexate combination therapy; efficacy and safety of continuous/on-demand NSAIDs; opioids, paracetamol, corticosteroids, antidepressants, neuromodulators and muscle relaxants role and effectiveness; risk factors for the development of chronic pain and the role of topic analgesics.

CONCLUSION

The portuguese recommendations for the pain management by pharmacotherapy in inflammatory arthritis were formulated according to the best evidence and supported by a panel of 63 rheumatologists. The differences between the national and international recommendations are reported in this article.

2011 Portuguese recommendations for the use of biological therapies in patients with psoriatic arthritis

OBJECTIVE

To develop recommendations for the treatment of psoriatic arthritis (PsA) with biological therapies, endorsed by the Portuguese Society of Rheumatology.

METHODS

These treatment recommendations were formulated by Portuguese rheumatologists based on literature evidence and consensus opinion. A draft of the recommendations was first circulated to all Portuguese rheumatologists and their suggestions were incorporated in the draft. At a national meeting the recommendations were discussed and all attending rheumatologists voted on the level of agreement for each recommendation. A second draft was again circulated before publication.

RESULTS

A consensus was achieved regarding the initiation, assessment of response and switching biological therapies in patients with PsA. Specific recommendations were developed for several disease domains: peripheral arthritis, axial disease, enthesitis and dactylitis.

CONCLUSION

These recommendations may be used for guidance in deciding which patients with PsA should be treated with biological therapies. They cover a rapidly evolving area of therapeutic intervention. As more evidence becomes available and more biological therapies are licensed, these recommendations will have to be updated.

Portuguese guidelines for the use of biological agents in rheumatoid arthritis - October 2011 update

The authors present the revised version of the Portuguese Society of Rheumatology (SPR) guidelines for the treatment of Rheumatoid Arthritis (RA) with biological therapies. In these guidelines the criteria for introduction and maintenance of biological agents are discussed as well as the contraindications and procedures in the case of nonresponders. Biological treatment (with a tumour necrosis factor antagonist, abatacept or tocilizumab) should be considered in RA patients with a disease activity score 28 (DAS 28) equal to or greater than 3.2 despite treatment with at least 20mg-weekly-dose of methotrexate (MTX) for at least 3 months or, if such treatment is not possible, after 3 months of other conventional disease modifying drug or combination therapy. A DAS 28 score between 2.6 and 3.2 with a significant functional or radiological deterioration under treatment with conventional regimens could also constitute an indication for biological treatment. The treatment goal should be remission or, if that is not achievable, at least a low disease activity, defined by a DAS28 lower than 3.2, without significative functional or radiological worsening. The response criteria, at the end of the first 3 months of treatment, are a decrease of at least 0.6 in the DAS28 score. After 6 months of treatment res­ponse criteria is defined as a decrease greater than 1.2 in the DAS28 score. Non-responders, in accordance to the Rheumatologist’s clinical opinion, should try a switch to another biological agent (tumour necrosis factor antagonist, abatacept, rituximab or tocilizumab).

Frequent users of an acute psychiatric inpatient unit: A 5-year retospective study

Introduction

A small subset of patients with above average admissions to psychiatric inpatient units is recognized in clinical practice. These frequent users tend to be younger and to have a diagnosis of schizophrenia or affective disorder. Social conditions and the severity of the illness seem to be associated with this increased number of admissions.

Aims/Objectives

To study demographic and clinical characteristics of frequent and non-frequent users of a psychiatric inpatient unit.

Methods

Retrospective data of all the patients admitted to a psychiatric inpatient unit from January 2004 to December 2008 were reviewed. Frequent-users were defined as patients with 3 or more admissions over that period of time, and non-frequent users as those with less than 3 admissions. The two groups were compared in terms of age, gender, ethnicity, psychiatric diagnosis and compulsory admissions

Results

In a total of 2018 admissions and 1348 patients, the frequent-user group represented 10.2% (n = 137) of the patients and 28.9%(n = 584) of the admissions. Frequent-users were significantly younger (39.5 vs. 44.5 years, p = .001), more frequently black (22.6 vs. 19.4%, p < .001) and compulsorily admitted (27.7 vs. 14%, p < .001) than non-frequent users. Patients with bipolar disorder (p = .001), schizophrenia (p = .003) belonged significantly more to frequent-users group, while unipolar depressive patients (p = .016) and other diagnosis (p = .011) was more significantly represented in the non-frequent users group. Frequency of admission did not differ with gender.

Conclusions

The results concerning age and psychiatric diagnosis are consistent with previous studies. Compulsory admissions and black ethnicity were significantly higher among frequent- users.

Energy resolution of gamma-ray spectroscopy of JET plasmas with a LaBr3 scintillator detector and digital data acquisition

A new high efficiency, high resolution, fast γ-ray spectrometer was recently installed at the JET tokamak. The spectrometer is based on a LaBr3(Ce) scintillator coupled to a photomultiplier tube. A digital data acquisition system is used to allow spectrometry with event rates in excess of 1 MHz expected in future JET DT plasmas. However, at the lower rates typical of present day experiments, digitization can degrade the energy resolution of the system, depending on the algorithms used for extracting pulse height information from the digitized pulses. In this paper, the digital and analog spectrometry methods were compared for different experimental conditions. An algorithm based on pulse shape fitting was developed, providing energy resolution equivalent to the traditional analog spectrometry method.