Can subcutaneous treprostinil be an alternative for treating pulmonary hypertension in patients with systemic sclerosis-related interstitial lung disease?

Pulmonary hypertension (PH) is one of the most feared complications of systemic sclerosis (SSc). There are currently specific drugs approved for PH group I (pulmonary arterial hypertension - PAH), but for PH related to lung disease (group III) the use of vasodilators is still controversial and not routinely recommended in patients with non-severe PH. However, SSc-PH-interstitial lung disease (ILD) has a poorer survival compared with SSc-PAH, making the management of these patients a challenge, ideally carried out in a reference centre. Herein we report the case of a a 45-year-old female with systemic sclerosis-myositis overlap syndrome, with documented lung involvement (ILD with fibrotic nonspecific interstitial/organizing pneumonia pattern), who was diagnosed with pre-capillary PH. She started sequential combination vasodilator therapy including parenteric prostanoid, with clinical benefit and without evidence of ILD worsening.

Systematic literature review to inform the Portuguese recommendations for the management of Raynaud's phenomenon and digital ulcers in systemic sclerosis and other connective tissue diseases

OBJECTIVE

To perform a systematic literature review (SLR) aimed at evaluating the efficacy and safety of pharmacological and non-pharmacological treatments for Raynaud's phenomenon (RP) and digital ulcers (DU) in patients with systemic sclerosis (SSc) and other connective tissue diseases (CTD), in order to inform the Portuguese recommendations for managing RP and DU in these patients.

METHODS

A SLR was conducted until May 2022 to identify studies assessing the efficacy and safety of pharmacological and non-pharmacological interventions for RP and DU in SSc and other CTD. Eligible study designs included randomized controlled trials (RCTs), controlled clinical trials, and their extensions for assessing efficacy and safety of interventions. Observational studies with a comparator were included for evaluating the efficacy and safety of non-pharmacological interventions and safety of pharmacological interventions. The risk of bias of each study was assessed using standard tools.

RESULTS

Out of 71 publications meeting the inclusion criteria, 59 evaluated pharmacological and 12 non-pharmacological interventions. We found moderate quality evidence supporting the efficacy of calcium channel blockers, phosphodiesterase-5 inhibitors, and intravenous prostacyclin analogues in reducing RP frequency, severity, and duration. Intravenous iloprost had a small to moderate effect size in improving DU healing. Phosphodiesterase-5 inhibitors were effective in reducing total DU count, new DU occurrence, and enhancing DU healing. Bosentan effectively prevented new DU in SSc patients. No new safety concerns were associated with these treatments. The studies on non-pharmacological interventions were, in general, of low quality, and had a small sample size. Warming measures decreased frequency and duration of RP attacks; laser therapy improved RP-related outcomes; local oxygen-ozone therapy improved RP outcomes as an add-on therapy; bone marrow mononuclear cell implantation improved DU-associated pain; periarterial sympathectomy and vascular bypass reduced DU number and finger amputation risk.

CONCLUSION

The available evidence supports the efficacy and safety of pharmacological interventions, namely nifedipine, sildenafil, iloprost, and bosentan in treating RP and DU in patients with SSc and other CTD. Scarce and low-quality evidence does support the use of some non-pharmacological interventions but with only a modest effect size. This SLR underscores the limited availability of high-quality evidence for determining the optimal treatment.

Phage Lytic Protein CHAPSH3b Encapsulated in Niosomes and Gelatine Films

Antimicrobial resistance (AMR) has emerged as a global health challenge, sparking worldwide interest in exploring the antimicrobial potential of natural compounds as an alternative to conventional antibiotics. In recent years, one area of focus has been the utilization of bacteriophages and their derivative proteins. Specifically, phage lytic proteins, or endolysins, are specialized enzymes that induce bacterial cell lysis and can be efficiently produced and purified following overexpression in bacteria. Nonetheless, a significant limitation of these proteins is their vulnerability to certain environmental conditions, which may impair their effectiveness. Encapsulating endolysins in vesicles could mitigate this issue by providing added protection to the proteins, enabling controlled release, and enhancing their stability, particularly at temperatures around 4 °C. In this work, the chimeric lytic protein CHAPSH3b was encapsulated within non-ionic surfactant-based vesicles (niosomes) created using the thin film hydrating method (TFH). These protein-loaded niosomes were then characterized, revealing sizes in the range of 30-80 nm, zeta potentials between 30 and 50 mV, and an encapsulation efficiency (EE) of 50-60%. Additionally, with the objective of exploring their potential application in the food industry, these endolysin-loaded niosomes were incorporated into gelatine films. This was carried out to evaluate their stability and antimicrobial efficacy against Staphylococcus aureus.

Early detection of interstitial lung disease in rheumatic diseases: A joint statement from the Portuguese Pulmonology Society, the Portuguese Rheumatology Society, and the Portuguese Radiology and Nuclear Medicine Society

INTRODUCTION

Interstitial lung disease (ILD) contributes significantly to morbidity and mortality in connective tissue disease (CTD). Early detection and accurate diagnosis are essential for informing treatment decisions and prognosis in this setting. Clear guidance on CTD-ILD screening, however, is lacking.

OBJECTIVE

To establish recommendations for CTD-ILD screening based on the current evidence.

METHOD

Following an extensive literature research and evaluation of articles selected for their recency and relevance to the characterization, screening, and management of CTD-ILD, an expert panel formed by six pulmonologists from the Portuguese Society of Pulmonology, six rheumatologists from the Portuguese Society of Rheumatology, and six radiologists from the Portuguese Society of Radiology and Nuclear Medicine participated in a multidisciplinary discussion to produce a joint statement on screening recommendations for ILD in CTD.

RESULTS

The expert panel achieved consensus on when and how to screen for ILD in patients with systemic sclerosis, rheumatoid arthritis, mixed connective tissue disease, Sjögren syndrome, idiopathic inflammatory myopathies and systemic lupus erythematous.

CONCLUSIONS

Despite the lack of data on screening for CTD-ILD, an expert panel of pulmonologists, rheumatologists and radiologists agreed on a series of screening recommendations to support decision-making and enable early diagnosis of ILD to ultimately improve outcomes and prognosis in patients with CTD.

The phenotype of mixed connective tissue disease patients having associated interstitial lung disease

OBJECTIVE

We aimed to compare two matched populations of patients with MTCD with and without associated ILD and to identify predictive factors for ILD progression and severity.

METHODS

This international multicenter retrospective study (14 tertiary hospitals), included MCTD patients who fulfilled at least one historical MCTD classification criteria. ILD was defined by the presence of typical chest high-resolution computed tomography (HRCT) abnormalities. Factors associated with ILD were assessed at baseline. Long-term progressive ILD was assessed in MCTD-ILD patients with multiple forced vital capacity (FVC) measurements.

RESULTS

300 patients with MCTD were included. Mean age at diagnosis was 39.7 ± 15.4 years and 191 (63.7%) were women. Mean follow-up was 7.8 ± 5.5 years. At baseline, we identified several factors associated with ILD presence: older age (p = 0.01), skin thickening (p = 0.03), upper gastro-intestinal (GI) symptoms (p<0.001), FVC <80% (p<0.0001), diffusing capacity for carbon monoxide <80% (p<0.0001), anti-topoisomerase antibodies (p = 0.01), SSA/Ro antibodies (p = 0.02), cryoglobulinemia (p = 0.04) and elevated C-reactive protein (p<0.001). Patients with MTCD-ILD were more likely to be treated with synthetic immunosuppressant agents (p<0.001) in particular mycophenolate mofetil (p = 0.03). Digital ulcers (DU) were identified as a risk factor for FVC decline >10%. During follow-up mortality was higher in the MTCD-ILD group (p<0.001).

CONCLUSION

In this large international cohort of patients with MTCD, we identified different factors associated with ILD. Our findings also provide evidence that MCTD-ILD patients have increased mortality and that DU are associated with progressive lung disease.

Influence of the timing of biological treatment initiation on Juvenile Idiopathic Arthritis long-term outcomes

BACKGROUND

Juvenile idiopathic arthritis (JIA) treatment is aimed at inducing remission to prevent joint destruction and disability. However, it is unclear what is the long-term impact on health-related outcomes of the timing of biological disease-modifying antirheumatic drug (bDMARD) initiation in JIA. Our aim was to evaluate the long-term impact of the time between JIA onset and the initiation of a bDMARD in achieving clinical remission, on physical disability and health-related quality of life (HRQoL).

METHODS

Adult JIA patients registered in the Rheumatic Diseases Portuguese Register (Reuma.pt) and ever treated with bDMARD were included. Data regarding socio-demographic, JIA-related characteristics, disease activity, physical disability (HAQ-DI), HRQoL (SF-36), and treatments were collected at the last visit. Patients were divided into 3 groups (≤ 2 years, 2-5 years, or > 5 years), according to the time from disease onset to bDMARD initiation. Regression models were obtained considering remission on/off medication, HAQ-DI, SF-36, and joint surgeries as outcomes and time from disease onset to bDMARD start as an independent variable.

RESULTS

Three hundred sixty-one adult JIA patients were evaluated, with a median disease duration of 20.3 years (IQR 12.1; 30.2). 40.4% had active disease, 35.1% were in remission on medication, and 24.4% were in drug-free remission; 71% reported some degree of physical disability. Starting a bDMARD > 5 years after disease onset decreased the chance of achieving remission off medication (OR 0.24; 95% CI 0.06, 0.92; p = 0.038). Patients who started a bDMARD after 5 years of disease onset had a higher HAQ and worse scores in the physical component, vitality, and social function domains of SF-36, and more joint surgeries when compared to an earlier start.

CONCLUSION

Later initiation of bDMARDs in JIA is associated with a greater physical disability, worse HRQoL, and lower chance of drug-free remission in adulthood.

Assessment of calcinosis in Portuguese patients with systemic sclerosis - a multicenter study

INTRODUCTION/OBJECTIVES

The study aims to define the clinical and subclinical calcinosis prevalence, the sensitivity of radiographed site and clinical method for its diagnosis, and the phenotype of Portuguese systemic sclerosis (SSc) patients with calcinosis.

METHOD

A cross-sectional multicenter study was conducted with SSc patients fulfilling Leroy/Medsger 2001 or ACR/EULAR 2013 classification criteria, registered in the Reuma.pt. Calcinosis was assessed through clinical examination and radiographs of hands, elbows, knees, and feet. Independent parametric or non-parametric tests, multivariate logistic regression, and sensitivity calculation of radiographed site and clinical method for calcinosis detection were performed.

RESULTS

We included 226 patients. Clinical calcinosis was described in 63 (28.1%) and radiological calcinosis in 91 (40.3%) patients, of which 37 (40.7%) were subclinical. The most sensitive location to detect calcinosis was the hand (74.7%). Sensitivity of the clinical method was 58.2%. Calcinosis patients were more often female (p = 0.008) and older (p < 0.001) and had more frequently longer disease duration (p < 0.001), limited SSc (p = 0.017), telangiectasia (p = 0.039), digital ulcers (p = 0.001), esophageal (p < 0.001) and intestinal (p = 0.003) involvements, osteoporosis (p = 0.028), and late capillaroscopic pattern (p < 0.001). In multivariate analysis, digital ulcers (OR 2.63, 95% CI 1.02-6.78, p = 0.045) predicted overall calcinosis, esophageal involvement (OR 3.52, 95% CI 1.28-9.67, p = 0.015) and osteoporosis (OR 4.1, 95% CI 1.2-14.2, p = 0.027) predicted hand calcinosis, and late capillaroscopic pattern (OR 7.6, 95% CI 1.7-34.9, p = 0.009) predicted knee calcinosis. Anti-nuclear antibody positivity was associated with less knee calcinosis (OR 0.021, 95% CI 0.001-0477, p = 0.015).

CONCLUSIONS

Subclinical calcinosis high prevalence suggests that calcinosis is underdiagnosed and radiographic screening might be relevant. Multifactorial pathogenesis may explain calcinosis predictors' variability. Key Points • Prevalence of subclinical calcinosis in SSc patients is substantial. • Hand radiographs are more sensitive to detect calcinosis than other locations or clinical method. • Digital ulcers were associated with overall calcinosis, esophageal involvement and osteoporosis were associated with hand calcinosis, and late sclerodermic pattern in nailfold capillaroscopy was associated with knee calcinosis. • Anti-nuclear antibody positivity may be a protective factor for knee calcinosis.

Self-Standing Bioinspired Polymer Films Doped with Ultrafine Silver Nanoparticles as Innovative Antimicrobial Material

Thin self-standing films with potential antimicrobial synergistic activity have been produced by a simple green chemical synthesis with overnight thermal treatment. Their properties have been studied by scanning electron microscopy, X-ray photoelectron spectroscopy and other techniques to understand their potential range of applications. In this work, the focus was set on the development of a potential novel and effective alternative to conventional antimicrobial materials. By creating an antimicrobial polymer blend, and using it to develop and immobilize fine (~25 nm) silver nanophases, we further aimed to exploit its film-forming properties and create a solid composite material. The resulting polymer matrix showed improved water uptake percentage and better stability in the presence of water. Moreover, the antimicrobial activity of the films, which is due to both organic and inorganic components, has been evaluated by Kirby-Bauer assay against common foodborne pathogens (Staphylococcus aureus and Salmonella enterica) and resulted in a clear inhibition zone of 1.2 cm for the most complex nanocomposition. The excellent performance against bacteria of fresh and 6-month-old samples proves the prospects of this material for the development of smart and biodegradable food packaging applications.

The Daily Expression of ABCC4 at the BCSFB Affects the Transport of Its Substrate Methotrexate

The choroid plexuses (CPs), located in the brain ventricles, form an interface between the blood and the cerebrospinal fluid named the blood-cerebrospinal barrier, which, by the presence of tight junctions, detoxification enzymes, and membrane transporters, limits the traffic of molecules into the central nervous system. It has already been shown that sex hormones regulate several CP functions, including the oscillations of its clock genes. However, it is less explored how the circadian rhythm regulates CP functions. This study aimed to evaluate the impact of sex hormones and circadian rhythms on the function of CP membrane transporters. The 24 h transcription profiles of the membrane transporters rAbca1, rAbcb1, rAbcc1, rAbcc4, rAbcg2, rAbcg4, and rOat3 were characterized in the CPs of intact male, intact female, sham-operated female, and gonadectomized rats. We found that rAbcc1 is expressed in a circadian way in the CPs of intact male rats, rAbcg2 in the CPs of intact female rats, and both rAbcc4 and rOat3 mRNA levels were expressed in a circadian way in the CPs of intact male and female rats. Next, using an in vitro model of the human blood–cerebrospinal fluid barrier, we also found that methotrexate (MTX) is transported in a circadian way across this barrier. The circadian pattern of Abcc4 found in the human CP epithelial papilloma cells might be partially responsible for MTX circadian transport across the basal membrane of CP epithelial cells.

The druggability of bitter taste receptors for the treatment of neurodegenerative disorders

The delivery of therapeutic drugs to the brain remains a major pharmacology challenge. A complex system of chemical surveillance to protect the brain from endogenous and exogenous toxicants at brain barriers hinders the uptake of many compounds with significant in vitro and ex vivo therapeutic properties. Despite the advances in the field in recent years, the components of this system are not completely understood. Recently, a large group of chemo-sensing receptors, have been identified in the blood-cerebrospinal fluid barrier. Among these chemo-sensing receptors, bitter taste receptors (TAS2R) hold promise as potential drug targets, as many TAS2R bind compounds with recognized neuroprotective activity (quercetin, resveratrol, among others). Whether activation of TAS2R by their ligands contributes to their diverse biological actions described in other cells and tissues is still debatable. In this review, we discuss the potential role of TAS2R gene family as the mediators of the biological activity of their ligands for the treatment of central nervous system disorders and discuss their potential to counteract drug resistance by improving drug delivery to the brain.

Clinical features and outcome of 1054 patients with Systemic Sclerosis: analysis of Reuma.pt/SSc registry

BACKGROUND

Systemic sclerosis (SSc) is a rare connective tissue disorder with heterogeneous manifestations and outcomes. Besides differences in disease characteristics among distinct ethnic groups and geographical regions, several questions regarding the impact of the disease and the effectiveness of treatments remain unanswered. To address these questions, the Rheumatic Diseases Portuguese Register (Reuma.pt) launched a specific protocol for the prospective follow-up of SSc patients.

OBJECTIVES

To describe the baseline characteristics, disease subsets, treatments used and survival of SSc patients registered in Reuma.pt/SSc.

METHODS

Data from adult patients with SSc included in Reuma.pt up to November 2020 were analysed. Demographic features, SSc subsets, fulfilment of classification criteria, main clinical and immunological features, comorbidities, treatments used and survival data were described and compared between diffuse cutaneous (dc) and limited cutaneous (lc) disease subsets. Survival was calculated for patients included in Reuma.pt within the first two years of diagnosis.

RESULTS

In total, 1054 patients were included, 87.5% female, with a mean age at diagnosis of 52.7 +/- 14.8 years. The most common subset was lcSSc (56.3%), followed by dcSSc (17.5%), preclinical SSc (13%), overlap syndrome (9.8%) and SSc sine scleroderma (3.3%). Raynaud's phenomenon (93.4%) and skin thickening (76.9%) were the most frequently observed clinical manifestations. Gastrointestinal (62.8% versus 47.8%), pulmonary (59.5% versus 23%) and cardiac (12.8% versus 6.9%) involvements were significantly more prevalent in dcSSc than lcSSc. Ninety per-cent of patients were Antinuclear antibody positive, 52.5% were Anti-centromere antibody positive and 21% anti-topoisomerase positive, with significant differences between lcSSc and dcSSc. One-third of patients were treated with immunomodulators, 53.6% with vasodilators, 23% with glucocorticoids and 2.3% with biologics. During follow-up, 83 deaths (7.9%) were reported. The overall 1-, 2- and 5-year survivals were 98.0%, 96.8% and 92.6%, respectively, without significant differences between lcSSc and dcSSc.

CONCLUSION

Reuma.pt/SSc data highlights the importance of registries in improving knowledge about rare and complex diseases, such as SSc. Clinical features of Portuguese SSc patients are similar to those of other populations. In recently diagnosed patients, 5-year survival is over 92%. To the best of our knowledge, this is the first study showing that clinical features of Portuguese SSc are similar to those of other cohorts.

Health-related quality of life and disability in adults with juvenile idiopathic arthritis: comparison with adult-onset rheumatic diseases

Objective

To compare physical disability, mental health, fatigue and health-related quality of life (HRQoL) across juvenile idiopathic arthritis (JIA) categories in adulthood and between JIA and adult-onset rheumatic diseases.

Methods

Cross-sectional analysis nested in a cohort of adult patients with JIA registered in the Rheumatic Diseases Portuguese Register (Reuma.pt). Physical disability (Health Assessment Questionnaire—Disability Index), mental health symptoms (Hospital Anxiety and Depression Scale), fatigue (Functional Assessment of Chronic Illness Therapy—Fatigue Scale (FACIT-F)) and HRQoL (EuroQol-5D (EQ5D) and Short Form (SF-36)) were compared across JIA categories. Patients with polyarticular JIA and enthesis-related arthritis (ERA) JIA were compared respectively to patients with rheumatoid arthritis (RA) and spondyloarthritis (SpA), matched for gender and age, adjusted for disease duration and activity.

Results

585 adult patients with JIA were included. Comparison across JIA categories showed that persistent oligoarthritis and patients with ERA reported a higher score in EQ5D and SF-36 physical component when compared with other JIA categories.

Polyarticular JIA reported less disability and fatigue than patients with RA (median Health Assessment Questionnaire of 0.25 vs 0.63; p<0.001 and median FACIT-F score 42 vs 40; p=0.041). Polyarticular JIA had also better scores on EQ5D and all domains of SF-36, than patients with RA. Patients with ERA reported less depression and anxiety symptoms (0% vs 14.8%; p=0.003% and 9% vs 21.3%; p=0.002) and less fatigue symptoms (45 vs 41; p=0.01) than patients with SpA.

Conclusion

Persistent oligoarticular JIA and ERA are the JIA categories in adulthood with better HRQoL. Overall, adult polyarticular and patients with ERA JIA have lower functional impairment and better quality-of-life than patients with RA and SpA.

Gender differences in clinical features and outcomes of a Portuguese systemic sclerosis cohort

Evidence for the role of sex in the clinical manifestations of systemic sclerosis (SSc) patients is emerging. Some multicenter cohorts have shown that male SSc patients have more severe disease and worse survival. To assess the differences in clinical manifestations and survival in Portuguese SSc patients according to gender. Data from male and female adult SSc patients included in the Rheumatic Diseases Portuguese Register (Reuma.pt) were analysed and compared. Survival was calculated for patients included in Reuma.pt. within the first two years of diagnosis (inception cohort). In total, 1054 adult patients with SSc were included, 12.5% males. No differences in demographic features and comorbidities were found between the sexes, except for a higher rate of cigarette smokers among men. Diffuse cutaneous SSc and anti-topoisomerase antibodies were more prevalent in males than females. Additionally, male patients presented significantly more myositis, interstitial lung disease and gastric involvement. There were no differences in the patterns of drug use between the sexes. During follow-up, more deaths were reported in men than women (12.1% vs 7.3%, p = 0.04). The overall 1-, 3-, and 5-year survivals from diagnosis of the inception cohort (N = 469) for men vs women were 96.4% vs 98.2%, 93% vs 95.9%, and 75.8% vs 93.2%, respectively, with statistically significant differences (p < 0.01). This study confirms the existence of gender differences in clinical and immunological SSc features. Although SSc is less common in men than women, men have a more severe expression of skin and internal organ involvement and worse survival. Key Points • There are differences in SSc disease manifestations between sexes. • Males more commonly have diffuse cutaneous SSc, anti-topoisomerase antibodies, pulmonary and musculoskeletal involvement. • In the inception cohort, men had worse survival rates than women.

Happiness, quality of life and their determinants among people with systemic sclerosis: a structural equation modelling approach

BACKGROUND

Patients' objectives and experiences must be core to the study and management of chronic diseases, such as SSc. Although patient-reported outcomes are attracting increasing attention, evaluation of the impact of disease on the overall subjective well-being, equivalent to 'happiness', is remarkably lacking.

OBJECTIVES

To examine the determinants of happiness and quality of life in patients with SSc, with emphasis on disease features and personality traits.

METHODS

Observational, cross-sectional multicentre study, including 142 patients, with complete data regarding disease activity, disease impact, personality, health-related quality of life (HR-QoL) and happiness. Structural equation modelling was used to evaluate the association between the variables.

RESULTS

The results indicated an acceptable fit of the model to the data. Perceived disease impact had a significant negative direct relation with HR-QoL (β = -0.79, P < 0.001) and with happiness (β = -0.52, P < 0.001). Positive personality traits had a positive relation with happiness (β = 0.36, P = 0.002) and an important indirect association upon QoL (β = 0.43) and happiness (β = 0.23). Perceived disease impact is influenced by body image, fatigue and SSc-related disability to a higher degree (β = 0.6-0.7) than by disease activity (β = 0.28) or form (β = 0.17). Impact of disease had a much stronger relation with HR-QoL than with happiness.

CONCLUSIONS

The results suggest that treatment strategies targeting not only disease control but also the mitigation of relevant domains of disease impact (body image, fatigue, global disability) may be important to improve patients' experience of the disease. The reinforcement of resilience factors, such as positive psychological traits, may also play a contributory role towards better patient outcomes.

Granulomatosis with polyangiitis - the incomplete puzzle

Granulomatous with polyangiitis (GPA) is a necrotizing granulomatous vasculitis that mostly affects small-sized vessels. The disease can affect many organs, although renal and respiratory tract involvement are the most frequent and distinguishing features. Musculoskeletal manifestations have been reported in about 50% of patients and can occur as myalgia, oligoarthralgia/arthritis of large joints or polyarthralgia/arthritis of small joints. Infrequently musculoskeletal symptoms can be the first disease manifestation, and in this clinical scenario GPA diagnosis might be delayed or mistaken by other rheumatic diseases. The authors describe three patients with musculoskeletal symptoms as earliest GPA manifestations, illustrating the clinical challenge.

Gram-Positive Pneumonia: Possibilities Offered by Phage Therapy

Pneumonia is an acute pulmonary infection whose high hospitalization and mortality rates can, on occasion, bring healthcare systems to the brink of collapse. Both viral and bacterial pneumonia are uncovering many gaps in our understanding of host–pathogen interactions, and are testing the effectiveness of the currently available antimicrobial strategies. In the case of bacterial pneumonia, the main challenge is antibiotic resistance, which is only expected to increase during the current pandemic due to the widespread use of antibiotics to prevent secondary infections in COVID-19 patients. As a result, alternative therapeutics will be necessary to keep this disease under control. This review evaluates the advantages of phage therapy to treat lung bacterial infections, in particular those caused by the Gram-positive bacteria Streptococcus pneumoniae and Staphylococcus aureus, while also highlighting the regulatory impediments that hamper its clinical use and the difficulties associated with phage research.

The relationship between the phageome and human health: are bacteriophages beneficial or harmful microbes?

In the context of the global antibiotic resistance crisis, bacteriophages are increasingly becoming promising antimicrobial agents against multi-resistant bacteria. Indeed, a huge effort is being made to bring phage-derived products to the market, a process that will also require revising the current regulations in order to facilitate their approval. However, despite the evidence supporting the safety of phages for humans, the general public would still be reluctant to use 'viruses' for therapeutic purposes. In this scenario, we consider that it is important to discuss the role of these microorganisms in the equilibrium of the microbiota and how this relates to human health. To do that, this review starts by examining the role of phages as key players in bacterial communities (including those that naturally inhabit the human body), modulating the species composition and contributing to maintain a 'healthy' status quo. Additionally, in specific situations, e.g. an infectious disease, bacteriophages can be used as target-specific antimicrobials against pathogenic bacteria (phage therapy), while being harmless to the desirable microbiota. Apart from that, incipient research shows the potential application of these viruses to treat diseases caused by bacterial dysbiosis. This latter application would be comparable to the use of probiotics or prebiotics, since bacteriophages can indirectly improve the growth of beneficial bacteria in the gastrointestinal tract by removing undesirable competitors. On the other hand, possible adverse effects do not appear to be an impediment to promote phage therapy. Nonetheless, it is important to remember their potentially negative impact, mainly concerning their immunogenicity or their potential spread of virulence and antibiotic resistance genes, especially by temperate phages. Overall, we believe that phages should be largely considered beneficial microbes, although it is paramount not to overlook their potential risks.

Bronchiectasis in rheumatoid arthritis. A clinical appraisial

Bronchiectasis is defined as irreversibly damaged and dilated bronchi and is one of the most common pulmonary manifestations in patients with rheumatoid arthritis (RA). The model of RA-associated autoimmunity induced in some individuals by chronic bacterial infection in bronchiectasis is becoming increasingly acceptable, although a genetic predisposition to RA-associated bronchiectasis has also been demonstrated. Bronchiectasis should be suspected in RA patients with chronic cough and sputum production or frequent respiratory infections and the diagnosis must be confirmed by thoracic high-resolution computed tomography. Management of patients with RA-associated bronchiectasis includes a multimodal treatment approach. Similar to all patients with non-cystic fibrosis bronchiectasis, patients with RA-associated bronchiectasis benefit from a pulmonary rehabilitation program, including an exercise/muscle strengthening program and an education program with a specific session on airway clearance techniques. Prophylactic antibiotics are recommended for patients with frequent (3 or more infective exacerbations per year) or severe infections requiring hospitalization/intravenous antibiotics and inhaled corticosteroids and long-acting β2-agonists should be used in patients with non-cystic fibrosis bronchiectasis and associated airway hyper-responsiveness. In patients with RA-associated bronchiectasis the use of immunomodulatory drugs has to be carefully considered, as they are essential to control disease activity, despite being associated with an increased infectious risk. Pneumococcal and influenza vaccines are advised to all patients with RA-associated bronchiectasis in order to reduce the risk of infection. Patients with RA-associated bronchiectasis have a poorer prognosis than those with either RA or bronchiectasis alone and require regular follow-up, under the joint care of a rheumatologist and a pulmonologist.

How challenging can neuropsychiatric systemic lupus erythematous be? experience from a tertiary care centre

Neuropsychiatric Systemic Lupus Erythematous comprises several neurologic and psychiatric manifestations attributable to Lupus Erythematous Systemic. Diagnosis implies exclusion of non- Systemic Lupus Erythematous -related diseases that might mimic the same symptoms and should be prompt in order to avoid delaying the treatment. Treatment is dictated by the underlying pathogenesis and includes immunosuppression and/or anti-platelet agents/anticoagulation. We report four cases of Neuropsychiatric Systemic Lupus Erythematous, illustrating how challenging it can be to diagnose and treat these patients.

Real-world Longterm Effectiveness of Tumor Necrosis Factor Inhibitors in Psoriatic Arthritis Patients from the Rheumatic Diseases Portuguese Register

Objective.

To assess longterm effectiveness of tumor necrosis factor inhibitors (TNFi) in patients with psoriatic arthritis (PsA) registered in the Rheumatic Diseases Portuguese Register, exposed to at least 1 TNFi, prospectively followed between 2001 and 2017.

Methods.

Kaplan-Meier analysis was performed for first-, second-, and third-line TNFi. Responses included European League Against Rheumatism (EULAR) criteria, Disease Activity Index for Psoriatic Arthritis (DAPSA), minimal disease activity (MDA), and Ankylosing Spondylitis Disease Activity Score (ASDAS) at 3 and 6 months. Baseline predictors of discontinuation and response were studied using Cox and multivariable multinomial/logistic regression models.

Results.

The 750 patients with PsA showed drug retention of 4.1 ± 3.4 years (followup 5.8 ± 3.8 yrs) for first TNFi. Switching to a second (189 patients) or third (50 patients) TNFi further decreased survival by 1.1 years. Female sex, higher baseline 28-joint count Disease Activity Score, and infliximab were predictors of first TNFi discontinuation. After 6 months of the first TNFi, 48.7% of patients achieved a good EULAR criteria response and 20.9% were in DAPSA remission. There were 11.4% in MDA, and 56.4% had a good ASDAS. Responses to the second TNFi were significantly inferior compared to responses to the first TNFi. Female sex and higher baseline Health Assessment Questionnaire–Disability Index were negatively associated with good EULAR response at 3 months, and obesity decreased the chance of response at 6 months.

Conclusion.

In this study, switching to a second or third TNFi was associated with significantly lower drug survival and response rates for patients with axial and peripheral PsA subtypes. More successful therapeutic approaches will require considering the effect of sex and obesity on TNFi effectiveness.

How to diagnose lupus enteritis early? Lessons learned from a multicenter case series

INTRODUCTION

Lupus enteritis (LE) is a rare, potentially life-threatening manifestation of systemic lupus erythematosus (SLE). Early diagnosis is crucial for early treatment and prevention of serious complications such as ischemic enteritis, bowel infarction with bleeding and/or perforation and peritonitis. The objective of this case review is to identify strategies for early diagnosis of LE.

METHODS

Retrospective analysis of patients with SLE (fulfilling ACR 1997 and/or SLICC classification criteria) and presenting LE from three tertiary SLE centers was conducted. The diagnosis was based on clinical and imaging features consistent with LE and exclusion of other causes of GI disorders.

RESULTS

We report seven cases of LE (female: 100%; age range: 16-55 years). All presented with acute onset abdominal pain, nausea and vomiting at the emergency room. Two patients had lupus enteritis as inaugural manifestation of SLE. Of the remaining five, one presented at the previous visit to the lupus clinic with clinically active disease and two had serologically active/ clinically inactive SLE. High anti-dsDNA antibodies and low serum complement were universally present at time of the LE event. Abdominal ultrasound was the first imaging exam to be performed in the emergency room. In all cases it showed bowel wall thickening, dilatation of intestinal segments, increased reflectivity of mesenteric fat and mild ascites, raising the suspicion of LE and immediate start of treatment. These features were later confirmed by CT scan in five patients.

DISCUSSION

Despite being rare, LE must always be considered in any SLE patient presenting with GI symptoms. Abdominal ultrasound can be a reliable first line diagnostic tool for LE.

Tocilizumab and rituximab have similar effectiveness and are both superior to a second tumour necrosis factor inhibitor in rheumatoid arthritis patients who discontinued a first TNF inhibitor

OBJECTIVES

To compare the effectiveness of a 2nd TNF inhibitor (TNFi), Tocilizumab (TCZ) and Rituximab (RTX), measured by drug retention and by response rates, in RA patients after discontinuing a first-line TNFi and to clarify the reasons and predictors for discontinuation of a second-line biologic.

MATERIAL AND METHODS

Non-interventional prospective study of RA patients exposed to a 2nd TNFi, TCZ or RTX after previous TNFi discontinuation using real-world data from Reuma.pt database. Drug retention was estimated using Kaplan-Meier analysis and Cox models. Crude and LUNDEX adjusted response rates were evaluated at 6 months, 1 and 2 years and reasons for discontinuation were compared according to biologic class.

RESULTS

In total, 643 patients were included, 88.8% females, with a mean age of 59.4±12.8 years. Of those, 390 (60.7%) initiated a 2nd TNFi, 147 (22.9%) TCZ and 106 (16.5%) RTX. Drug retention was significantly greater among patients who initiated TCZ (76.4±4.3 months) or RTX (80.8±4.8 months), compared with those who initiated a 2nd TNFi (52.7±2.6 months) (log rank test, p < 0.001). In the adjusted Cox model, hazards of discontinuation were significantly lower for TCZ (HR 0.39, 95% CI 0.23-0.64, p < 0.001) and RTX (HR 0.42, 95% CI 0.25-0.72, p=0.001). Smokers had a significantly higher risk for discontinuation (HR 2.43, 95%CI 1.50-3.95, p < 0.001) as well as patients with higher HAQ at baseline (HR 1.51, 95%CI 1.14-2.00, p=0.004). The proportion of patients in remission or low disease activity according to Clinical Disease Activity Index (CDAI) at 6 months, 1 and 2 years was, respectively, 46.5%/50.0%/61.2% for TNFi, 52.9%/53.6%/ 69.2% for TCZ and 37.7%/48.0%/50.0% for RTX. After LUNDEX adjustment, response rates were, respectively, 33.0%/31.0%/31.8% for 2nd TNFi, 42.8%/41.8%/53.3% for TCZ and 32.0%/39.4%/39.0% for RTX. The main reasons for discontinuation were inefficacy for 2nd TNFi and RTX and adverse events for TCZ (p < 0.001).

CONCLUSIONS

Our findings showed a significantly higher drug retention for TCZ and RTX, compared with 2nd TNFi, and similar persistence among TCZ and RTX, in patients who discontinued a first-line TNFi. These data corroborate the notion that switching to a biologic with a different mode of action is more effective than to a second TNFi.

Antifibrotics in interstitial lung disease related to connective tissue diseases - a paradigm shift in treatment and outcome

Interstitial lung disease (ILD) is one of the major causes of morbidity and mortality in patients with connective tissue disease (CTD) and the treatments available until nowadays are in most cases unable to halt disease progression. CTD-ILD pathogenesis includes an initial inflammatory phase, followed by a fibrotic phase, in which extracellular matrix proteins are produced and fibrotic scaring tissue within the lung develops. Steroids and immunosuppressants are the weapons we currently have to treat CTD-ILD. However, mortality rates remain high and identification of new therapeutic targets is crucial. Antifibrotic drugs, which include nintedanib and pirfenidone, have been approved for the treatment of idiopathic pulmonary fibrosis (IPF) and due to similar pathogenesis between IPF and CTD-ILD, their use seems attractive in patients with CTD-IL. We report 3 cases of patients with different CTDs, with predominantly fibrotic changes in high resolution computed tomography that progressed despite immunosuppression, and who have attained disease stability after introduction of antifibrotic drugs.

Osteopoikilosis: case series from Portuguese Rheumatology Centers

Osteopoikilosis (OPK) is a rare, hereditary, usually asymptomatic disease characterized by the presence of multiple, well-defined sclerotic lesions distributed in peri-articular locations, frequently diagnosed as an incidental finding. Differential diagnosis with osteoblastic metastases is fundamental. This article reports six cases of OPK diagnosed in Portuguese Rheumatology Centers.

Evaluation of a single extraction test to estimate the human oral bioaccessibility of potentially toxic elements in soils: Towards more robust risk assessment

Intake of soil by children and adults is a major exposure pathway to contaminants including potentially toxic elements (PTEs). However, only the fraction of PTEs released in stomach and intestine are considered as bioaccessible and results from routine analyses of the total PTE content in soils, therefore, are not necessarily related to the degree of bioaccessibility. Experimental methods to determine bioaccessibility usually are time-consuming and relatively complicated in terms of analytical procedures which limits application in first tier assessments. In this study we evaluated the potential suitability of a recently developed single extract method (ISO-17586:2016) using dilute (0.43M) nitric acid (HNO₃) to mimic the bioaccessible fraction of PTEs in soils. Results from 204 soils from Portugal, Brazil and the Netherlands including all major soil types and a wide range of PTEs' concentrations showed that the extraction efficiency using 0.43M HNO₃ of Ba, Cd, Cu, Ni, Pb and Zn in soils is related to that of in vitro methods including the Simple Bioaccessibility Extraction Test (SBET) and Unified BARGE Method (UBM). Also, differences in the degree of bioaccessibility resulting from differences in parent material, geology and climate conditions did not affect the response of the 0.43M HNO₃ extraction which is a prerequisite to be able to compare results from different soils. The use of 0.43M HNO₃ as a first screening of bioaccessibility therefore offers a robust and representative way to be included in first tier standard soil tests to estimate the oral bioaccessibility.

CAPSULE

The single dilute (0.43M) nitric acid extraction can be used in first tier soil risk assessment to assess both geochemical reactivity and oral bioaccessibility of PTEs.

Iloprost infusion through elastomeric pump for the outpatient treatment of severe Raynaud's phenomenon and digital ulcers - a single centre experience

Raynaud's phenomenon (RP) and digital ulcers (DU) are the main clinical features of vasculopathy that occurs in several systemic rheumatic diseases. Intravenous iloprost is recommended for the treatment of severe RP and DU in patients with systemic sclerosis and portable devices for iloprost infusion have been recently designed, allowing outpatient treatment. This new alternative for drug administration not only avoids absenteeism, with the patient having the opportunity to continue his own family and work life, but also reduces the costs associated with hospitalization. We describe our protocol and report our experience with 12 patients, for a total of 25 infusions, who have received domiciliary iloprost through elastomeric pump. Patients could easily manage the device and the treatment outcomes were promising, with all patients having DU healing, without any special safety concerns.

Intravenous human immunoglobulin for the treatment of severe longitudinal extensive transverse myelitis associated with systemic lupus erythematous

A 39-year-old female with systemic lupus erythematous (SLE) presented with fever, headaches and rash and was treated with empiric antibiotics for a presumable meningitis. However, cerebrospinal fluid turned out to be sterile and fever persisted with onset of hyporeflexive paraparesis with sensory loss below D10. Magnetic resonance imaging (MRI) demonstrated intradural-extramedullary hematoma (related to traumatic lumbar puncture), which was successfully drained. Subsequent surgical scar infection occurred and was treated accordingly. Due to persistent deficits and urinary retention development, she repeated MRI, which showed holocord abnormal T2 hyperintensity. After excluding other causes, SLE-associated longitudinal extensive transverse myelitis was diagnosed and treated with high-dose steroids and intravenous human immunoglobulin (IVIG), with reduction in intensity and extension of abnormal T2 signal within only one week. Monthly IVIG was kept for 6 months with progressive ability to walk and MRI findings resolution in 3 months. Four months after IVIG suspension no recurrence occurred.

Removal and recovery of Critical Rare Elements from contaminated waters by living Gracilaria gracilis

The experiments performed in this work proved the ability of Gracilaria gracilis to concentrate and recover Critical Rare Elements (CRE) from contaminated waters. The importance of recycling these elements is related to their very limited sources in Nature and progressive use in technologies. Moreover, their mining exploitation has negative environmental impact, and recent studies point them as new emerging pollutants. To the best of our knowledge, this is the first report on the application of living macroalgae for the removal and recovery of CRE. G. gracilis (2.5gL^-1, fresh weight) was exposed to mono- and multi-element saline solutions of 500μgL^-1 of Y, Ce, Nd, Eu and La. Removal was up to 70% in 48h, with bioaccumulation following Elovich kinetic model. In multi-element solutions, selectivity was not observed although removal of lanthanides improved comparatively to single-element solutions. No mortality or adverse effect on growth was registered. The subsequent macroalgae digestion allowed collecting virtually 100% of all elements in a 300-fold more concentrated solution. The overall results suggest the application of living macroalgae as a simple and effective alternative technology for removing and recovering CRE from wastewaters, contributing to an improvement of water quality and CRE recycling.

Addressing the impact of mercury estuarine contamination in the European eel (Anguilla anguilla L., 1758) - An early diagnosis in glass eel stage based on erythrocytic nuclear morphology

The decline of the European eel (Anguilla anguilla L., 1758) population throughout Europe has been partially attributed to pollution. As glass eel estuarine migration may represent a considerable threat, the impact of mercury (Hg) contamination at this stage was evaluated through an in situ experiment (7days). Total Hg (tHg) bioaccumulation was evaluated concomitantly with erythrocytic nuclear morphology alterations: erythrocytic nuclear abnormalities assay (ENA), frequency of immature erythrocytes (IE) and the erythrocytic maturity index (EMI). The ENA results suggested a genotoxic pressure at the most contaminated sites, in line with the tHg increase. The EMI data, together with IE frequency, showed that fish exposed to high levels of Hg exhibited alterations of haematological dynamics, translated into an erythropoiesis increment. Despite the presence of these compensatory mechanisms, the present findings suggest a harmful impact of Hg on genome integrity at this early development stage, potentially affecting eels' condition and ultimately the population sustainability.

Availability of polycyclic aromatic hydrocarbons to earthworms in urban soils and its implications for risk assessment

Polycyclic aromatic hydrocarbons (PAHs) are a global problem, and in urban soils they can be found at potentially hazard levels. Nevertheless, the real risks that these contaminants pose to the environment are not well known, since the bioavailability of PAHs in urban soils has been poorly studied. Therefore, the bioavailability of PAHs in some selected urban soils from Lisbon (Portugal) was evaluated. Moreover, the applicability of a first screening phase based on total contents of PAHs was assessed. Results show that bioavailability of PAHs is reduced (low levels in earthworms, low accumulation percentages, and low biota-to-soil accumulation factors values), especially in more contaminated soils. The aging of these compounds explains this low availability, and confirms the generally accepted assumption that accumulation of PAHs in urban areas is mostly related with a long-term deposition of contaminated particles. The comparison of measured PAHs concentrations in earthworm tissues with the ones predicted based on theoretical models, reinforce that risks based on total levels are overestimated, but it can be a good initial approach for urban soils. This study also highlights the need of more reliable ecotoxicological data.

Portuguese recommendations for the prevention, diagnosis and management of primary osteoporosis - 2018 update

BACKGROUND

Advances in osteoporosis (OP)case definition, treatment options, optimal therapy duration and pharmacoeconomic evidence in the national context motivated the Portuguese Society of Rheumatology (SPR) to update the Portuguese recommendations for the diagnosis and management of osteoporosis published in 2007.

METHODS

SPR bone diseases' working group organized meetings involving 55 participants (rheumatologists, rheumatology fellows and one OP specialist nurse) to debate and develop the document. First, the working group selected 11 pertinent clinical questions for the diagnosis and management of osteoporosis in standard clinical practice. Then, each question was investigated through literature review and draft recommendations were built through consensus. When insufficient evidence was available, recommendations were based on experts' opinion and on good clinical practice. At two national meetings, the recommendations were discussed and updated. A draft of the recommendations full text was submitted to critical review among the working group and suggestions were incorporated. A final version was circulated among all Portuguese rheumatologists before publication and the level of agreement was anonymously assessed using an online survey.

RESULTS

The 2018 SPR recommendations provide comprehensive guidance on osteoporosis prevention, diagnosis, fracture risk assessment, pharmacological treatment initiation, therapy options and duration of treatment, based on the best available evidence. They attained desirable agreement among Portuguese rheumatologists. As more evidence becomes available, periodic revisions will be performed. Target audience and patient population: The target audience for these guidelines includes all clinicians. The target patient population includes adult Portuguese people. Intended use: These recommendations provide general guidance for typical cases. They may not be appropriate in all situations - clinicians are encouraged to consider this information together with updated evidence and their best clinical judgment in individual cases.

Salinity induced effects on the growth rates and mycelia composition of basidiomycete and zygomycete fungi

Soil salinization, as the combination of primary and secondary events, can adversely affect organisms inhabiting this compartment. In the present study, the effects of increased salinity were assessed in four species of terrestrial fungi: Lentinus sajor caju, Phanerochaete chrysosporium, Rhizopus oryzae and Trametes versicolor. The mycelial growth and biochemical composition of the four fungi were determined under three exposure scenarios: 1) exposure to serial dilutions of natural seawater (SW), 2) exposure to serial concentrations of NaCl (potential surrogate of SW); and 3) exposure to serial concentrations of NaCl after a period of pre-exposure to low levels of NaCl. The toxicity of NaCl was slightly higher than that of SW, for all fungi species: the conductivities causing 50% of growth inhibition (EC₅₀) were within 14.9 and 22.0 mScm^-1 for NaCl and within 20.2 and 34.1 mScm^-1 for SW. Phanerochaete chrysosporium showed to be the less sensitive species, both for NaCl and SW. Exposure to NaCl caused changes in the biochemical composition of fungi, mainly increasing the production of polysaccharides. When fungi were exposed to SW this pattern of biochemical response was not observed. Fungi pre-exposed to low levels of salinity presented higher EC₅₀ than fungi non-pre-exposed, though 95% confidence limits overlapped, with the exception of P. chrysosporium. Pre-exposure to low levels of NaCl also induced changes in the biochemical composition of the mycelia of L. sajor caju and R. oryzae, relatively to the respective control. These results suggest that some terrestrial fungi may acquire an increased tolerance to NaCl after being pre-exposed to low levels of this salt, thus, suggesting their capacity to persist in environments that will undergo salinization. Furthermore, NaCl could be used as a protective surrogate of SW to derive safe salinity levels for soils, since it induced toxicity similar or higher than that of SW.

A macroalgae-based biotechnology for water remediation: Simultaneous removal of Cd, Pb and Hg by living Ulva lactuca

Metal uptake from contaminated waters by living Ulva lactuca was studied during 6 days, under different relevant contamination scenarios. In mono-metallic solutions, with concentrations ranging from 10 to 100 μg L^-1 for Hg, 10-200 μg L^-1 for Cd, and 50-1000 μg L^-1 for Pb, macroalgae (500 mg L^-1, d.w.) were able to remove, in most cases 93-99% of metal, allowing to achieve water quality criteria regarding both surface and drinking waters. In multi-metallic solutions, comprising simultaneously the three metals, living macroalgae still performed well, with Hg removal (c.a. 99%) not being significantly affected by the presence of Cd and Pb, even when those metals were in higher concentrations. Removal efficiencies for Cd and Pb varied between 57 and 96%, and 34-97%, respectively, revealing an affinity of U. lactuca toward metals: Hg > Cd > Pb. Chemical quantification in macroalgae, after bioaccumulation assays demonstrated that all Cd and Hg removed from solution was really bound in macroalgae biomass, while only half of Pb showed to be sorbed on the biomass. Overall, U. lactuca accumulated up to 209 μg g^-1 of Hg, up to 347 μg g^-1 of Cd and up to 1641 μg g^-1 of Pb, which correspond to bioconcentration factors ranging from 500 to 2200, in a dose-dependent accumulation. Pseudo-first order, pseudo-second order and Elovich models showed a good performance in describing the kinetics of bioaccumulation, in the whole period of time. In the range of experimental conditions used, no mortality was observed and U. lactuca relative growth rate was not significantly affected by the presence of metals. Results represent an important contribution for developing a macroalgae-based biotechnology, applied for contaminated saline water remediation, more "green" and cost-effective than conventional treatment methods.

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.

Histopathological and molecular effects of microplastics in Eisenia andrei Bouché

The ocean has been assumed as the main sink of microplastics (MPs), however, soils may also receive MPs from different sources and through different pathways, which may affect the biota and their role in soil functions. To the best of our knowledge, only one study, until now, reported the effects of MPs on the survival and fitness of soil organisms (Lumbricus terrestris). In our study, epigeic earthworms, of the species E. andrei, were exposed to different concentrations of MPs (0, 62.5, 125, 250, 500 and 1000 mg/kg soil_dw) in an OECD artificial soil and tested for reproduction, survival and growth of adults, following a standard protocol. The size of the polyethylene MPs to which earthworms were exposed ranged between 250 and 1000 μm. No significant effects were recorded on survival, number of juveniles and, in the final weight of adult earthworms after 28d of exposure, to the different concentrations of MPs. Nevertheless, FTIR-ATR of earthworms and histopathological analysis of the gut provided evidences of damages and immune system responses to MPs.

Efficacy and Safety of Vaccination in Pediatric Patients with Systemic Inflammatory Rheumatic Diseases: a systematic review of the literature

INTRODUCTION

Children and adolescents with systemic rheumatic diseases have an increased risk of infections. Although some infections are vaccine-preventable, immunization among patients with juvenile rheumatic diseases is suboptimal, partly due to some doubts that still persist regarding its efficacy and safety in this patient population.

OBJECTIVES

To review the available evidence regarding the immunological response and the safety of vaccination in children and adolescents with systemic inflammatory rheumatic diseases (SIRD).

METHODS

A systematic review of the current literature until December 2014 using MEDLINE, EMBASE and abstracts from the American College of Rheumatology and European League Against Rheumatism congresses (2011-2014), complemented by hand search was performed. Eligible studies were identified and efficacy (seroprotection and/or seroconversion) and safety (reactions to vaccine and relapse of rheumatic disease) outcomes were extracted and summarized according to the type of vaccine.

RESULTS

Twenty-eight articles concerning vaccination in pediatric patients with SIRDs were found, that included almost 2100 children and adolescents, comprising nearly all standard vaccinations of the recommended immunization schedule. Children with SIRDs generally achieved seroprotection and seroconversion; nevertheless, the antibody levels were often lower when compared with healthy children. Glucocorticoids and conventional disease-modifying anti-rheumatic drugs do not seem to significantly hamper the immune responses, whereas TNF inhibitors may reduce antibody production, particularly in response to pneumococcal conjugate, influenza, meningococcal C and hepatitis A vaccine. There were no serious adverse events, nor evidence of a relevant worsening of the underlying rheumatic disease. Concerning live attenuated vaccines, the evidence is scarce, but no episodes of overt disease were reported, even in patients under biological therapy.

CONCLUSIONS

Existing literature demonstrates that vaccines are generally well tolerated and effective in stable SIRD patients, yet antibody titers are frequently lower than in healthy controls. There is some evidence that biological therapy could hamper the immune response. Data on safety of live attenuated vaccines is limited. Although the available literature covers most vaccines included in the national immunization plan, there is a need for more information regarding new vaccines and new anti-rheumatic therapies.

Lead and PAHs contamination of an old shooting range: A case study with a holistic approach

Soil pollution at firing ranges is an issue of growing importance, due to the accumulation in soils of contaminants derived from ammunition and clay targets. The concentration of Pb and PAHs was determined in five soils of an abandoned shooting range in Galicia (northwest Spain), and an ecotoxicological characterization was performed in order to obtain an assessment of risks. Therefore, the retention capacity of soils was assessed using test organisms of different trophic levels, and the role of soils as habitat for soil invertebrates was assessed by reproduction tests and bioaccumulation assays with earthworms. The sum of 15 PAHs ranged between 38 and 360mgkg^-1, which exceed, together with Pb (160-720mgkg^-1), the Galician generic reference value for urban and sporting field soils. Bioaccumulation in E. andrei showed contents up to 104,000μgPbkg^-1_dw, and up to 645μgPAHskg^-1_fw. High contents of Pb and PAHs in soil samples and in Eisenia andrei whole body, caused a reduction in the number of juveniles produced, whereas, Vibrio fischeri, Raphidocelis subcapitata and Daphnia magna displayed a slight toxic response to the soil elutriates tested. Therefore, the function of these soils to retain contaminants seemed not compromised, probably due to the high organic matter content and pH values, which are weakly acidic. The habitat function was affected, indicating that soil solution is not the only route of exposure to contaminants to E. andrei. The integration of chemical and ecotoxicological lines of evidence give rise to high risks values, restricting the use of these areas, and pointing for risks to surrounding ecosystems due to possible trophic transferences. The calculation of risks using the chemical and ecotoxicological data, required by Spanish legislation, could be a good approach to communicate with those responsible and/or involved in the management of contaminated sites.

Cytotoxicity and oxidative stress responses of silica-coated iron oxide nanoparticles in CHSE-214 cells

The present study aimed at investigating cytotoxicity and oxidative stress induced by silica-coated iron oxide nanoparticles functionalized with dithiocarbamate (Fe₃O₄ NPs) in Chinook salmon cells (CHSE-214) derived from Oncorhynchus tshawytscha embryos. A significant reduction in cell viability was evident in response to Fe₃O₄ NPs as revealed by the 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyl tetrazolium bromide (MTT) assay after 24 h of exposure. Out of the tested concentrations (10, 20, and 30 μg/ml), the highest concentration has shown significant decrease in the viability of cells after 24 h of exposure. Alterations in the morphology of CHSE-214 cells was also evident at 10 μg/ml concentration of Fe₃O₄ NPs after 24 h. Fe₃O₄ NPs elicited a significant dose-dependent reduction in total glutathione content (TGSH), catalase (CAT), glutathione reductase (GR) with a concomitant increase in lipid peroxidation (LPO), and protein carbonyl (PC) at highest concentration (30 μg/ml) after 24 h of exposure. In conclusion, our data demonstrated that Fe₃O₄ NPs have potential to induce cytotoxicity in CHSE-214 cells, which is likely to be mediated through reactive oxygen species generation and oxidative stress.

Sex Hormone Decline and Amyloid β Synthesis, Transport and Clearance in the Brain

Sex hormones (SH) are essential regulators of the central nervous system. The decline in SH levels along with ageing may contribute to compromised neuroprotection and set the grounds for neurodegeneration and cognitive impairments. In Alzheimer's disease, besides other pathological features, there is an imbalance between amyloid β (Aβ) production and clearance, leading to its accumulation in the brain of older subjects. Aβ accumulation is a primary cause for brain inflammation and degeneration, as well as concomitant cognitive decline. There is mounting evidence that SH modulate Aβ production, transport and clearance. Importantly, SH regulate most of the molecules involved in the amyloidogenic pathway, their transport across brain barriers for elimination, and their degradation in the brain interstitial fluid. This review brings together data on the regulation of Aβ production, metabolism, degradation and clearance by SH.

Effects of dietary exposure to herbicide and of the nutritive quality of contaminated food on the reproductive output of Daphnia magna

Risk assessment of pesticides has been based on direct toxic effects on aquatic organisms. Indirect effects data are taken into account but with limitations, as it is frequently difficult to predict their real impacts in the ecosystems. In this context the main aim of this work was to assess how the exposure to the herbicide pendimethalin (Prowl(®)), under environmentally relevant concentrations, may compromise the nutritional composition of food for a relevant group of primary consumers of freshwater food webs-the daphnids, thus affecting their reproduction performance and subsequently the long-term sustainability of active populations of this grazer. Therefore, Daphnia magna individuals were chronically exposed in a clean medium to a control diet (NCF - i.e., non-contaminated green algae Raphidocelis subcapitata) and to a contaminated diet (CF - i.e., the same monoalgal culture grown in a medium enriched with pendimethalin in a concentration equivalent to the EC20 for growth inhibition of algae), during which reproductive endpoints were assessed. The algae were analysed for protein, carbohydrate and fatty acid content. The chemical composition of R. subcapitata in the CF revealed a slight decrease on total fatty acid levels, with a particular decrease of essential ω9 monounsaturated fatty acids. In contrast, the protein content was high in the CF. D. magna exposed to CF experienced a 16% reduction in reproduction, measured as the total number of offspring produced per female. Additionally, an internal pendimethalin body burden of 4.226μgg(-1) was accumulated by daphnids fed with CF. Hence, although it is difficult to discriminate the contribution of the pesticide (as a toxic agent transferred through the food web) from that of the food with a poor quality-compromised by the same pesticide, there are no doubts that, under environmentally relevant concentrations of pesticides, both pathways may compromise the populations of freshwater grazers in the long term, with consequences in the control of the primary productivity of these systems.

Sex Hormones Protect Against Amyloid-β Induced Oxidative Stress in the Choroid Plexus Cell Line Z310

The choroid plexus (CP) epithelium is a unique structure in the brain that forms an interface between the peripheral blood on the basal side and the cerebrospinal fluid (CSF) on the apical side. It is a relevant source of many polypeptides secreted to the CSF with neuroprotective functions and also participates in the elimination and detoxification of brain metabolites, such as β-amyloid (Aβ) removal from the CSF through transporter-mediated influx. The CP is also a target tissue for sex hormones (SHs) that have recognised neuroprotective effects against a variety of insults, including Aβ toxicity and oxidative stress in the central nervous system. The present study aimed to understand how SHs modulate Aβ-induced oxidative stress in a CP cell line (Z310 cell line) by analysing the effects of Aβ1-42 on oxidative stress, mitochondrial function and apoptosis, as well as by assessing how 17β-oestradiol (E2 ) and 5α-dihydrotestosterone (DHT) modulated these effects and the cellular uptake of Aβ1-42 by CP cells. Our findings show that E2 and DHT treatment reduce Aβ1-42 -induced oxidative stress and the internalisation of Aβ1-42 by CP epithelial cells, highlighting the importance of considering the background of SHs and therefore sex-related differences in Aβ metabolism and clearance by CP cells.

Advantages and limitations of chemical extraction tests to predict mercury soil-plant transfer in soil risk evaluations

In this study, we compared the size of the mobile Hg pool in soil to those obtained by extractions using 2 M HNO3, 5 M HNO3, and 2 M HCl. This was done to evaluate their suitability to be used as proxies in view of Hg uptake by ryegrass. Total levels of Hg in soil ranged from 0.66 to 70 mg kg(-1) (median 17 mg kg(-1)), and concentrations of Hg extracted increased in the order: mobile Hg < 2 M HNO3 < 5 M HNO3 < 2 M HCl. The percentage of Hg extracted relative to total Hg in soil varied from 0.13 to 0.79 % (for the mobile pool) to 4.8-82 % (for 2 M HCl). Levels of Hg in ryegrass ranged from 0.060 to 36 mg kg(-1) (median 0.65 mg kg(-1), in roots) and from 0.040 to 5.4 mg kg(-1) (median 0.34 mg kg(-1), in shoots). Although results from the 2 M HNO3 extraction appeared to the most comparable to the actual total Hg levels measured in plants, the 2 M HCl extraction better expressed the variation in plant pools. In general, soil tests explained between 66 and 86 % of the variability of Hg contents in ryegrass shoots. Results indicated that all methods tested here can be used to estimate the plant total Hg pool at contaminated areas and can be used in first tier soil risk evaluations. This study also indicates that a relevant part of Hg in plants is from deposition of soil particles and that splashing of soil can be more significant for plant contamination than actual uptake processes. Graphical Abstract Illustration of potential mercury soil-plant transfer routes.