POS0316 SEMIQUANTITATIVE ASSESSMENT OF SYNOVITIS ON US-GUIDED SYNOVIAL MEMBRANE BIOPSIES IS CONTINGENT ON DISEASE PHASE AND PREDICTIVE OF TREATMENT RESPONSE IN NAIVE TO TREATMENT PSORIATIC ARTHRITIS

Background

Ultrasound (US)-guided minimally invasive Synovial Tissue (ST) biopsy serves as a safe and well tolerated procedure for basic and translational research on chronic inflammatory joint disease.

Objectives

(i) to assess the diagnostic value of the Krenn score (KSS) on ST samples obtained from US-guided biopsies in a large bio-samples dataset of patients with Psoriatic Arthritis (PsA) across different disease phases; (ii) to develop a multiparametric nomogram integrating clinical and histological characteristics enabling treatment response prediction in naïve to treatment PsA.

Methods

410 patients fulfilling the CASPAR criteria for PsA who underwent US-guided ST biopsy were enrolled. At baseline, patients were categorized based on their disease phase and treatment: n=207 naïve to DMARDs; n=101 resistant to c-DMARDs; n=48 resistant to b-DMARDs and n=54 in sustained clinical and ultrasound remission or in low disease activity (LDA) state (DAPSA ≤ 4 or among 4-14, respectively). Clinical, demographic, and immunological characteristics were recorded for each patient. All ST specimens were stained with H&E and classified by a pathologist, blinded to clinical characteristics, using the Krenn score to assess ST inflammation degree (1) implemented with the determination of lymphocytes, plasma cells, granulocytes and tissue oedema presence. Each naive to treatment PsA was treated according to the EULAR recommendations (2) and DAPSA remission rate at 6 months was recorded.

Results

Considering the whole enrolled cohort, the distribution of KSS was significantly different among patients across the different PsA phases (ANOVA p<0.001). In particular, among the different phases, KSS was significantly higher in b-DMARDs resistant (p<0.0001) and c-DMARDs resistant (p<0.0001) compared to remission/LDA disease patients as well as naive to treatment PsA (p<0.0001). Interestingly, regardless to the disease phase, KSS of the biopsied joint directly correlated to disease activity in terms of DAPSA (r=0.476, p<0.001) and DAS28 scores (r=0.476, p<0.001). Considering the naïve to treatment PsA cohort, patients achieving DAPSA defined-LDA/remission had, before treatment, significantly lower KSS (p<0.001), lower rate of ST plasmacells presence (p<0.001) and shorter symptoms duration (p=0.01) as compared to naïve to treatment PsA not achieving this clinical outcome. Moreover, considering distinct clinical phenotype domains, naive to treatment PsA patients with concomitant dactylitis and skin disease were less likely to achieve DAPSA LDA/remission (p<0.001), regardless of treatment scheme. On logistic regression, at baseline, having a KSS <5 [OR: 5.30 (95%CI:2.21-12.74) p<0.001], absence of plasma cells ST infiltrate [OR: 3.87 (2.11-7.10 95%CI) p<0.001], concomitant dactylitis [OR: 2.55 (95%CI:1.24-5.25) p=0.01] and skin involvement [OR: 2.06 (95%CI:1.17-3.62) p=0.01] were independent factors associated with DAPSA score-LDA/remission achievement at 6 months. Finally, a multiparametric nomogram integrating baseline clinical and histological characteristics of naïve PsA enabling to predict up to 75% of probability to achieve DAPSA remission at 6 months was developed.

Conclusion

KSS is a reliable tool for synovitis assessment in PsA, being contingent on disease phases, related to disease burden and included within a treatment response predictive multiparametric nomogram in naïve PsA.

References

[1]Krenn V, et al. Histopathology 2006

[2]Gossec L, et al. Annals of the Rheumatic Diseases 2020

Disclosure of Interests

None declared

POS0105 IMMUNOLOGICAL AND TISSUE DERIVED BIOMARKERS OF EARLY RESPONSE IN MODERATE-TO-SEVERE RHEUMATOID ARTHRITIS TREATED WITH JAK-INHIBITORS

Background

Among Janus kinase inhibitors (JAKi) approved for Rheumatoid Arthritis (RA) treatment, tofacitinib and baricitinib are considered as pan-JAKi (pJAKi) while upadacitinib and filgotinib as selective anti-JAK1 (sJAKi) drugs. To date, despite ≈30% of RA patients exposed to JAKi achieve DAS28-CRP remission at 12 weeks, there is still lack of predictive biomarkers of response in RA treated with distinct JAKi.

Objectives

To determine whether pre-treatment immunological and synovial tissue features can predict clinical improvement in moderate-to-severe RA treated with JAKi.

Methods

Among 174 RA patients treated with JAKi, 84 underwent peripheral blood (PB) drawing and US-guided synovial tissue (ST) biopsy. Demographic, clinical and immunological features were collected for each patient at baseline and after 12 weeks. The distribution of PB-derived B lymphocytes subsets was assessed by flow cytometry, using CD27/IgD classification. Synovitis degree assessment was determined using Krenn score (KSS) by trained pathologist, blinded to clinical characteristics.

Results

Among enrolled RA patients, 82.7% was treated with pJAKi and 17.3% with sJAKi. Moreover, 35.6% of RA patients was b/ts-DMARDs naïve, 18.4% b/ts-DMARDs non-responder and 46.0% was difficult-to-treat (D2T) RA. In the whole cohort, 49.2% and 50.8% of RA patients achieved DAS28-CRP and CDAI low disease activity (LDA), respectively, after 12 weeks of JAKi treatment. Moreover, 37.7% and 5.9% of RA patients achieved DAS28-CRP and CDAI remission (REM), respectively, after 12 weeks of JAKi treatment regardless to JAKi category. Considering the immunological profile, RA patients achieving CDAI LDA were more likely rheumatoid factor (60.0%) and ACPA positive (60.5%) compared to RA patients not achieving this outcome (RF: 40.0%, p= 0.03 and ACPA: 39.5%, p= 0.02). Considering PB-derived B cell phenotype, b/ts-DMARDs naïve RA achieving DAS28-CRP LDA at 12 week had pre-treatment lower unswitched memory B (IgDposCD27pos) cell rate (6.91±7.70%) compared to b/ts-DMARDs naïve RA not achieving the same outcome (13.21±5.68%, p= 0.009). ROC analysis identified a cut-off value of 6.89% for IgDposCD27pos cells discriminating b/ts-DMARDs naïve RA achieving DAS28-CRP LDA at 12 week [AUC: 0.174±0.086; p= 0.008; OR(95%CIs): 18.20 (1.761-188.069)]. Furthermore, b/ts-DMARDs naïve RA achieving DAS28-CRP REM at 12-week follow up visit, had PB enrichment of naïve B cells (IgDposCD27neg: 68.08±17.38%) and lower percentage of unswitched memory B lymphocytes (5.10±4.29%) compared to RA not achieving the same outcome (IgDposCD27neg: 54.68±16.16%, p= 0.05; IgDposCD27pos: 13.96±8.34%, p= 0.001) [IgDposCD27neg cut-off: 62.6%, AUC:0.727±0.101, p=0.05; OR(95%CIs): 7.33(1.272-42.294); IgDposCD27pos cut-off: 6.89%, AUC: 0.139±0.073, p= 0.002; OR(95%CIs): 12.37 (1.828-83.767)]. Interestingly, considering the D2T RA subgroup, patients achieving DAS28-CRP LDA at 12 week follow up had lower rates of PB-derived IgDnegCD27neg B cells (3.83±0.96%) compared to RA not achieving the same outcome (7.25±2.83%, p= 0.04; cut-off: 5.46%, AUC: 0.083±0.095, p=0.041). Considering the pre-treatment synovitis degree, b/ts-DMARDs naïve RA achieving CDAI LDA status had significantly higher KSS at baseline (3.8±2.2) compared to RA not achieving the same outcome [1.7±1.4, p= 0.02; KSS cut-off: 3.00, AUC: 0.795±0.097; p=0.018; OR(95%CIs): 14.0 (1.39-141.49)]. Finally, no significant associations were observed between PB-derived B cell subpopulations rate and synovitis degree both in the whole RA cohort as well as stratifying patients for disease phase.

Conclusion

Pre-treatment immunological profile, peripheral blood-derived B cell phenotype and synovitis degree are associated with the early achievement of at least DAS28-CRP/CDAI LDA in RA patients receiving JAKi despite their selectivity.

References

[1]Gremese E et. J Leukoc Biol. 2019

[2]Alivernini S et al. Pharmacol Res. 2019

[3]Alivernini S et al. Arthritis Rheumatol. 2021

Disclosure of Interests

None declared

OP0084 DIGITAL SPATIAL PROFILING REVEALS DISTINCT SYNOVIAL TISSUE MACROPHAGE TRANSCRIPTOMIC SIGNATURE OF SUSTAINED REMISSION IN RHEUMATOID ARTHRITIS PATIENTS AT RISK OF DISEASE FLARE AFTER TREATMENT CESSATION

Background

Sustained remission is the treatment goal for Rheumatoid Arthritis (RA) and once achieved patients are eligible to treatment tapering or discontinuation. However, this exposes patients to the occurrence of unpredictable disease flare, and to date there are no definitive predictive biomarkers of flare for RA in remission that could be used in clinical practice.

Objectives

To assess the impact of clinical classification of remission on synovial tissue (ST) features of RA in sustained remission and to identify predictive biomarkers of disease flare.

Methods

200 RA in sustained clinical (102 RA with DAS<1.6 and 98 RA fulfilling Boolean remission criteria for at least 9 months, respectively) and ultrasound (US) remission (PD negative) under Methotrexate with or without biological-Disease Modifying Anti-Rheumatic Drugs (bDMARDs) were enrolled and underwent to US guided ST biopsy. 373 naive RA were included as comparison. For each patient, synovitis degree was determined using a H&E-based semiquantitative score1. Some ST samples of remission RA were used for synovial tissue macrophage (STMs)(CD206/MerTK) FACS phenotyping and digital spatial profiling (GeoMx DSP, Nanostring) to quantitate transcript abundance of CD68pos cells in 138 spatially distinct ST regions of interest (ROI). After study entry, RA were randomly assigned to tapering/discontinuation (TAP/DISC) (tapering c- or b-DMARD treatment for 6 months and discontinuing c- or bDMARD afterwards) or maintaining the same therapeutic scheme (CONT). Each RA was followed every 3 months to assess flare rate after treatment modifications for 24 months.

Results

Regardless of either DAS- or Boolean-defined, remission patients had significantly lower KSS than naive RA (p<0.0001 for both). However, ST of RA in Boolean remission had lower KSS (p<0.0001) and was enriched in CD206posMerTKpos STMs (p=0.0012) as compared to DAS-defined remission RA. 73(36.5%) RA experienced a disease flare regardless of the treatment change during 24 months follow-up. Stratifying RA in remission based on remission definition and treatment group, DAS-defined remission RA who had a disease flare within at least 6 months follow-up had, at study entry, significantly higher KSS (p<0.0001) than RA who maintained a sustained remission, regardless of the treatment change (CONT:p=0.0027 and TAP/DISC:p=0.0011). Logistic regression analysis revealed that baseline KSS≥3 [AUC:0.748(95%CI:0.649-0.846)p<0.0001] was an independent predictive factor of disease flare [OR:6.9(95%CI:2.82-16.81)] within 24 months follow-up in DAS-defined remission RA. Conversely, RA in Boolean remission did not differ for KSS at study entry in both the CONT (p>0.05) and the TAP/DISC (p>0.05) group in relation to disease flare. However, considering STMs phenotype, RA in Boolean remission in the TAP/DISC group who had low levels of CD206posMerTKpos (<38.1%), experienced more likely a disease flare compared to RA in the CONT subgroup with CD206posMerTKpos≥38.1% (p=0.0014). Logistic regression analysis confirmed that, before treatment change, STMs phenotype (CD206posMerTKpos <38.1%) in RA in remission is an independent predictor of disease flare [OR:6.25(95%CI:1.33-29.43)] within 24 months. Finally, DSP analysis using CD68 morphology marker, revealed that lining and sublining layer CD68pos spatial transcriptomics distinguished, at baseline, remission RA who flared after treatment modification from those who did not.

Conclusion

Disease flare is a common event in RA in sustained remission after treatment modification. KSS and STMs phenotype identified by flow cytometry or by tissue spatial transcriptomic can identify RA in remission at higher risk of flare after treatment modification. Thus, spatial transcriptomic with defined panel of markers on histological biopsy tissues could be a way forward in predicting disease flare.

References

[1]Alivernini S, et al. Arthritis & Rheumatology 2021

Disclosure of Interests

Simone Perniola: None declared, Barbara Tolusso: None declared, Aziza Elmesmari: None declared, Marco Gessi: None declared, Clara Di Mario: None declared, Maria Rita Gigante: None declared, Luca Petricca: None declared, Dario Bruno: None declared, Domenico Somma: None declared, Annamaria Paglionico: None declared, Valentina Varriano: None declared, Laura Bui: None declared, Maria Antonietta D’Agostino: None declared, Mariola Kurowska-Stolarska Grant/research support from: Pfizer, GSK, Novartis, Eli Lilly, Elisa Gremese Speakers bureau: Abbvie, BMS, Novartis, GSK, Galapagos, Eli Lilly, Pfizer., Grant/research support from: Abbvie, BMS., Stefano Alivernini Speakers bureau: Abbvie, BMS, Novartis, Galapagos, Eli Lilly, Pfizer., Grant/research support from: Pfizer, Novartis, GSK.

POS0662 BIOLOGIC DISEASE-MODIFYING ANTIRHEUMATIC DRUGS PRESCRIPTION OVER TIME IN A COHORT OF EARLY RHEUMATOID ARTHRITIS PATIENTS

Background

According to 2019 updated EULAR recommendations, therapy of Early Rheumatoid Arthritis (ERA) with biological disease-modifying antirheumatic drugs(bDMARDs) is adviced in presence of poor prognostic factors,i.e. persistently moderate/high disease activity, high acute phase reactants, high swollen joint count, autoantibody positivity, presence of early erosions, failure of two/more conventional synthetic DMARD.

Objectives

To evaluate over time prevalence of bDMARD therapy and factors associated to rapid initiation in our EA Clinic (EAC), comparing two different periods: from 2004 to 2012 and from 2012 to 2020.

The last two years were not considered because of the adverse influence of COVID19 pandemia on early access to EAC and on timely scheduled visits.

Methods

A total of 281 ERA patients with less than 12 months of disease duration (53.9 years mean age, 75% female, 77% seropositive), followed according to the treat-to-target (T2T) strategy, were enrolled in the study. At baseline, and every three months, the ACR/EULAR core data set variables were recorded. At baseline and every year, hand and foot radiographs were examined according to modified Total Sharp score (mTSS). At each visit, clinical improvement and remission were evaluated according to EULAR criteria. The achievement of Comprehensive Disease Control (CDC) (28-joint Disease Activity Score using C reactive protein <2.6, Health Assessment Questionnaire <0.5 and change from baseline in mTSS ≤0.5) was assessed every year.

Results

We examined 164 patients from 2004 to 2012 and 117 subjects from 2012 to 2020. In the first group 72 patients (43.9%) initiated bDMARDs during the 8-year FU, with a mean delay of 41.8 months. In the second group 37 patients (31.6%) started biotechnological drugs over time, with a mean delay of 50.4 months.

Analyzing the period from 2004 to 2012, ERA patients starting bDMARDs were younger (p<0.0001), had longer disease duration (p=0.02) and higher body mass index (BMI) (p=0.01) compared to subjects not undergoing to biological therapy. Moreover, ERA patients in bDMARDs were in higher percentage anti-citrullinated peptide antibody (ACPA) positive (80.6%) and reached to a lesser extent CDC at 12months of FU (26.1%) compared to patients that didn’t initiate bDMARDs (60.9% ACPA positive, p=0.01; 63% achieving CDC, p<0.0001, respectively).

Examining the period from 2012 to 2020, bDMARD-treated ERA patients were younger (p=0.06),in higher percentage ACPA positive (81.1%) and erosive at baseline (35.1%) compared to patients that didn’t initiate bDMARDs (64% ACPA positive, p=0.02; 17.5% erosive, p=0.04, respectively). As previously, patients in bDMARD reached to a lesser extent CDC at 12 month of FU (35.1%) compared to subjects not undergoing to biological therapy (55% achieving CDC, p=0.05).

On multivariate analysis, ACPA positivity was associated with initiation of bDMARD in both patient groups (p=0.02), whereas older age at onset and reaching CDC at 12 month were inversely associated (p=0.001; p<0.0001, respectively).

Conclusion

Despite the widest choice of bDMARDs currently available in the last 8 years, we did not observe an increase in the prescription of these drugs from 2012 to 2020.

As in other ERA cohorts, bDMARD initiation is associated to poor prognostic factors, in particular ACPA positivity, presence of erosions at baseline and not achieving CDC at 12 months of FU.

In the last 8 years, the decreased influence of disease duration at onset and of BMI could be a consequence of the improvement in strategies of early referral and control of modifiable risk factors.

Disclosure of Interests

None declared

Clinical characteristics of vulnerable populations hospitalized and diagnosed with COVID-19 in Buenos Aires, Argentina

There is not in Argentina publications regarding the presentation of patients with COVID-19 requiring hospitalized and emergency care in vulnerable populations (lower incomes and less education tend at greater risk for poor health status and healthcare access), and it has few reports in developing countries. The objective is to determine whether in the care of vulnerable patients, to succeed against COVID-19, multiple public health tools and interventions will be needed to minimize morbidity and mortality. The study is a prospective cohort investigation of patients with lab-confirmed COVID-19, who required to any of the Health Centers response from April 8, 2020, to August 18, 2020. In Buenos Aires Metropolitan Area (AMBA), April 8, 2020 the virus was identified in patients hospitalized in the "Southeast Network" (SN), AMBA. SN covering an area of 661 square kilometers, with 1.8 million inhabitants residing in urban, and rural areas. A total of 14 health centers with different levels of care complexity provide care to patients in the region. The information of each patient with COVID-19 evaluated by SN, was incorporated in an Epidemiological Dashboard. The investigation was designed and reported with consideration of observational studies in epidemiology. We describe the hospitals presentation and care of persons who required SN response and were ultimately diagnosed with COVID-19. From April 8, 2020, to August 18, 2020, were included 1495 patients with lab-confirmed COVID-19 in SN. A total of 58% patients were men, and the mean age (SD) was 48.9 (15.59) years. Eighty one percent patients with pre-existing diseases, most frequent hypertension and diabetes, but hypertension, chronic lung disease, and cardiovascular disease presented higher risk. A total of 13% were hospitalized in Intensive Therapy Unit. The mortality of the cohort was 9.77%. Mortality was higher for patients aged 65 or more (OR 5.09), and for those had some pre-existing disease (OR 2.61). Our observations are consistent with reports demonstrating older persons, and those with comorbidities have the highest risk of mortality related to COVID-19. However, unlike other reports from developed or some developing countries, the mortality in our study is lower. This finding may be related to age of our cohort is younger than other published. Also, the health system was able to respond to the demand.

Robotic treatment of the upper limb in chronic stroke and cerebral neuroplasticity: a systematic review

Stroke is the second cause of mortality and the third cause of long-term disability worldwide. Deficits in upper limb (UL) capacity persist at 6 months post-stroke in 30-66% of hemiplegic stroke patients with major limitations in activity of daily living (ADL), thus making the recovery of paretic UL function the main rehabilitation goal. Robotic rehabilitation plays a crucial role since it allows to perform a repetitive, intensive, and task-oriented treatment, adaptable to the patients' residual abilities, necessary to facilitate recovery and the rehabilitation of the paretic UL. It has been proposed that robot-mediated training may amplify neuroplasticity by providing a major interaction of proprioceptive and/or other sensory inputs with motor outputs, with significant modifications in functional connectivity (coherence) within the fronto-parietal networks (inter- and intra-hemispheric functional connectivity) related to processes of movement preparation and execution. However, the neurophysiological mechanisms underlying this reorganization are not entirely clear yet. Therefore, the aim of this study is to revise the literature, which assesses the effect of robotic treatment in the recovery of UL deficits measured in terms of neuroplasticity in patients affected by chronic stroke. This systematic review was conducted using PubMed, PEDro, Cinahl (EBSCOhost), Scopus and Cochrane databases. The research was carried out until February 2020 it included articles written in English language, published between 2009 and 2020, and the outcomes considered were neuroplasticity assessments. We included 23 studies over 6145 records identified from the preliminary research. The selected studies proposed different methods for neuroplasticity assessment (i.e. transcranial direct current stimulation (tDCS), EEG-Based Brain Computer Interface (BCI) and Neuroimaging (fMRI)), and different Robotic Rehabilitation treatments. These studies demonstrated a positive correlation between changes in central nervous circuits and post-treatment clinical outcomes. Our study has highlighted the effectiveness of robotic therapy in promoting mechanisms that facilitate re-learning and motor recovery in patients with post-stroke chronic disabilities. However, future studies should overcome the limitations of heterogeneity found in the current literature, by proposing a greater number of high-level RCTs, to better understand the mechanisms of robot-induced neuroplasticity, follow the clinical progress, estimate a prognosis of recovery of motor function, and plan a personalized rehabilitative programme for the patients.

AB1234 MICRO-RNA 155 AND MIR-34A: POSSIBLE BIOMARKERS OF INFLAMMATORY BURDEN AND DISEASE ACTIVITY IN ANCA-ASSOCIATED VASCULITIS WITH RENAL INVOLVEMENT

Background:

Predicting clinical outcomes in ANCA-related glomerulonephritis remains a major challenge. To date, there is no reliable biomarker able to predict renal prognosis in patients with ANCA-associated vasculitis (AAV). Micro-RNA (miRNA) are non-coding RNAs involved in the fine tuning of immune cells biology and this epigenetic modulation associates with different phenotypes and prognosis in several diseases.

Objectives:

To investigate the expression of miR-155 and miR-34a in kidney biopsies of AAV patients according with renal outcome.

Methods:

Fifteen patients with AAV and renal involvement (mean age 63.0 ±13.3 years, disease duration 4.9±2.2 months), who underwent renal biopsy. Demographic, clinical and autoimmune parameters were recorded for each patient. Each kidney biopsy was classified according to the Berden Classification, Risk group (according to the ANCA Renal Risk Score) and the chronicity Classification of the Mayo Clinic’s proposed score.

MiR-155 and miR-34a expression was investigated on kidney biopsy tissue using the miRNeasy FFPE kit (Qiagen). The quantitative expression of miR-155, miR-34a and housekeeping gene U1, used as control, was assessed by Real Time-PCR. MiR-155 and miR-34a expression was correlated with histopathological and clinical-laboratory parameters.

Each patient was followed for 12 months and renal outcome was considered according toKDIGO CKDClassification. Markers of inflammation (ESR, CRP) and urine analysis data were recorded at baseline and after 12 months.

Results:

Six (40%) patients were p-ANCA positive and 9 (60%) c-ANCA positive. Eight patients (53%) also had pulmonary involvement. The mean baseline GFR was 30.7±28.8 ml/min/1.73 m2and 10 patients (66%) showed an active urinary sediment.

At disease onset, the mean expression of miR-155 was 9.5±21.1, while the expression of mir-34a was 13.1±46.2. Considering the autoimmune profile, kidney tissue of p-ANCA positive patients was enriched of mir-155 (19.6±30.6 fold) compared to c-ANCA positive patients (1.9±2.9 fold; p=0.001). Particularly, considering the renal function, kidney tissue of patients with greater impairment of renal function (KDIGO stage 5) was enriched of miR-155 (21.5±38.3 fold) compared to patients with less renal impairment (KDIGO stage 1-4) (4.72±8.16 fold, p=0.004).

Tissue expression of miR-155 and miR-34a did not correlated with the abovementioned histopathological classifications.

After 12 months from kidney biopsy, 3(20%) patients had a worsening of renal function, 5 (33%) still presented elevated markers of inflammation and 3 (20%) still had proteinuria at urine analysis. At baseline, kidney tissue of patients with higher CRP plasma levels and proteinuria at follow-up presented higher expression of miR-155 (p=0.002 and p=0.001), whereas no significant differences were found about miR-34a kidney tissue expression.

Conclusion:

MiRNAs may play a potential role in the pathogenesis of ANCA-related glomerulonephritis. MiR-155 kidney enrichment seems to mirror the disease inflammatory burden and activity at the onset and after 12 months representing a possible biomarker in ANCA vasculitis with renal involvement. This finding may represent the basis for further studies on miRNA expression in blood samples, aiming to identify a non-invasive biomarker of kidney damage, predicting disease’s relapses and patients’ prognosis.

References:

[1]Renauer et al, Clin Rev Allergy Immunol. 2016

Disclosure of Interests:

Dario Bruno: None declared, Pier Giacomo Cerasuolo: None declared, Clara Di Mario: None declared, Silvia Laura Bosello Speakers bureau: Abbvie, Pfizer, Boehringer, Laura Gigante: None declared, Alessia Musto: None declared, Gisella Vischini: None declared, Stefano Costanzi: None declared, Stefano Alivernini: None declared, Barbara Tolusso: None declared, Giuseppe Grandaliano: None declared, Elisa Gremese Speakers bureau: Abbvie, BMS, Celgene, Jannsen, Lilly, MSD, Novartis, Pfizer, Sandoz, UCB

SAT0259 ANCA-ASSOCIATED VASCULITIS WITH RENAL INVOLVEMENT: THE ROLE OF A COMBINED HISTOPATHOLOGICAL ASSESSMENT AS PREDICTOR OF PATIENTS’ PROGNOSIS

Background:

Anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis often affect the kidney and renal involvement has a considerable clinical impact on patient’s prognosis. Currently used histopathological classifications are basically focused on the glomerular damage and assessing chronic damage progression, but their prognostic role presented some limitations.

Objectives:

To combine the Berden Classification, the ANCA Renal Risk Score (ARRS) and the Mayo Clinic-Renal Chronicity Score (RCS) with the inflammatory interstitial infiltrate and to evaluate the prognostic value of the combined assessment in patients with AAV

Methods:

We included 19 AAV patients with renal involvement (mean age 63±13.2 years; disease duration 4.9±5.2 months) who underwent renal biopsy. Patients were classified according to age, sex, disease duration, ANCA positivity. The histopathological evaluation was performed assessing the Berden category, Risk group (low, medium, high) according to the ARRS and Chronicity class according to the RCS; we also assessed the % of inflammatory interstitial infiltrate. Each patient was followed-up for 12 months; we considered the stage IV (eGFR < 30 ml/min/m2) of theKDIGO CKDClassification as renal outcome.

Results:

8 (42.1%) AAV patients were p-ANCA and 11 (57.9%) c-ANCA. 12 months after renal biopsy, 8 patients (42.1%) had a GFR <30 ml/min. According to the ARRS, 10 (52.6%) patients were in low, 7 (36.8%) in medium and 2 (10.5%) in high risk group. According to the RCS, 2 (10.5%) biopsies had minimal, 10 (52.6%) mild and 7 (36.8%) moderate chronic changes, no one presented severe chronic changes. According to the Berden classification, 6 (31.6%) samples represented the focal, 2 (10.5%) the crescentic and 11 (57.9%) the mixed category, no one represented the sclerotic class. The mean % of inflammatory infiltrate was 37.4±25.2. The interstitial inflammatory infiltrate showed a direct correlation with the severity of the Berden category (R=0.51; p=0.025), the % of sclerotic glomeruli (R=0.6; p=0.007) and the number of fibrocellular crescents (0.46; p=0.05) and an inverse correlation with the GFR at 12 months (R=-0.48; p=0.045). A ROC curve study identified a 22.5% cut-off of inflammatory infiltrate to predict the outcome of GFR at 12 months < 30 ml/min (sensitivity 88%, specificity 97.5%). Patients in focal class developed less frequently a GFR<30 (χ2=9.1; p=0.003), but there were no differences in the outcomes between the crescentic and mixed class. ARRS could differentiate risk group with regard to the renal outcome stage IV (χ2=9.0 e p=0.01) as well as the chronicity Score (χ2=8.1; p=0.017). Finally, we built a matrix combining the different histopathological scores and the % of inflammatory infiltrate to predict the outcome; we found that an inflammatory infiltrate wider than 22.5% characterizes most of patients developing stage IV chronic renal failure at the 12th month. In fact, more than 75% of patients with eGFR < 30 ml/min had inflammatory infiltrate wider than 22.5% at biopsy, despite they were in the low risk class (ARRS) and in minimal changes class (RCS).

Conclusion:

Our results underline the importance of the inflammatory infiltrate in renal outcome and histology. Despite the limited number of patients, our data suggest that a combined histological score assessing the chronicity and activity of renal disease from both glomerular and interstitial perspective could better predict patients’ global and renal prognosis.

References:

[1]Berden, J Am Soc Nephrol, 2010 Berti, Nephrol Dial Transplant 2018 Brix, Kidney Int. 2018

Disclosure of Interests:

Laura Gigante: None declared, Pier Giacomo Cerasuolo: None declared, Gisella Vischini: None declared, Francesco Federico: None declared, Dario Bruno: None declared, Alessia Musto: None declared, Stefano Costanzi: None declared, Silvia Laura Bosello Speakers bureau: Abbvie, Pfizer, Boehringer, Elisa Gremese Speakers bureau: Abbvie, BMS, Celgene, Jannsen, Lilly, MSD, Novartis, Pfizer, Sandoz, UCB

THU0306 ROLE OF 18-FDG PET/CT IN DIAGNOSIS AND FOLLOW UP OF LARGE VESSELS VASCULITIS

Background:

18-FDG PET/CT is a functional imaging method which allows to identify inflammation of vessel walls. The use of PET in large vessels vasculitis(LVV) at disease onset and during follow up is still debate either to confirm clinical remission either to drive the therapy choice. American Society of Nuclear Cardiology (ASNC) recently advanced recommendations aimed to standardize the application of PET in LVV(1).

Objectives:

The aim of our study was to assess the clinical role of PET performed in patients affected by LVV at the diagnosis and during the follow up.

Methods:

We retrospectively evaluated PET/CT of 49 patients affected by clinically active LVV according to LVV visual grading (LVG, grading 0-3) and measured the standardized uptake value(SUV) of large vessels. 38 (77,6%) patients were affected by Giant Cells Arteritis and 11(22,4%) by Takayasu Arteritis. 32(65.3%) patients repeated the imaging after a mean follow-up of 11.5±5.4 months.

All baseline (T0) and follow up (T1) clinical data of disease activity were collected. Patients were treated according to EULAR LVV management recommendations(2). T0 PET/CT study was performed in patients with a clinically active disease defined by suggestive symptoms/signs and/or high inflammatory markers. The mean disease duration before T1 PET/CT examination was 4 months. T0 PET was performed in 25/49 patients(52%) at the diagnosis of LVV, whereas in 24/49(48%) patients with already diagnosed but active LVV disease.

Results:

Baseline PET was positive in 21 patients(42.9%). According to ASNC recommendations, 19 patients (38.8%) presented a LVG=3, 2(4.0%) a LVG=2, 6(12.2%) LVG=1 and 22 (44.9%) LVG=0. Patients performing PET at disease onset(75%) had higher LVG score than patients performing PET during the disease course (25%),p=0,002. At T0, aortic, carotid, axillary and subclavian SUV did not correlate with inflammatory markers.

Follow up PET/CT studies were performed in 32 patients, 13 (40.6%) with a clinically active disease despite therapy, while 19(59.4%) in clinical remission.

Follow up PET was still positive in 8 patients (25%) with a LVG=3, 10 (31.2%) patients presented LVG=1 and 14 (43.8%) LVG=0. T1 PET/CT study showed a significant reduction of SUV values in descending aorta, left and right subclavian arteries, and left and right axillary arteries when compared with first PET/CT study. According to LVG, 12 patients with active PET/CT study at T0 (19 pts) presented a reduction of LVG from score 2 and 3 to grade 1 or 0 (64.2%) at second PET/CT study. Only 3 patients presented an increased LVG score at T1, while in the other 17 patients T1 PET confirmed the previous score. No significant difference was found between LVG scores according with clinical characteristics, but among 8 patients presenting an active T1 PET, 4(50%) were in clinical remission.

Conclusion:

The use of ASNC recommendations for FDG PET/CT in LVV enables to confirm a metabolically active disease in 40% of patients and in 75% of patients at disease onset, suggesting that post-posing the exam could lead to underrate the real extension of disease. Our data, even if limited, suggest that PET/CT could be crucial in management of patients in clinical remission, detecting patients with still metabolically active LVV. Further prospective studies are necessary to evaluate the role of PET/CT in driving therapeutic strategies.

References:

[1]Slart R et all - Eur J Nucl Med Mol Imaging, 2018

[2]Hellmich et all – Ann Rheum Dis 2018

Disclosure of Interests:

Laura Gigante: None declared, Dario Bruno: None declared, Vanessa Feudo: None declared, Silvia Laura Bosello Speakers bureau: Abbvie, Pfizer, Boehringer, Lucia Leccisotti: None declared, Alessia Musto: None declared, Pier Giacomo Cerasuolo: None declared, Angelo Zoli: None declared, Alessandro Giordano: None declared, Elisa Gremese Speakers bureau: Abbvie, BMS, Celgene, Jannsen, Lilly, MSD, Novartis, Pfizer, Sandoz, UCB

THU0193 CLINICO-DEMOGRAPHIC, IMMUNOLOGIC AND SYNOVIAL HISTOLOGIC FEATURES INFLUENCING RESPONSE TO JAK-INHIBITORS IN RHEUMATOID ARTHRITIS: A MONOCENTRIC COHORT

Background:

Janus kinase Inhibitors (JAKis) are approved for the treatment of Rheumatoid Arthritis (RA) in over 40 countries. The updated EULAR recommendations for RA treatment revised the preference of bDMARDs over tsDMARDs based on the new data related to JAKis long-term efficacy and safety. [1].

Objectives:

To evaluate the efficacy and safety of JAKis molecules in an observational single center cohort of RA patients in a real life outpatient clinical setting.

Methods:

76 RA patients [mean age: 55.7±12.5 years, 64(84.2%) female, disease duration: 120.7±97.2 months, 43 (61.4%) seropositive (AB+) for ACPA and/or IgM-RF, 34(44.7%) with BMI ≥25.0 kg/m2] were followed after starting JAKis treatment monotherapy or in combination with conventional synthetic DMARDs (csDMARDs). At study entry, and every 3 months, the ACR/EULAR core data set variables were recorded for each patient. Clinical improvement and remission rate were evaluated according to Disease Activity Score (DAS) and Clinical Disease Activity Index (CDAI) and any therapy-related adverse effect was reported. Among the whole RA cohort, 20 patients underwent US-guided synovial tissue (ST) biopsy before JAKis treatment and classified using the Krenn score for the semiquantitative assessment of ST inflammation[2].

Results:

Among the whole RA cohort who started JAKis [mean follow-up (FU) duration: 6.1±3.7 months], 22(28.9%) showed DAS-defined high disease activity. 54(71.1%) patients were previously treated with at least 1 csDMARD and 33(43.4%) were naive to biologic DMARDs (bDMARDs). Among RA previously exposed to b-DMARDs, 23(30.3%) were using anti-TNF and 14(18.4%) anti-IL6R, whereas 6(7.9%) patients received other bDMARD. In particular, 11(14.5%) patients were previously treated only with one bDMARD.

During the FU, 12(15.8%) patients discontinued JAKis [7 due to treatment failure and 5 to adverse events (1 anemia, 2 gastrointestinal intolerance, 2 H.Zoster infection)]. All RA who discontinued JAKis for incomplete or no-response were previously exposed to bDMARDs.

DAS Remission was achieved in 29 of 65(44.6%) patients during the FU, of whom 21(32.5%) achieved remission at 3 months. Similarly, 16(24.6%) patients reached CDAI remission of whom 12(18.5%) patients achieved remission at 3 months.

At baseline, there were no differences of DAS-remission rate based on age, gender, disease duration, BMI and high disease activity. Similarly, concomitant steroid and csDMARDs therapy did not impact on the rate of DAS and CDAI Remission. However, RA reaching DAS remission during FU had more likely a shorter disease duration (p=0.01) and were less previously exposed to bDMARDs (p=0.001) than patients not achieving DAS remission. Conversely, the DAS Remission rate was higher in AB+ (55.3%) than in AB- RA patients (27.3%, p=0.04).

Furthermore, bDMARDs naive RA showed higher probability to reach remission compared to bDMARD previously exposed RA [DAS remission: 66.7% vs 28.9%, respectively, p=0.003; OR(95%): 4.90 (1.69-14.3) and CDAI-remission: 37.0% vs 15.8%, p=0.05; OR(95%CIs): 3.12(0.97-10.10)], regardless to the type of the previous bDMARDs used.Finally, considering the baseline ST features, RA achieving clinical improvement did not differ in terms of Krenn score and microanatomical organization compared to RA not achieving the clinical improvement.

Conclusion:

The efficacy rate of JAKis therapy is not influenced by BMI and baseline high disease activity. Previous exposure to bDMARDs impacts both on the clinical response and on the rate of JAKis therapy discontinuation. Therapy-related adverse effects mainly occurred in bDMARD previously exposed RA patients.

References:

[1]Smolen JS, et al. Ann Rheum Dis 2020

[2]Krenn V, et al. Histopathology 2006

Disclosure of Interests:

Dario Bruno: None declared, Maria Rita Gigante: None declared, Luca Petricca: None declared, Anna Laura Fedele: None declared, Simone Perniola: None declared, Marco Gessi: None declared, Barbara Tolusso: None declared, Stefano Alivernini: None declared, Elisa Gremese Speakers bureau: Abbvie, BMS, Celgene, Jannsen, Lilly, MSD, Novartis, Pfizer, Sandoz, UCB

AB0757 ASSOCIATION BETWEEN DEPRESSIVE SYMPTOMS AND ENDOTHELIAL DYSFUNCTION IN PATIENTS WITH PSORIATIC ARTHRITIS

Background:

Cardiovascular complications are the leading cause of death in patients with psoriatic arthritis (PsA), but current strategies for reducing cardiovascular risk are still inadequate. Depression is a common comorbidity in PsA patients and it is recognized as an independent cardiovascular risk factor in the general population. Endothelial dysfunction, assessed as a reduction in brachial artery Flow Mediated Dilation (FMD), is a predictor of major cardiovascular events in high and low risk populations.

Objectives:

To investigate the relationship between endothelial function and depressive symptoms in a cohort of patients with PsA.

Methods:

Sixty consecutive patients with PsA, aged between 30 and 79 years, with no history of major cardiovascular events, were characterized for traditional cardiovascular risk factors and features of psoriatic disease. The risk of cardiovascular events according to traditional risk factors was calculated using the Framingham Risk Score (FRS) and the presence of depressive symptoms was defined through the Hospital Anxiety and Depression Scale (HDS) using the validated cut-off of 8. Endothelial function was assessed by FMD. Serum IL-6 was quantified by ELISA, IL-17 and TNF-α levels by Luminex method.

Results:

Patients had an average age of 52.1±11.0 years, 43.3% of them were male, 23.3% obese and 25.0% active smokers; 38.3%, 25.0% and 11.7% were treated for high blood pressure, dyslipidemia and diabetes mellitus, respectively. The 10-year risk of major cardiovascular events estimated by FRS was 10.4%. The mean duration of PsA was 9.4 years, 30.0% of patients were in minimal disease activity (MDA) and 61.7% and 46.7% were treated with conventional and biotechnological DMARDs, respectively. The mean HDS value was 6.9±3.2 and 43.4% of patients had significant depressive symptoms. The severity of depressive symptoms according to HDS correlated with disease activity according to DAPSA (r=0.449, p=0.001). The mean FMD was 7.8±3.8%, this value correlated inversely with age (r=-0.408,p<0.001), risk of major cardiovascular events according to FRS (r=-0.327, p=0.011) and severity of depressive symptoms according to HDS (r=-0.285, p=0.027). The correlation between FMD and serum IL-6, IL-17 and TNF-alpha levels was not statistically significant. In multivariate linear regression models, the relationship between FMD and HDS was significant also when corrected for age (β=-0.26, p=0.03, R2=0.23) and FRS normalized through logarithmic transformation (β=-0.32, p=0.009, R2=0.22).

Conclusion:

The degree of endothelial dysfunction quantified by FRS correlates with the severity of the depressive symptoms in patients with PsA, independently of the cardiovascular risk attributable to classical risk factors. The weak relationship between FRS and serum levels of IL-6, IL-17 and TNF-alpha suggests a role of factors independent of inflammation in the regulation of endothelial function in patients with PsA. Systematic research and treatment of depressive symptoms could contribute to a more complete stratification and a better management of cardiovascular risk in patients with PsA.

Disclosure of Interests:

Enrico De Lorenzis: None declared, Angela Di Giorgio: None declared, Gerlando Natalello: None declared, Antonio Nesci: None declared, Dario Bruno: None declared, Donatella Lucchetti: None declared, Giacomo Tanti: None declared, Clara Di Mario: None declared, Pietro Rubortone: None declared, Maria Rosaria Magurano: None declared, Barbara Tolusso: None declared, Angelo Santoliquido: None declared, Giusy Peluso: None declared, Elisa Gremese Consultant of: AbbVie, Bristol-Myers Squibb, Celgene, Eli Lilly, Janssen, Merck Sharp & Dohme, Novartis, Sanofi, UCB, Roche, Pfizer, Speakers bureau: AbbVie, Bristol-Myers Squibb, Celgene, Eli Lilly, Janssen, Merck Sharp & Dohme, Novartis, Sanofi, UCB, Roche, Pfizer

FRI0216 STEROID SPARING EFFECT, LOWER INCIDENCE OF DISEASE RELAPSE AND DIABETES IN GIANT CELL ARTERITIS TREATED WITH IMMUNOSUPPRESSORS AB INITIO OR VERY EARLY: A MULTICENTER RETROSPECTIVE CASE-CONTROL STUDY

Background:

Glucocorticoids (GC) are associated with serious side effects in giant cell arteritis (GCA). Immunosuppressive therapies (IT) gave conflicting results in GCA, regarding GC sparing effect. Recently, tocilizumab by blocking IL-6, has been licensed as first biologic treatment for GCA, being clinically effective and saving GC (1).

Objectives:

To evaluate the usefulness of IT for GCA in: 1) minimizing the rate of GC-induced adverse events (AEs) and 2) reducing the risk of relapse.

Methods:

A multicenter retrospective case-control study included 165 GCA was performed. The first group of patients (GCA-IT) included 114 patients who were treated with at least one IT given ab initio or within 3 months from the start of GC. The control group included 51 GCA who received only GC or an IT later than 3 months (GCA-steroid). The primary endpoints were the rate of GC-related side effects: infections, hospitalized infections, new onset systemic arterial hypertension, GC-induced diabetes and osteoporotic fractures.

Results:

Methotrexate up to 20 mg/week (138 patients), followed by cyclophosphamide (48 patients) and tocilizumab (27 patients) were the most frequently used IT. No difference was observed as concerns the follow-up time between the two groups [48.5 (IQR 26-72) vs 40 (IQR 24-69), p=0,3, rank-sum test)]. The two groups were similar as concerns sex (p=0,13), while the first group (69±8 yrs) was slightly younger than the second one (72±7 yrs) (p=0,005). Comorbidity was similar between groups. Patients in the GCA-IT group showed a significant lower incidence of GC-induced diabetes (8/114, 7% vs 12/51, 23,5%; p=0,003, chi-square test), while no differences were documented for rate of infections (p=0,64), including hospitalized infections (p=0,44), new onset systemic arterial hypertension (p=0,68), or osteoporotic fractures (p=0,32). Forty-four patients in the GCA-IT group (38,6%), while 34 patients in the GCA-steroid group (66,7%) experienced at least one relapse (p=0,001, chi square test). There was no difference in terms of time to first relapse between the two groups (p=0,53, log-rank test). GCA-IT group was exposed to lower dose of GC at first (p<0,0001, rank-sum test) and third (p<0,0001, rank-sum test) month, while no differences were recorded at the other time points. Clinical outcomes were similar between the two groups.

Conclusion:

Very early introduction of IT in GCA provided a greater steroid sparing in the first 3 months of treatment, leading to a lower incidence of diabetes. Relapse rate was even lower. IT was usually well tolerated without an increase incidence of infections. A randomized prospective trial is required to support this strategy in the management of GCA.

References:

[1]Hellmich B, et al. 2018 Update of the EULAR recommendations for the management of large vessel vasculitis. Ann Rheum Dis. 2020;79:19-30.

Disclosure of Interests:

Luca Quartuccio Consultant of: Abbvie, Bristol, Speakers bureau: Abbvie, Pfizer, Miriam Isola: None declared, Dario Bruno: None declared, Elena Treppo: None declared, Laura Gigante: None declared, Francesca Angelotti: None declared, Riccardo Capecchi: None declared, Gianfranco Vitiello: None declared, Elena Cavallaro: None declared, Antonio Tavoni: None declared, Silvia Laura Bosello: None declared, Daniele Cammelli: None declared, Salvatore De Vita Consultant of: Roche, GSK, Speakers bureau: Roche, GSK, Novartis, Elisa Gremese Speakers bureau: Abbvie, BMS, Celgene, Jannsen, Lilly, MSD, Novartis, Pfizer, Sandoz, UCB

SAT0027 DEVELOPMENT AND VALIDATION OF A NOMOGRAM COMBINING CLINICAL AND HISTOPATHOLOGICAL SYNOVIAL FEATURES FOR PREDICTING EARLY TREATMENT RESPONSE IN NAIVE TO TREATMENT RHEUMATOID ARTHRITIS

Background:

Rheumatoid Arthritis (RA) is characterized by synovial tissue (ST) heterogeneity at disease onset in terms of inflammatory degree and microanatomical organization being related to treatment response.

Objectives:

To develop a multiparametric tool for baseline treatment response prediction including disease characteristics and histopathologic features of ST biopsies, using a large single center (SYNGem Unit) naive to treatment RA cohort.

Methods:

240 naive to treatment RA who underwent US-guided ST biopsy, at the first clinical evaluation, were enrolled. Clinical and immunological characteristics were recorded for each patient. All ST FFPE specimens were stained with H&E and classified by a pathologist, blinded to clinical characteristics, using the Krenn score [1] to assess the degree of ST inflammation. All naive to treatment RA were treated according to the T2T scheme and DAS remission rate at 6-12 months was recorded. On the basis of the regression analysis, a nomogram was constructed that incorporated the significant factors predicting the “achievement of DAS-Remission at 6 months follow-up” in naive RA. The performance of the nomogram was assessed by discrimination and calibration.

Results:

Univariate analysis showed that RA who achieved early (6 months) DAS-remission had, at baseline, significantly lower total Krenn score (p<0.001), shorter symptoms duration (p=0.005) and lower disease activity (p<0.001) than RA not achieving this clinical outcome. ROC curve analysis revealed that RA having, at baseline, a total Krenn score <4.5 [(AUC)95%C.I.: 0.67(0.60-0.74),p<0.001] achieved more likely DAS-remission at 6 months (53.1%) than RA with total Krenn score ≥4.5(28.9%,p<0.001). Interestingly, RA whose ST was biopsied within 3 months from joint symptoms beginning showed significantly lower ST inflammation as total Krenn score than RA whose ST was analyzed among 3-12 months (p=0.04) or after 12 months (p=0.002) since symptoms beginning. However, in terms of follicular structure presence, the microanatomical organization of the synovial inflammatory infiltrate did not differ comparing RA whose ST was biopsied within 3 months from joint symptoms beginning (44.4%) and RA whose ST was biopsied among 3-12 months (47.6%, p=0.74) or after 12 months (52.7%,p=0.33) since symptoms beginning.

Logistic regression analysis revealed that, at baseline, being VERA, not having HDA and having a total Krenn score <4.5 were synergistic factors of DAS-remission achievement at 6 months [OR:10.5(95%IC:2.28-48.01);p<0.05]. Based on the regression analysis, a nomogram integrating baseline clinical (disease activity and duration) and histological (total Krenn score) characteristics was developed in which the value of each of the variables was given a point score. A total score was calculated by adding each single point score and, by projecting the value of the “total points” score to the “probability” line up to 87.5%.

Conclusion:

Krenn score is a reliable tool for the semi-quantitative assessment of ST inflammation on US-guided ST biopsies being contingent to baseline disease characteristics and can be integrated within a nomogram to better predict the therapeutic response in naive to treatment RA.

References:

[1] Krenn V, et al. Histopathology 2006

Disclosure of Interests:

Stefano Alivernini: None declared, Barbara Tolusso: None declared, Marco Gessi: None declared, Maria Rita Gigante: None declared, Alice Mannocci: None declared, Luca Petricca: None declared, Simone Perniola: None declared, Clara Di Mario: None declared, Anna Laura Fedele: None declared, Laura Bui: None declared, Annunziata Capacci: None declared, Dario Bruno: None declared, Giuseppe La Torre: None declared, Francesco Federico: None declared, Gianfranco Ferraccioli: None declared, Elisa Gremese Speakers bureau: Abbvie, BMS, Celgene, Jannsen, Lilly, MSD, Novartis, Pfizer, Sandoz, UCB

Experimental Demonstration of Hadron Beam Cooling Using Radio-Frequency Accelerated Electron Bunches

Cooling of beams of gold ions using electron bunches accelerated with radio-frequency systems was recently experimentally demonstrated in the Relativistic Heavy Ion Collider at Brookhaven National Laboratory. Such an approach is new and opens the possibility of using this technique at higher energies than possible with electrostatic acceleration of electron beams. The challenges of this approach include generation of electron beams suitable for cooling, delivery of electron bunches of the required quality to the cooling sections without degradation of beam angular divergence and energy spread, achieving the required small angles between electron and ion trajectories in the cooling sections, precise velocity matching between the two beams, high-current operation of the electron accelerator, as well as several physics effects related to bunched-beam cooling. Here we report on the first demonstration of cooling hadron beams using this new approach.

Generation of Paramoeba perurans clonal cultures using flow cytometry and confirmation of virulence

Amoebic gill disease (AGD) in farmed Atlantic salmon is caused by the amoeba Paramoeba perurans. The recent establishment of in vitro culture techniques for P. perurans has provided a valuable tool for studying the parasite in detail. In this study, flow cytometry was used to generate clonal cultures from single-sorted amoeba, and these were used to successfully establish AGD in experimental Atlantic salmon. The clonal cultures displayed differences in virulence, based on gill scores. The P. perurans load on gills, determined by qPCR analysis, showed a positive relationship with gill score, and with clonal virulence, indicating that the ability of amoebae to proliferate and/or remain attached on gills may play a role in virulence. Gill scores based on gross signs and histopathological analysis were in agreement. No association between level of gill score and specific gill arch was observed. It was found that for fish with lower gill scores based on histopathological examination, gross examination and qPCR analysis of gills from the same fish were less successful in detecting lesions and amoebae, respectively.

Functional redundancy as a tool for bioassessment: A test using riparian vegetation

There is an urgent need to track how natural systems are responding to global change in order to better guide management efforts. Traditionally, taxonomically based metrics have been used as indicators of ecosystem integrity and conservation status. However, functional approaches offer promising advantages that can improve bioassessment performance. In this study, we aim to test the applicability of functional redundancy (FR), a functional feature related to the stability, resistance and resilience of ecosystems, as a tool for bioassessment, looking at woody riparian communities in particular. We used linear mixed-effect models to investigate the response of FR and other traditional biomonitoring indices to natural (drought duration) and anthropogenic stress gradients (flow regulation and agriculture) in a Mediterranean basin. Such indices include species richness, a taxonomic index, and the Riparian Quality Index, which is an index of ecological status. Then, we explored the ability of FR and the other indices to discriminate between different intensities of human alteration. FR showed higher explanatory capacity in response to multiple stressors, although we found significant negative relationships between all the biological indices (taxonomic, functional and ecological quality) and stress gradients. In addition, FR was the most accurate index to discriminate among different categories of human alteration in both perennial and intermittent river reaches, which allowed us to set threshold values to identify undisturbed (reference condition), moderately disturbed and highly disturbed reaches in the two types of river. Using these thresholds and the best-fitting model, we generated a map of human impact on the functional redundancy of riparian communities for all the stretches of the river network. Our results demonstrate that FR presents clear advantages over traditional methods, which suggests that it should be part of the biomonitoring toolbox used for environmental management so as to obtain better predictions of ecosystem response to environmental changes.

Hyperpigmentation in North Sea dab Limanda limanda. I. Spatial and temporal patterns and host effects

Hyperpigmentation is a term describing a specific pigment anomaly affecting common dab Limanda limanda in the North Sea and, less frequently, in adjacent areas, e.g. the English Channel, Irish and Celtic Seas, western Baltic Sea and Icelandic waters. Other North Sea flatfish species are also affected, but at a markedly lower prevalence. The condition is characterised by the occurrence of varying degrees of green to black patchy pigment spots in the skin of the upper (ocular) body side and pearly-white pigment spots in the skin of the lower (abocular) body side. In the course of fish disease monitoring programmes carried out by Germany and the UK (England and Scotland), a pronounced spatial pattern of hyperpigmentation has been detected in the North Sea. An increase in prevalence has been recorded in almost all North Sea areas studied in the past 2 decades. The prevalence recorded in hot spot areas of the condition increased from 5 to >40% between 1988 and 2009. Analysis of the German data indicates that the prevalence and intensity (degree of discolouration) of hyperpigmentation increase with size and age, indicating a temporal progression of the condition with size and age. Intense hyperpigmentation is associated with increased growth (length) and decreased condition factor. Potential causes of the condition (UV-B radiation nutrition, water temperature increase, demographic changes) and, in particular, of the spatial/temporal patterns recorded as well as the relationship to host-specific factors (sex, age, length, growth, condition factor) are discussed.

Periventricular heterotopia in common microdeletion syndromes

Periventricular heterotopia (PH) is a brain malformation characterised by heterotopic nodules of neurons lining the walls of the cerebral ventricles. Mutations in FLNA account for 20-24% of instances but a majority have no identifiable genetic aetiology. Often the co-occurrence of PH with a chromosomal anomaly is used to infer a new locus for a Mendelian form of PH. This study reports four PH patients with three different microdeletion syndromes, each characterised by high-resolution genomic microarray. In three patients the deletions at 1p36 and 22q11 are conventional in size, whilst a fourth child had a deletion at 7q11.23 that was larger in extent than is typically seen in Williams syndrome. Although some instances of PH associated with chromosomal deletions could be attributed to the unmasking of a recessive allele or be indicative of more prevalent subclinical migrational anomalies, the rarity of PH in these three microdeletion syndromes and the description of other non-recurrent chromosomal defects do suggest that PH may be a manifestation of multiple different forms of chromosomal imbalance. In many, but possibly not all, instances the co-occurrence of PH with a chromosomal deletion is not necessarily indicative of uncharacterised underlying monogenic loci for this particular neuronal migrational anomaly.

Quantum Zeno effect in a model multilevel molecule

We study the dynamics of the populations of a model molecule endowed with two sets of rotational levels of different parity, whose ground levels are energetically degenerate and coupled by a constant interaction. The relaxation rate from one set of levels to the other one has an interesting dependence on the average collision frequency of the molecules in the gas. This is interpreted as a quantum Zeno effect due to the decoherence effects provoked by the molecular collisions.

Anakinra is safe and effective in controlling hyperimmunoglobulinaemia D syndrome-associated febrile crisis

Hyper-IgD and periodic fever syndrome (HIDS) is a hereditary autoinflammatory syndrome, characterized by recurrent inflammatory attacks. Treatment of HIDS is difficult. Recently, the IL-1ra analogue anakinra was reported to be successful in aborting the IgD inflammatory attacks in a vaccination model. We report a clinical case of spectacular reduction of febrile attacks in a severe HIDS patient.

Polarized proton collisions at 205 GeV at RHIC

The Brookhaven Relativistic Heavy Ion Collider (RHIC) has been providing collisions of polarized protons at a beam energy of 100 GeV since 2001. Equipped with two full Siberian snakes in each ring, polarization is preserved during acceleration from injection to 100 GeV. However, the intrinsic spin resonances beyond 100 GeV are about a factor of 2 stronger than those below 100 GeV making it important to examine the impact of these strong intrinsic spin resonances on polarization survival and the tolerance for vertical orbit distortions. Polarized protons were first accelerated to the record energy of 205 GeV in RHIC with a significant polarization measured at top energy in 2005. This Letter presents the results and discusses the sensitivity of the polarization survival to orbit distortions.

Hypogonadism and hormone replacement therapy on bone mass of adult women with thalassemia major

We studied bone mass and metabolism in 30 adult women (age 28.5 +/- 1.3) with thalassemia major (TM) and evaluated whether prolonged hormone replacement therapy (HRT) was able to optimize bone accrual. TM patients had reduced bone mass, increased bone turnover and lower serum gonadotropin and estradiol levels compared with 10 normal women of similar age. A significant correlation was found between bone mass and sex hormone levels. Six TM patients with normal ovarian function had normal bone turnover markers and modestly low bone mass (lumbar spine -1.29 +/- 0.31; femoral neck -0.60+/-0.21; Z-score). The other 24 TM women were hypogonadic and had significantly lower bone mass for age (lumbar spine -2.35 +/- 0.2, femoral neck -1.83 +/- 0.2) and increased bone turnover relative to eugonadal women. Of the hypogonadal patients, 13 had taken HRT since age 15 +/- 1 years, but their bone mass and turnover markers were not different than untreated hypogonadal patients. In conclusion, while hypogonadism negatively affects bone mass acquisition in adult TM women, HRT at the standard replacement doses is not sufficient to secure optimal bone accrual.

[Motivation, expectations, realization: from education to work]

This paper presents the outcomes of a research oriented to exploration and description of the motivations and expectations that concur to assumption af an active and intentional role from students engagaged for achievement of knowledges, skills and highly qualitative consistent attitudes with practice of nursing service.

Genitourinary complications of sickle cell disease

PURPOSE

In the last half century the molecular biology, pathophysiology and natural history of sickle cell disease have been well defined. Sickle cell disease causes microvascular occlusion, which is manifested in most organ systems. The genitourinary tract is most commonly affected by hematuria, urinary tract infection and priapism but other more serious sequelae have been identified.

MATERIALS AND METHODS

We performed a computerized MEDLINE search from 1965 to the present and a bibliographic review of cross references. These references were analyzed for meaningful findings and case reports.

RESULTS

The diagnosis and management of sickle cell disease have advanced rapidly with a significant increase in the life expectancy of affected patients and recognition of a greater number of genitourinary complications. Renal function may be mildly altered or lost completely. Patients with sickle cell disease are at increased risk for urinary tract infection. Priapism is a painful complication of sickle cell disease that is poorly understood and challenging to treat and prevent. Testicular infarction has also been noted. Furthermore, renal medullary carcinoma, a highly lethal tumor, develops almost exclusively in young patients with sickle cell trait.

CONCLUSIONS

Heightened awareness of the genitourinary complications of sickle cell disease may prevent end stage disease, including renal failure and impotence. New forms of therapy for sickle cell disease, such as hydroxyurea, may prevent these complications in the future.

Cis-acting requirements in flanking DNA for the programmed elimination of mse2.9: a common mechanism for deletion of internal eliminated sequences from the developing macronucleus of Tetrahymena thermophila

During macronuclear development in the ciliated protozoan Tetrahymena thermophila, extensive DNA deletions occur, eliminating thousands of internal eliminated sequences (IESs). Using an rDNA-based transformation assay we have analyzed the role during DNA deletion of DNA flanking mse2.9, an IES within the second intron of a gene encoding an as yet incompletely characterized protein. We establish that a cis-acting sequence for mse2.9 deletion acts at a distance to specify deletion boundaries. A complex sequence element necessary for efficient and accurate mse2.9 deletion is located in the region 47-81 bp from the right side of mse2.9. The ability of a variety of IES flanking sequences to rescue a processing deficient mse2.9 construct indicates that some cis-acting signal is shared among different IESs. In addition, the short intronic sequence that flanks mse2.9 is able to direct efficient and accurate processing. Despite no obvious sequence similarity between mse2.9 and other IESs, we suggest that a common mechanism is used to delete different families of IESs in Tetrahymena.

Successful management of lower-pole moiety ureteropelvic junction obstruction in a partially duplicated collecting system using minimally invasive retrograde endoscopic techniques

Although the true incidence of ureteropelvic junction (UPJ) obstruction in the lower-pole moiety of an incompletely duplicated renal collecting system remains elusive, the description of this entity in the published literature is exceedingly rare. To our knowledge, we report the first case of this entity managed successfully by ureteroscopic holmium laser incision of the stenotic UPJ segment. This case underscores the utility of minimally invasive techniques in the management of selected cases of UPJ obstruction associated with a partially duplicated collecting system.