POS0852 HIGH DOSE INTRAVENOUS PULSE METHOTREXATE IN REFRACTORY EOSINOPHILIC FASCIITIS: WHAT ARE THE ADVERSE EVENTS?

Background:

Eosinophilic Fasciitis (EF) is a disease of unknown origin initially characterized by limb or trunk edema, and collagenous thickening of the subcutaneous fascia in later stages. Eosinophilia in peripheral blood is commonly observed. Being a rare disease, evidence regarding treatment is mainly based on case series and anecdotal evidence. The mainstay systemic treatment is prednisone, and Methotrexate (MTX) up to doses of 25 mg/week is the leading prednisone-sparing agent. Mycophenolate can be considered in refractory cases. As an alternative we explored the use of intravenous (i.v.) pulse MTX. We already showed this to be a potentially effective and safe treatment option in a prospective single-arm study1, but more data on adverse events (AEs) are needed.

Objectives:

To present an overview of AEs of high dose i.v. pulse MTX in refractory EF.

Methods:

Adult patients with EF based on clinical appearance combined with histology and/or MRI, who were unresponsive to prednisone combined with low-dose MTX or presenting with severe disease, were selected for this retrospective cohort study. Patients received 6-9 monthly infusions of 4 mg/kg MTX followed by oral folinic acid rescue therapy, which is comparable to treatment schedules for trophoblast disease. An additional number of six pulses could be administered in case of a partial effect or flare. Safety data were monitored during each visit and classified according to the Common Terminology Criteria for Adverse Events (CTCAE) from the National Institute of Health (2009).

Results:

Twenty-seven patients (26 with EF, one with deep linear morphea) were included in this study (five males), with a mean age of 59 (sd 11.5) years, based on clinical presentation and histology and/or MRI. Previous treatment data were available for 22 patients of which 21 received oral prednisone (20-60 mg) whether or not combined with low dose MTX and/or UVA1 therapy. All patients reported ≥ 1 AEs at some stage, exactly 100 in total. ‘Gastro-intestinal disorders’ (n=36) and ‘General disorders and administration site conditions’ (n=15) were most common; especially nausea (n=6) and fatigue (n=11). One patient was hospitalized for blood transfusion. In four cases, treatment was discontinued due to AEs (acute kidney injury (AKI), depression, nausea/vomiting, and leukopenia resp.). Each reported AE appeared reversible. The patient with AKI had an MTX level in the toxic range; methotrexate-induced crystal nephropathy seemed the most likely explanation, probably due to a combination of high body weight (and thus high absolute dosage of MTX) and the concomitant use of omeprazole. Oral folinic acid rescue therapy was prolonged, together with 500 cc i.v. fluid, after which kidney function normalized.

Organ systemAEFrequencyGastro-intestinal disordersNausea, oral mucositis, diarrhea, vomiting, abdominal pain, anorexia36General disorders, administration site conditionsMalaise, fatigue15Respiratory, thoracic, mediastinal disordersCough and dyspnea10Skin and subcutaneous tissue disordersSkin hyperpigmentation, hair loss, alopecia, other9Nervous systemHeadache, nerve abducens disorder7Infections and infestinationsSkin, urinary tract, upper respiratory tract, other6Blood, lymphatic system disordersAnemia, leukopenia, pancytopenia4Psychiatric conditionsDepression3Renal, urinary disordersAcute Kidney Injury1Other systems9100

Conclusion:

AEs were common among patients receiving high dose i.v. pulse MTX, especially nausea and fatigue, but were generally mild and reversible in all cases. This is in line with studies performed with patients with trophoblast disease. One episode of reversible AKI occurred that seemed to be related to high body weight and the use of concomitant medication. The safety profile of i.v. pulse MTX thus seems auspicious, but the case of AKI illustrates that further data on safety is needed.

References:

[1]Mertens JS et al. High-dose intravenous pulse methotrexate in patients with eosinophilic fasciitis. JAMA Dermatol 2016; 1(152):1262-5.

Disclosure of Interests:

None declared

AB0842 DISCOVERY OF ARTHRITIS IN PSORIASIS FOR EARLY RHEUMATOLOGIC REFERRAL (DAPPER): A CROSS-SECTIONAL STUDY

Background:

One in three patients with psoriasis (Pso) will develop psoriatic arthritis (PsA) (1). When untreated, this can lead to disability and irreversible joint damage (2). Current screening methods are mostly based on questionnaires. These lack specificity and sensitivity (3,4). Thus, a significant portion of PsA patients remains undetected.

Objectives:

Our main objective is to ascertain the prevalence of PsA in a cohort of Pso patient, treated at a dermatology outpatient clinic. Secondary, we wish to make a referral tool for dermatologist to detect patients suspected of PsA.

Methods:

A sample of 300 patients, stratified for current skin therapy (topical, systemic non-biologic, biologic), will be screened by a rheumatology resident for PsA signs and symptoms. When PsA is suspected, patients are referred to a rheumatologist for confirmation. We gather information about demography, treatment (past and current) and comorbidity. On top of that, we gather data on disease specifics (age of onset, disease duration, severity). We store biomaterials and DNA. Eventually, all these data will be used to form a more specific prediction model which can be used at the dermatology department for more efficient referral.

Results:

We will present preliminary data of the first 100 patients. In this cohort, we found 14 patients with known PsA. 10 patients were suspected of (previously undiagnosed) PsA, and were referred to a rheumatology clinic. Three cases were confirmed, and 4 are still under analysis. This makes the prevalence of PsA in Pso 17-21%. Of these three new cases, one was treated with topical therapy only, one was treated with a biologic, and one received targeted therapy. In the patients with PsA, we found a higher amount of men. On top of that, we found a trend towards more intensive therapy. This may be due to indication bias, were the presence of arthritis may lead to a more aggressive treatment. Interestingly, 2 of the 3 previously undiagnosed PsA patients were treated with a biological for their skin symptoms.

Conclusion:

Preliminary data of the DAPPER study reveal that the prevalence of confirmed PsA in Pso patients is 17%. If all suspected PsA are confirmed, this rises to 21%. Even under systemic biologic treatment, arthritis can still be active.

References:

[1]Mease PJ, Gladman DD, Papp KA et al. Prevalence of rheumatologist-diagnosed psoriatic arthritis in patients with psoriasis in European/North American dermatology clinics. J Am Acad Dermatol 2013;69(5):729-735.

[2]Kane D, Stafford L, Bresnihan B, FitzGerald O. A prospective, clinical and radiological study of early psoriatic arthritis: an early synovitis clinic experience. Rheumatology (Oxford) 2003;42(12):1460-1468.

[3]Coates LC, Aslam T, Al BF et al. Comparison of three screening tools to detect psoriatic arthritis in patients with psoriasis (CONTEST study). Br J Dermatol 2013;168(4):802-807.

[4]Haroon M, Kirby B, FitzGerald O. High prevalence of psoriatic arthritis in patients with severe psoriasis with suboptimal performance of screening questionnaires. Ann Rheum Dis 2013;72(5):736-740.

Disclosure of Interests:

Tamara van Hal Speakers bureau: Lilly Eli, Michelle Mulder: None declared, Mark Wenink: None declared, Marcel Pasch: None declared, Juul Van den Reek Speakers bureau: Abbvie, Eli Lilly, Elke De Jong Grant/research support from: Abbvie, Janssen Pharmaceutica, Consultant of: AbbVie, Janssen Pharmaceutica, Novartis, Eli Lily and Company, Celgene, and Leo Pharma., Speakers bureau: AbbVie, Janssen Pharmaceutica, Novartis, Eli Lily and Company, Celgene, and Leo Pharma.

Staphylococcus hyicus-infecties bij varkens

Staphylococcus hyicus is het oorzakelijke agens van exsudatieve epidermitis, een belangrijke huidziekte bij varkens. Bij de klassieke vorm zijn algemene dermatitis en epidermitis zonder jeuk aanwezig waarbij dehydratatie en sterfte kunnen optreden. Deze vorm komt vooral voor bij dieren jonger dan acht weken. Gelokaliseerde vormen, waarbij voornamelijk de oortoppen, de kop, de flanken of overige extremiteiten aangetast zijn, komen ook voor maar dan vooral bij dieren ouder dan zes weken. De door de kiem geproduceerde toxines zijn samen met andere predisponerende factoren die huidbeschadigingen kunnen veroorzaken, belangrijk om klinische symptomen te veroorzaken. De klinische symptomen en letsels zijn karakteristiek maar om de diagnose te bevestigen, is een isolatie van de kiem uit de letsels noodzakelijk. De behandeling bestaat uit vochttherapie, het topicale gebruik van antiseptica en het toedienen van antimicrobiële middelen. De preventie berust op het voorkomen van huidletsels, het optimaliseren van de huisvesting, het stalklimaat en de voeding en het toepassen van een goede reiniging en stalhygiëne om de infectiedruk te verlagen.

Detailed modeling of the epitaxial growth of GaAs nanowires

A detailed continuum model is presented for predicting the growth characteristics of GaAs nanowires during chemical beam epitaxy. The model describes the transport processes of Ga and As adatoms on the substrate and nanowire sidewalls, and through the nanoparticle and the nanowire-catalyst interface (NCI). The growth mechanisms of nanowires within the NCI are described using an extended step-flow kinetic model. The vapor-liquid-solid and vapor-solid-solid growth mechanisms are both described in the kinetic model. The growth rate of the nanowires, the surface and bulk concentrations of adatoms, and the role of transport processes of Ga and As adatoms during chemical beam epitaxy were investigated. The growth mechanisms of the nanowires were found to vary with increasing length of the nanowire.

[The first woman surgeons in the Netherlands]

This article describes the position of woman surgeons in the Netherlands. In 1913 the first woman, Heleen Robert, was accepted as member of the Dutch Society of Surgery. Three others, Jeanne Knoop, Frieda van Hasselt and Rosalie Wijnberg, followed during the next ten years. The nomination of Rosalie Wijnberg caused a turbulent discussion as she was working as a gynaecologist and not as a surgeon. One can wonder about this argument as other members were gynaecologists too. It seems that the male attitudes towards women were changing as more women entered the male dominated field. Nevertheless, from 1931 on, the year in which the registration of specialists was created, a number of women succeeded in obtaining a registration in surgery. Four of them were interviewed: dr. D.A.E. Norel, A.G. Wiersum-de Kwaadsteniet, J. Leeksma-Lievense and A.A. Fierstra. The general opinion still is that surgery is not a female profession. At the moment there are some twenty women working as general surgeon compared to a seven hundred men.

Cellobiose dehydrogenase, an active agent in cellulose depolymerization

The ability of cellobiose dehydrogenase purified from Phanerochaete chrysosporium to modify a Douglas fir kraft pulp was assessed. Although the addition of cellobiose dehydrogenase alone had little effect, supplementation with cellobiose and iron resulted in a substantial reduction in the degree of polymerization of the pulp cellulose. When the reaction was monitored over time, a progressive depolymerization of the cellulose was apparent with the concomitant production of cellobiono-1,5-lactone. Analysis of the reaction filtrates indicated that glucose and arabinose were the only neutral sugars generated. These sugars are derived from the degradation of the cellobiose rather than resulting from modifications of the pulp. These results suggest that the action of cellobiose dehydrogenase results in the generation of hydroxyl radicals via Fenton's chemistry which subsequently results in the depolymerization of cellulose. This appears to be the mechanism whereby a substantial reduction in the degree of polymerization of the cellulose can be achieved without a significant release of sugar.

HST imaging of atmospheric phenomena created by the impact of comet Shoemaker-Levy 9

Hubble Space Telescope (HST) images reveal major atmospheric changes created by the collision of comet Shoemaker-Levy 9 with Jupiter. Plumes rose to 3000 kilometers with ejection velocities on the order of 10 kilometers second-1; some plumes were visible in the shadow of Jupiter before rising into sunlight. During some impacts, the incoming bolide may have been detected. Impact times were on average about 8 minutes later than predicted. Atmospheric waves were seen with a wave front speed of 454 +/- 20 meters second-1. The HST images reveal impact site evolution and record the overall change in Jupiter's appearance as a result of the bombardment.

"Split" pancreaticojejunostomy in the surgical treatment of chronic pancreatitis

"Split" pancreaticojejunostomy is a procedure consisting of vertical transection of the pancreas and anastomosis of both sides of the cut pancreatic duct with an interposed, Roux-en-Y jejunal loop. In this paper we report the long term results of this procedure in the treatment of eight patients with chronic pancreatitis (CP).

Voyager 2 at Neptune: Imaging Science Results

Voyager 2 images of Neptune reveal a windy planet characterized by bright clouds of methane ice suspended in an exceptionally clear atmosphere above a lower deck of hydrogen sulfide or ammonia ices. Neptune's atmosphere is dominated by a large anticyclonic storm system that has been named the Great Dark Spot (GDS). About the same size as Earth in extent, the GDS bears both many similarities and some differences to the Great Red Spot of Jupiter. Neptune's zonal wind profile is remarkably similar to that of Uranus. Neptune has three major rings at radii of 42,000, 53,000, and 63,000 kilometers. The outer ring contains three higher density arc-like segments that were apparently responsible for most of the ground-based occultation events observed during the current decade. Like the rings of Uranus, the Neptune rings are composed of very dark material; unlike that of Uranus, the Neptune system is very dusty. Six new regular satellites were found, with dark surfaces and radii ranging from 200 to 25 kilometers. All lie inside the orbit of Triton and the inner four are located within the ring system. Triton is seen to be a differentiated body, with a radius of 1350 kilometers and a density of 2.1 grams per cubic centimeter; it exhibits clear evidence of early episodes of surface melting. A now rigid crust of what is probably water ice is overlain with a brilliant coating of nitrogen frost, slightly darkened and reddened with organic polymer material. Streaks of organic polymer suggest seasonal winds strong enough to move particles of micrometer size or larger, once they become airborne. At least two active plumes were seen, carrying dark material 8 kilometers above the surface before being transported downstream by high level winds. The plumes may be driven by solar heating and the subsequent violent vaporization of subsurface nitrogen.

[Anatomy of the ano-rectal region]

Following a survey of the anatomical characteristics of the rectum and the posterior part of the pelvic floor, a description is given of the fibrous sheath enveloping the rectum, and of the fibrous leaves and septa which traverse the adipose tissue of the subperitoneal space and the ischiorectal fossa. These fibrous structures contain the blood vessels, the lymphatics and the nerves, the distribution of which is described in detail. The fibrous structures, in which many smooth muscle fibres are present, not only enclose the vessels and nerves but also form the suspensory apparatus of the rectum.