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

Background

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

Objectives

To clinically characterise the Reuma.pt/Myositis cohort.

Methods

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

Results

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

Table 1.

Autoantibodies in cancer-associated myositis

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

Conclusion

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

Disclosure of Interests

None declared

POS0564 SHOULD WE USE PHYSICIAN’S GLOBAL TO DEFINE REMISSION IN RHEUMATOID ARTHRITIS AND CONSIDER A SEPARATE PATIENT-CENTRED TARGET?

Background

The definitions of remission play a crucial role in the treat-to-target strategy in rheumatoid arthritis.The patient’s and physician’s global assessment (PGA|PhGA) of disease activity are considered in current definitions, but PGA has been criticized for its poor relationship with actual disease activity. This leads to a considerable risk of overtreatment in patients who are otherwise in remission but fail this target solely because of PGA: PGA-near-remission. A dual-target strategy, excluding PGA from the definition of biological remission and the creation of a second target focused on disease impact has been proposed.1 Another proposal is to substitute PGA by PhGA with the purpose of strengthening the definition with a fourth variable capable of conveying relevant unaccounted factors, such as comorbidity.2

Objectives

To assess the relationship of PGA and PhGA with objective measures of disease activity (DAS3v) and their impact upon near-remission and risk of overtreatment.

Methods

This is a cross-sectional analysis of data from RAID.PT, an observational, prospective and multicenter study, including adult patients fulfilling RA classification criteria. Tender (TJC28) and swollen (SJC28) 28 joint counts, C-Reactive Protein (CRP), Pain score, Health Assessment Questionnaire (HAQ), the Rheumatoid Arthritis Impact of Disease (RAID) total score, Hospital Anxiety and Depression Scale (HADS) scores, PGA and PhGA were collected. Disease Activity Score (DAS28-3v-CRP) was calculated and taken as the reference measure of current disease activity. Correlation between PGA and PhGA with other continuous variables was evaluated through Pearson´s Correlation Coefficient and variables with p<0.10 in univariate analysis were included in multivariable linear regression models.

Results

We included 299 patients, 81.3% women, mean age of 57.4±12.0 years and disease duration 9.4±9.5 years. Average DAS28-3v-PCR 2.4 (±1.9).

DAS3v-CRP is the strongest factor associated with PhGA, explaining 45% of its variance. Inversely, it only explains 2% of the variance of PGA, which is more affected by disease impact.

In this clinical cohort, 13% of patients were in full Boolean remission and 41% in PGA-near-remission. Only 49 of 123 patients in the latter group had a PhGA >1.

Considering PhGA instead of PGA in the Boolean definition of remission would increase the proportion of remission from 13 to 37.5% of the whole cohort.

Table 1.

Factors Associated with PGA and PhGA in multivariate regression analysis

PGAPhGA(β, 95% CI)(β, 95% CI)(β, 95% CI)ΔR2ΔR2DAS28-3v-CRP3.7 (1.9-5.5)10.9 (9.4 to12.5)0.020.45RAID7.7 (6.7-8.8)3.4 (2.5 to 4.3)0.610.09HAQ5.6 (1.0-8.1)-3.4 (-6.4 to -0.4)0.010.01R20.64*0.55*

DAS28-3v-CRP: Disease Activity Score-3 variables C-Reactive Protein. PGA: Patient global assessment; PhGA: Physician Global Assessment; HAQ (health assessment questionnaire); RAID: Rheumatoid Arthritis Impact Disease score. ΔR2 change of R2associated with the inclusion of the variable in the model. *p<0,01

Conclusion

PhGA is a closer representation of actual disease activity than PGA, thus providing a more valid basis for treatment decisions aimed at disease activity. These observations support the substitution of PGA by PhGA in the Boolean definition of remission as it would strengthen the representation of disease activity and significantly reduce the risk of overtreatment in comparison to current definitions. The consequences of this change upon the prediction of long-term function and structural stability warrant evaluation. The patient’s perspective will remain central to disease management in the form of a distinct target.

References

[1]Ferreira et al. Ann Rheum Dis 2019 Oct;78(10):e109.doi: 10.1136/annrheumdis-2018-214199

[2]Pazmino et al. J Rheumatol. 2021 Feb;48(2):174-178.doi: 10.3899/jrheum.200758

Disclosure of Interests

None declared.

POS0640 EFFECTIVENESS AND SAFETY OF ORIGINAL AND BIOSIMILAR ETANERCEPT IN bDMARD-NAÏVE PATIENTS IN A REAL-WORLD COHORT OF PORTUGAL

Background:

The patent expiration of the original etanercept in Europe has facilitated the development of biosimilar products. Non-significant differences in efficacy and safety were noted in clinical trials which are not expected to influence clinical performance. Nonetheless, daily practice data should be gathered to support the claim for biosimilarity.

Objectives:

To compare the effectiveness and safety of original and biosimilar etanercept, in biological-Disease Modifying Antirheumatic Drug (bDMARD)-naïve patients.

Methods:

A retrospective multicenter non-interventional study, using data collected prospectively from Reuma.pt (The Rheumatic Diseases Portuguese Register) was done, including patients with: age ≥ 18 years old; diagnosis of Rheumatoid Arthritis (RA), Psoriatic Arthritis (PsA) or Spondyloarthritis (SpA) (axial or peripheral); active disease who initiated treatment with etanercept as first line of biological treatment after 2010. Kaplan-Meyer was used to calculate the persistence rate in treatment. Disease activity at baseline and follow-up data at 6, 12, 18 and 24 months of treatment was compared using the chi-square for categorical variables and t-student or Mann-Whitney tests for continuous variables. Reasons for discontinuing therapy were summarized using descriptive statistics. Statistical significance was assumed for 2-sided p-values >0.05.

Results:

We included 1694 patients (413 on biosimilar and 1280 on original etanercept) 864 with RA, 335 with PsA and 494 with SpA. The population’s baseline characteristics were not significantly different among both groups, except concomitant treatment in RA (higher use of conventional DMARDs in biosimilar group and higher use of NSAIDs in original group) and in SpA patients (higher use of corticosteroids in original group).

At baseline, a higher joint count was found in patients treated with original etanercept with a statistical difference for swollen (p=0.03) and tender (p=0.01) joints count (SJC and TJC, respectively) in RA and in TJC in SpA patients (p=0.02). In RA patients, CDAI and SDAI were higher in patients who started original (p=0.03; p=0.04, respectively). Pain measured by visual analogic scale was higher in SpA patients treated with biosimilar (p=0.03).

The 3-year PR was not significantly different between both treatment groups in RA, PsA and SpA (Figure1). In RA, PR in biosimilar was 72.6%, with a median time-on-drug (TOD) of 28.3 months; for original etanercept PR was 63.6%, with a median TOD of 27.4 months (p=0.566). In PsA patients, the PR for biosimilar was 70.6%, with a median TOD of 27.6 months, and in original drug 67.0%, with a median TOD of 28.1 months (p=0.743). In SpA patients, the PR were 78.4% for biosimilar (median TOD of 27.4 months) and 71.5% for original treatment (median TOD of 28.0 months (p=0.816)).

Figure 1.

Drug survival in biosimilar and original etanercept in Rheumatoid Arthritis, Psoriatic Arthritis and Spondyloarthritis

In RA patients, we did not find differences between the two treatment groups for the proportion of patients in remission or low disease activity by CDAI ≤10, SDAI≤11 or DAS28 <3.2 at 6, 12, 18 and 24 months of treatment. For PsA, no differences were found in the same timelines for DAPSA≤14, DAS28<3.2, BASDAI<4, ASDAS<2.1 or PsARC response. Also, in SpA patients, no differences were found in BASDAI<4, BASFI<4, ASDAS<2.1, ASDAS response and BASDAI response in all the timelines with the exception of BASDAI response at 18 months, which was achieved in fewer patients in biosimilar therapy (p=0.02).

Overall, 535 (31.6%) patients stopped etanercept (428 patients on original and 107 patients on biosimilar). Discontinuations due to inefficacy were the most frequent, but there were no significant differences between both groups as for adverse events. Discontinuations due to “other reasons” were higher for the original group, both in RA (p=0.01) and in SpA (p=0.04).

Conclusion:

Biosimilar and original used as first-line biological treatment showed similar effectiveness and safety in our long-term cohort of patients with RA, PsA, and SpA

Disclosure of Interests:

None declared

POS0872 CLINICAL FEATURES AND OUTCOME OF 1054 PATIENTS WITH SYSTEMIC SCLEROSIS: AN ANALYSIS OF THE PORTUGUESE REUMA.PT REGISTRY FOR SCLERODERMA (REUMA.PT/SSC)

Background:

Systemic sclerosis (SSc) may present distinctive manifestations and survival in different ethnic and geographic groups.

Objectives:

To describe the clinical features, treatments, and survival of adult SSc patients registered in Reuma.pt/SSc.

Methods:

Demographic features, SSc subsets, fulfilment of classification criteria, clinical and immunologic characteristics, comorbidities, medication and deaths were reviewed. Survival was calculated for patients included in the registry within the first 2 years of diagnosis.

Results:

In total, 1054 patients were included, 87.5% female, mean age at diagnosis 52.7 ± 14.8 years. The most common subset was limited cutaneous (lc)SSc (56.3%), followed by diffuse cutaneous (dc)SSc (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 observed manifestations. Gastrointestinal (62.8% vs 47.8%), pulmonary (59.5% vs 23%) and cardiac (12.8% vs 6.9%) involvement were significantly more prevalent in dcSSc compared to lcSSc (Table 1). 52.5% of patients were ACA positive and 21% anti-topoisomerase positive, with significant differences between lcSSc and dcSSc. One third of patients was treated with immunomodulators, 53.6% with vasodilators, 23% received glucocorticoids and 2.3% biologics.

During the median follow-up 12.4 years, 83 deaths (7.9%) were verified. The overall 1, 2 and 5 years survival was 98.0%, 96.8% and 92.6% respectively, without significant differences between lcSSc and dcSSc (Figure 1).

Conclusion:

Reuma.pt/SSc register is useful in routine patient monitoring and contributes to improve knowledge about this rare and complex disease. Clinical features of Portuguese SSc patients are similar to what has been described in other populations although the overall 5-year survival in recently diagnosed patients appears to be higher than previously reported.

Table 1.

Cumulative clinical and immunologic characteristics of Portuguese SSc patients

Clinical and immunologic featuresTotalN=1054Limited cutaneous SScN= 576 (56.3%)Diffuse cutaneous SScN=180 (17.5%)P valueSkin involvement – N(%) N=987688 (90.6)525 (90.7)180 (100)<0.01Skin thickening * – N (%) N= 962680 (76.9)512 (88.9)180 (100)<0.01Digital ulcers – N (%) N=970325(33.5)186 (34.7)4 (51.5)<0.01Raynaud’s Phenomenon – N (%) N=1010943 (93.4)539 (95.7)157 (92.4)0.06Musculoskeletal involvement – N(%) N=972346 (45.6)247 (42.7)99 (55)<0.01Cardiac involvement –N(%) – N=92471 (7.7)36 (6.9)19 (12.8)0.02Renal involvement –N(%) – N= 91717 (1.9)8!1.5)6 (4.1)0.07Gastrointestinal involvement - N(%) N=933508 (48.2)277 (47.8)113 (62.8)<0.01Pulmonary involvement – N(%) N=915261 (28.5)119 (23)88 (59.5)<0.01PAH – N(%) N= 87114 (1.6)10 (2)1 (0.7)0.23Intersticial lung disease – N(%) N=765218 (28.5)100 (22.7)75 (57.7)<0.01Antinuclear antibodies - N(%) N=1040934 (89.8)522 (90.2)154 (88.5)0.57Anti-centromere – N(%) N= 1027540 (52.6)383 (67.1)16 (9.5)<0.01Anti-Scl70 – N(%) N=1020214 (21)12 (3.3)104 (60.1)<0.01Anti-RNA polymerase III – N(%) N=71025 (3.5)12 (3.3)7 (5.6)0.38ComorbiditiesHypertension – N(%) N=431117 (27.1)76 (29.7)67 (20.7)0.1Hyperlipidemia – N(%) N=43171 (13.4)72 (12.2)24 (15.9)0.08Neoplasia – N(%) N=105429 (2.8)12 (2.1)7 (3.9)0.14

PDE-5 (phosdiasterase-5); PPIs (proton pump inhibitors); PAH-Pulmonary arterial hypertension confirmed by right heart catheterization. Immunomodulators includes Metothrexate, Leflunomide, Hydroxycloroquine; Azathioprine, Mycophenolate Mofetil and Cyclophosphamide; * Does not include sclerodactyly.

Figure 1.

Panel A - Survival in years from diagnosis of patients with SSc included in Reuma.pt in the first 2 years of disease (N=472). Panel B - survival according to SSc subset (lcSSc and dcSSC).

Disclosure of Interests:

None declared

Effect of a therapeutic exercise program (FisioPausa) on the quality of life of employees from CESPU

Introduction In the context of work, labouring time is mainly spent in the sitting position and in a continuous way. This reality contributes for the increase of a sedentary lifestyle of workers, leading to health-related diseases and consequently decreasing they quality of life (QoL).

Objectives Verify the effect of a therapeutic exercise program in quality of life, and evaluate the association between different components of QoL, with back pain, physical activity and Body Mass Index (BMI).

Methodology A pré-post interventional study was realized in workers from the Cooperativa de Ensino Superior Politécnico Universitário. Fourteen participants were included and submitted to evaluations with a preliminary survey, the SF-36v2 (before and after 8 weeks of intervention) to assess the effects of the program in QoL. All the participants were submitted to a specific therapeutic exercise program of 20 minutes, twice a week, and during 8 weeks.

Results There was a general improvement in Health-Related Physical and Mental Quality of Life. These improvements were especially observed in the functional capacity with a higher median of 5.00 (p = 0,015). Although it was less evident, Vitality was the domain with higher improvements amongst all the four Mental domains (increase of 10.00 points across time, p = 0.341). Associations were observed between pain and functional capacity (p = 0,027) BMI and Mental Health (p = 0,027) and finally between Age and Mental Health (p = 0,028).

Conclusion Our therapeutic exercise program seems to have positive effect on quality of life, especially regarding functional capacity of workers. Participants with the highest pain were associated with decreased functional capacity and older people or those with higher BMI showed weaker mental health.

Phosphorus fractionation in sediments of tropical semiarid reservoirs

The reduction of external loads of phosphorus (P) is the main action to control eutrophication in lakes. However, the elimination of these sources is not always sufficient for lakes' recovery, because the P accumulated in the sediment can be released for decades after it has accumulated. Thus, to restore a lake, it is also necessary to reduce its internal P loading. For this, it is essential to know the composition of P in the sediment to evaluate the potential P availability. In this study, the forms of P in the sediment of two reservoirs in a semiarid tropical region were investigated. The forms of P were determined by fractionation, sorting out the forms in loosely sorbed P (P-Water), reductant-soluble P (P-BD), metal oxide-bound P (P-NaOH), P bound to organic matter (P-Humic), calcium-bound P (P-HCl) and residual P (P-residual). The sediment was collected in September 2016 and sliced in situ. The total amount of P forms in the sediment varied from 5mgkg^-1 to 349mgkg^-1 in the Gargalheiras Reservoir and from 12mgkg^-1 to 371mgkg^-1 in the Cruzeta Reservoir. Despite some variation in amounts at different depths, the general range of fractions in Gargalheiras and Cruzeta was: P-BD>P-NaOH>P-HCl>P-water>P-Residual>P-Humic. In both reservoirs, the predominant form was BD, followed by NaOH and HCl. The first two forms are available and released easily, making them bioavailable for eutrophication processes and thus phytoplankton growth.

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.

The association between the 4G/5G polymorphism in the promoter of the plasminogen activator inhibitor-1 gene and deep venous thrombosis in young people

Objective: To evaluate the association between the 4G/5G polymorphism in the promoter of the plasminogen activator inhibitor-1 (PAI-1) gene and deep venous thrombosis (DVT) in young people.

Methods: Prevalence of the 4G/5G polymorphism was investigated using DNA analysis in a population of 81 consecutive and unrelated patients with an objectively documented first episode of DVT under 40 years old and in a control group of 88 healthy subjects.

Results: The frequency of genotypes among patients was 0.27 4G/4G, 0.49 4G/5G and 0.23 5G/5G, corresponding to a frequency of 0.52 for the 4G allele. In the control group the results were, respectively, 0.24, 0.44 and 0.32, corresponding to a frequency of 0.46 for the 4G allele. The odds ratio (OR) for homozygous 4G genotype was 1.5 (95% confidence interval: 0.7–3.6), which was not statistically significant ( P = 0.51).

Conclusion: In this study, the 4G/5G polymorphism in the promoter of the PAI-1 gene, including the homozygous 4G genotype, was not associated with a significantly increased risk of DVT in young people.

In vivo dual-delivery of glucagon like peptide-1 (GLP-1) and dipeptidyl peptidase-4 (DPP4) inhibitor through composites prepared by microfluidics for diabetes therapy

Oral delivery of proteins is still a challenge in the pharmaceutical field. Nanoparticles are among the most promising carrier systems for the oral delivery of proteins by increasing their oral bioavailability. However, most of the existent data regarding nanosystems for oral protein delivery is from in vitro studies, lacking in vivo experiments to evaluate the efficacy of these systems. Herein, a multifunctional composite system, tailored by droplet microfluidics, was used for dual delivery of glucagon like peptide-1 (GLP-1) and dipeptidyl peptidase-4 inhibitor (iDPP4) in vivo. Oral delivery of GLP-1 with nano- or micro-systems has been studied before, but the simultaneous nanodelivery of GLP-1 with iDPP4 is a novel strategy presented here. The type 2 diabetes mellitus (T2DM) rat model, induced through the combined administration of streptozotocin and nicotinamide, a non-obese model of T2DM, was used. The combination of both drugs resulted in an increase in the hypoglycemic effects in a sustained, but prolonged manner, where the iDPP4 improved the therapeutic efficacy of GLP-1. Four hours after the oral administration of the system, blood glucose levels were decreased by 44%, and were constant for another 4 h, representing half of the glucose area under the curve when compared to the control. An enhancement of the plasmatic insulin levels was also observed 6 h after the oral administration of the dual-drug composite system and, although no statistically significant differences existed, the amount of pancreatic insulin was also higher. These are promising results for the oral delivery of GLP-1 to be pursued further in a chronic diabetic model study.

Phenotyping Rh/Kell and risk of alloimmunization in haematological patients

BACKGROUND

One of the biggest concerns in transfusion medicine is to avoid red blood cell alloimmunization. We evaluated the rate of alloimmunization in two groups of chronically transfused patients (A - not phenotyped and B - phenotyped for Rh/K antigens before the first transfusion) with primary haematological disorders and its distribution among the main haematological diseases, in order to adopt an efficient transfusional strategy.

STUDY DESIGN AND METHODS

As methodology, we used the SIBAS and SAM databases for the retrospective study of all patients with primary haematological disorder between January 2011 and April 2013.

RESULTS

A statistical difference in the rate of alloimmunization comparing groups A and B was found (P <0·0001). We also observed that alloimmunization was not homogeneously distributed in all primary haematological diseases.

CONCLUSIONS

The Rh/K phenotype should be performed on all patients diagnosed with bone marrow failure, plasma cell dyscrasia and myelodysplastic syndrome in order to avoid alloimmunization. In patients with acute leukaemia and lymphoma it seems not necessary to perform it. In patients with haemoglobinopathy and myeloproliferative disorders, a larger group of patients is needed to decide its efficacy.

Transmission of HIV Drug Resistance and the Predicted Effect on Current First-line Regimens in Europe

Transmitted human immunodeficiency virus drug resistance in Europe is stable at around 8%. The impact of baseline mutation patterns on susceptibility to antiretroviral drugs should be addressed using clinical guidelines. The impact on baseline susceptibility is largest for nonnucleoside reverse transcriptase inhibitors.

Background. Numerous studies have shown that baseline drug resistance patterns may influence the outcome of antiretroviral therapy. Therefore, guidelines recommend drug resistance testing to guide the choice of initial regimen. In addition to optimizing individual patient management, these baseline resistance data enable transmitted drug resistance (TDR) to be surveyed for public health purposes. The SPREAD program systematically collects data to gain insight into TDR occurring in Europe since 2001.

Methods. Demographic, clinical, and virological data from 4140 antiretroviral-naive human immunodeficiency virus (HIV)–infected individuals from 26 countries who were newly diagnosed between 2008 and 2010 were analyzed. Evidence of TDR was defined using the WHO list for surveillance of drug resistance mutations. Prevalence of TDR was assessed over time by comparing the results to SPREAD data from 2002 to 2007. Baseline susceptibility to antiretroviral drugs was predicted using the Stanford HIVdb program version 7.0.

Results. The overall prevalence of TDR did not change significantly over time and was 8.3% (95% confidence interval, 7.2%–9.5%) in 2008–2010. The most frequent indicators of TDR were nucleoside reverse transcriptase inhibitor (NRTI) mutations (4.5%), followed by nonnucleoside reverse transcriptase inhibitor (NNRTI) mutations (2.9%) and protease inhibitor mutations (2.0%). Baseline mutations were most predictive of reduced susceptibility to initial NNRTI-based regimens: 4.5% and 6.5% of patient isolates were predicted to have resistance to regimens containing efavirenz or rilpivirine, respectively, independent of current NRTI backbones.

Conclusions. Although TDR was highest for NRTIs, the impact of baseline drug resistance patterns on susceptibility was largest for NNRTIs. The prevalence of TDR assessed by epidemiological surveys does not clearly indicate to what degree susceptibility to different drug classes is affected.

Portuguese recommendations for the diagnosis and management of gout

OBJECTIVE

To develop Portuguese evidence-based recommendations for the Diagnosis and Management of Gout.

METHODS

As part of the 3e Initiative (Evidence, Expertise and Exchange), a panel of 78 international rheumatologists developed 10 relevant clinical questions which were investigated with systematic literature reviews. MEDLINE, EMBASE, Cochrane CENTRAL and abstracts from 2010-2011 EULAR and ACR meetings were searched. Based on the evidence found in the published literature, rheumatologists from 14 countries developed national recommendations that were merged and voted into multinational recommendations. We present the Portuguese recommendations for the Diagnosis and Management of Gout which were formulated and voted by Delphi method in April 2012, in Lisbon. The level of agreement and potential impact in clinical practice was also assessed.

RESULTS

Twelve national recommendations were elaborated from 10 international and 2 national questions. These recommendations addressed the diagnosis of gout; the treatment of acute flares and urate-lowering therapy; monitoring of gout and comorbidity screening; the influence of comorbidities in drug choice; lifestyle; flare prophylaxis; management of tophi and asymptomatic hyperuricaemia; the role of urine alkalinization; and the burden of gout. The level of agreement with the recommendations ranged from 6.8 to 9.0 (mean 7.7) on a 1-10 point visual analogue scale, in which 10 stands for full agreement.

CONCLUSION

The 12 Portuguese recommendations for the Diagnosis and Management of Gout were formulated according to the best evidence and endorsed by a panel of 42 rheumatologists, enhancing their validity and practical use in daily clinical practice.

Pharmacology of biosimilar candidate drugs in rheumatology: a literature review

OBJECTIVE

To review current evidence concerning pharmacology of biosimilar candidates to be used in rheumatology.

METHODS

A PubMed search up to August 2013 was performed using relevant search terms to include all studies assessing pharmacological properties of biosimilar candidates to be used in rheumatology. Data on study characteristics, type of intervention, pharmacokinetics (PK), pharmacodynamics (PD) and bioequivalence ratios was extracted.

RESULTS

Of 280 articles screened, 5 fulfilled our inclusion criteria. Two trials, PLANETAS and PLANETRA, compared CT-P13 and infliximab in patients with active ankylosing spondylitis and rheumatoid arthritis, respectively. PK bioequivalence was demonstrated in the phase 1 PLANETAS trial by highly comparable area under the curve (AUC) and maximum drug concentrations (Cmax), whose geometric mean ratios fell between the accepted bioequivalence range of 80-125%. Equivalence in efficacy and safety was demonstrated in the phase 3 PLANETRA trial. Two phase 1 trials comparing etanercept biosimilar candidates TuNEX and HD203 in healthy volunteers showed a high degree of similarity in AUC and Cmax, with respective geometric mean ratios between PK bioequivalence range. The last included trial referred to GP2013, a rituximab biosimilar candidate, which demonstrated PK and PD bioequivalence to reference product in three different dosing regimens in cynomolgus monkeys.

CONCLUSION

Infliximab, etanercept and rituximab biosimilar candidates have demonstrated PK bioequivalence in the trials included in this review. CT-P13 has recently been approved for use in the European market and the remaining biosimilar candidates are currently being tested in patients with rheumatoid arthritis.

A neural network for shortest path computation

This paper presents a new neural network to solve the shortest path problem for inter-network routing. The proposed solution extends the traditional single-layer recurrent Hopfield architecture introducing a two-layer architecture that automatically guarantees an entire set of constraints held by any valid solution to the shortest path problem. This new method addresses some of the limitations of previous solutions, in particular the lack of reliability in what concerns successful and valid convergence. Experimental results show that an improvement in successful convergence can be achieved in certain classes of graphs. Additionally, computation performance is also improved at the expense of slightly worse results.

Molecular epidemiology and prevalence of drug resistance-associated mutations in newly diagnosed HIV-1 patients in Portugal

BACKGROUND

Drug resistance transmission in newly diagnosed, drug-naïve HIV-1 infected individuals has been previously reported, with rates ranging from 5 to 27%. The aim of this study is to investigate the prevalence of resistance-associated mutations in drug-naïve, newly diagnosed patients, as well as monitoring the diversity of HIV-1 strains circulating in Portugal.

METHODS

One hundred eighty samples from newly diagnosed patients were prospectively collected during 2003, according to the distribution of HIV-1 infections in Portugal. Epidemiological, clinical and laboratory data was collected using a standardized form. Population sequencing was performed using an automated sequencer (ABI Prism 3100, Applied Biosystems) and a commercially available assay (ViroSeq HIV-1 Genotyping System, v2.0, Abbott). Stanford HIV Sequence Database was used for interpretation of resistance data; subtyping was performed using the REGA Subtyping Tool. When subtype was unassigned, further analysis was done using an alignment with reference sequences, and phylogenetic tools like Simplot and PHYLIP. Mutations listed by the International AIDS Society-USA were considered, except E44D and V118I.

RESULTS

Patient population included 124 males (69%) and 56 females (31%), the median age being 35. Western Europe was the main region of origin (77.2%), followed by Africa (18.3%), South America (2.8%) and Asia (1.1%). The most common route of transmission was heterosexual contact (54.4%), followed by intravenous drug use (20%), homo/bisexual individuals (19.4%) and blood transfusion (0.6%). The commonest subtypes were B (41.7%) and G (29.4%), while other non-B subtypes rated 12.8% and recombinant forms represented 16.1% of the samples. Fourteen patients (7.78%) were identified as carrying resistance-associated mutations. Ten were resistant to drugs from one class, three to drugs from two classes and one to drugs from all three classes. No statistically significant associations were found between age, gender, route of transmission, subtype and resistance.

CONCLUSIONS

The identification of newly diagnosed individuals carrying resistance-associated mutations confirms that drug resistance transmission is a public health problem in Portugal, with a possible impact on prevention, treatment and monitoring of HIV-1 infections.

Evaluation of internal exposure of nuclear medicine staff through in vivo and in vitro bioassay techniques

The manipulation of a wide variety of unsealed sources in Nuclear Medicine results in a significant risk of internal exposure of the workers. 131I should be highlighted among the most frequently used radionuclides because of its large application for diagnosis and therapy of thyroid diseases. The increasing use of radionuclides for medical purposes creates a demand for feasible methodologies to perform occupational control of internal contamination. Currently in Brazil, there are approximately 300 nuclear medicine centres in operation but individual monitoring is still restricted to the control of external exposure. This work presents the development of in vivo and in vitro bioassay techniques aimed to quantify incorporation of radionuclides used in Nuclear Medicine. It is also presented the results of a preliminary survey of internal exposure of a group of workers involved in the preparation of therapeutic doses of 131I. Workers were monitored with a gamma camera available in the Nuclear Medicine Service of the University Hospital of Rio de Janeiro and at the Institute of Radiation Protection and Dosimetry Whole-Body Counter (IRD-WBC). The in vivo detection systems were calibrated with a neck-thyroid phantom developed in IRD. Urine samples from radiopharmacy workers were collected after preparation and administration of therapeutic doses (10-250 mCi) of 131I and measured with a HPGe detection system available in the Bioassay Laboratory of IRD. The results show that the bioassay methods developed in this work present enough sensitivity for routine monitoring of nuclear medicine workers. All workers monitored in this survey presented positive results for 131I in urine samples and two workers presented detectable activities in thyroid when measured at the IRD-WBC. The highest committed effective dose per preparation was estimated to be 17 microSv.

A protocol for the calibration of gamma cameras to estimate internal contamination in emergency situations

The concern about accidents involving radioactive materials has led to the search of alternative methods to quickly identify and quantify radionuclides in workers and in the population. One of the options to face up an eventual demand for mass monitoring of internal contamination is the use of a nuclear medicine diagnostic equipment known as gamma camera, a device used to scan patients who have been administered specific amounts of radioactive materials for medical purposes. Although the gamma camera is used for image diagnosis, it can be calibrated with anthropomorphic phantoms or point sources for the quantification of radionuclide activities in the human body. This work presents a protocol for the calibration of gamma cameras for such application. In order to evaluate the suitability of this type of equipment, a gamma camera available in a public hospital located in Rio de Janeiro was calibrated for the in vivo measurement of 131I. The calibration includes the determination of detection efficiencies and minimum detectable activities for each radionuclide. The results show that the gamma camera presents enough sensitivity to detect activity levels corresponding to effective doses below 1 mSv. The protocol is the basis to establish a network of Nuclear Medicine Centres, located in public hospitals in eight countries of Latin America (Argentina, Brazil, Colombia, Cuba, Chile, Mexico, Peru and Uruguay) and in Spain that could be requested to collaborate in remediation actions in the event of an accident involving incorporation of radioactive materials. This protocol is one of the most significant outputs of the IAEA-ARCAL Project (RLA/9/049-LXXVIII) aimed to the Harmonization of Internal Dosimetry Procedures.

Combined Factor V Leiden (R506Q) and prothrombin G20210A genotyping in young patients presenting with deep venous thrombosis

Objective: To evaluate the association between the Factor V Leiden (FV R506Q) and prothrombin gene (FII G20210A) mutations and deep venous thrombosis (DVT) in young people.

Methods: Blood samples were drawn from 199 subjects: 100 healthy controls and 99 unselected patients, with an objectively documented first episode of DVT under 40 years old. DNA analysis was performed using the polymerase chain reaction.

Results: The mean age in the patient cohort was 27 years (range 16–40) and 68 (68.7%) were women. Patient prevalences were 20.6% and 10.1% for FV R506Q and FII G20210A, respectively. In the control group, carrier frequencies were 2% and 5%, respectively. We found an increased overall relative risk of DVT with statistical significance for FV R506Q carriers (OR: 12.8; 95% CI: 2.9–56.7; P < 0.001), but not for FII G20210A mutation (OR: 2.1; 95% CI: 0.7–6.5; P = 0.19).

Conclusions: Our results suggest a possible increase in DVT risk for the young G20210A allele carriers, which can be more expressed in the presence of a circumstantial risk factor. There is extremely strong evidence that the Factor V Leiden mutation is an important risk factor in the development of a first episode of DVT in young people.

Weak D type 2 is the most prevalent weak D type in Portugal

The weak D phenotype is the most common D variant, with a frequency of 0.2-1% in Caucasian individuals. There are several weak D types, with different frequencies in European countries, which may pose serologic problems and have the potential for alloimmunization. Samples from Portuguese individuals were tested for RhD by two or three distinct monoclonal and oligoclonal antisera, in direct agglutination tests. When discrepant results were observed, samples were tested with panels of monoclonal anti-D by LISS-indirect antiglobulin test. Cases that reacted weakly with IgM but positive with IgG anti-D were analysed by PCR-sequence-specific primers and real-time PCR. Ninety-nine samples were referred after being characterized as weak D. This genotype was recognized, with a preponderance of weak D type 2 (63.6%) over type 1 (16.2%) and 3 (14.1%). The high incidence of weak D type 2 in our population is in marked contrast to studies performed in other European populations and might be due to our sample selection criteria or ethnic variation. There are advantages in genotyping serologically depressed D samples to avoid the waste of D-negative RBC units and the use of immunoglobulin in pregnant women, who have no risk of alloimmunization.

Genetic Polymorphisms and Risk of Recurrent Deep Venous Thrombosis in Young People: Prospective Cohort Study

OBJECTIVE

To determine the incidence of deep venous thrombosis (DVT) recurrence in young people, and its association with some genetic polymorphisms (FV G1691A, FII G20210A, MTHFR C677T, PAI-1 4G/5G).

DESIGN

Prospective cohort study.

METHODS

A database was established prospectively to follow-up a cohort of unselected patients who had had a first episode of objectively proven DVT under the age of 40 years. All patients had DNA analysis for heritable thrombophilia. We excluded patients with deficiency of antithrombin, protein C or protein S, malignant disease, antiphospholipid syndrome, or a requirement for long-term antithrombotic treatment. The end-point was objective evidence of symptomatic DVT recurrence.

RESULTS

Eighty-seven patients were enrolled in the study. Mean duration of follow-up was 4.07 years. At 2 years, the cumulative recurrence rate was 19.3%. The risk of risk was not related to presence or absence of laboratory evidence of genetic polymorphisms: FV G1619A (HR 1.26 [95%CI: 0.64-2.46]; p = 0.51), FII G20210A (HR 0.81 [95%CI: 0.35-1.89]; p = 0.62), MTHFR C677T (HR 1.26 [95%CI: 0.56-2.81]; p = 0.58), PAI-1 4G/5G (0.84 [95%CI: 0.35-2.05]; p = 0.71).

CONCLUSION

In this study, the risk of recurrent deep venous thrombosis in young people was not related with the presence of FV G1691A, FII G20210A, MTHFR C677T or PAI-1 4G/5G polymorphisms.

Prevalences of hyperhomocysteinemia, unfavorable cholesterol profile and hypertension in European populations

BACKGROUND

Hyperhomocysteinemia (HHCY) is a risk factor for cardiovascular diseases (CVD). HHCY may interact with hypertension (HTEN) and an unfavorable cholesterol profile (UNFAVCHOL) to alter the risk of CVD.

OBJECTIVES

To estimate the prevalences of HHCY (1) isolated and (2) in combination with UNFAVCHOL and/or HTEN in different age categories. To provide information that may improve the screening and treatment of subjects at risk of CVD.

DESIGN

Cross-sectional data on 12,541 men and 12,948 women aged 20 + y were used from nine European studies.

RESULTS

The prevalence of isolated HHCY was 8.5% in subjects aged 20-40 y, 4.7% in subjects aged 40-60 y and 5.9% in subjects aged over 60 y. When combining all age groups, 5.3% had isolated HHCY and an additional 5.6% had HHCY in combination with HTEN and/or UNFAVCHOL. The combinations of risk factors increased with age and, except for HHCY&UNFAVCHOL, were more prevalent than predicted by chance. Of the young subjects (20-40 y), 24% suffered from one or more of the investigated CVD risk factors. This figure was 75.1% in the old subjects (60+ years).

CONCLUSIONS

A substantial number of subjects in selected European populations have HHCY (10.9%). In half of these cases, subjects suffer also from other CVD risk factors like UNFAVCHOL and HTEN. Older people in particular tend to have more than one risk factor. Healthcare professionals should be aware of this when screening and treating older people not only for the conventional CVD risk factors like UNFAVCHOL and HTEN but also HHCY, as this can easily be reduced through increased intake of folic acid via supplement or foods fortified with folic acid.