THU0505 MUSCULOSKELETAL ULTRASOUND MONITORING DURING MTX TAPERING IN JIA: A PROSPECTIVE BLINDED COHORT STUDY

Background:

Juvenile idiopathic arthritis (JIA) is the most common chronic rheumatic disease in children. Musculoskeletal ultrasound (MSUS) is a reliable tool in the assessment of chronic inflammatory arthropathies. MSUS in JIA has demonstrated a higher sensitivity for detecting synovitis and tenosynovitis as compared to physical examination. The occurrence of subclinical synovitis (Sub-S: MSUS+/ physical examination -) seems more frequent in wrist and foot joints; the clinical significance of Sub-S in real-life practice is still debated. Methotrexate (MTX) is the most widely used first-line DMARD in JIA therapy. Weekly treatment with MTX leads to clinical remission (CR) in 50-70% of patients. After a variable period of CR (usually 6-18 months), MTX is discontinued. Relapse rate after MTX suspension ranges between 40-50%; no predictors of disease flare have been identified so far.

Objectives:

We designed a cohort study in order to explore if MSUS monitoring during MTX tapering was able to predict disease flare.

Methods:

JIA patients in CR (as defined by the JADAS score) for at least 12 months were enrolled in the study. Patients at first attempt of suspension (G1) were tapered as follows: 1 week of suspension every 3 weeks for 3 months + 1 dose every 2 weeks for 3 months; if CR persisted, MTX was stopped. Patients who had a previous flare during/after MTX tapering (G2) had a similar tapering schedule but the step with 1 MTX dose every 2 weeks lasted 6 months. All patients underwent a complete MSUS of 48 joints every 3 months; clinicians who performed physical examinations and follow-up were blinded to US findings for the entire study period.

Results:

18 consecutive patients were enrolled between April 2018 and September 2019; patients had prevalently oligoJIA (55.5%) and RF- polyJIA (22.2%). Patients had been treated with MTX for 24.7 months (17.7–48.3), CR had been achieved 4.2 months after MTX start; 61.1% were at their first attempt of MTX tapering (G1).Baseline MSUS:at T0 MSUS detected 9/18 patients (50.0%) with Sub-S (MSUS+). Affected sites at T0 were distributed as follows: 4 MCP joints, 9 MTP joints, 1 f-IP joints, 11 knees. No significant differences resulted in comparing demographic and baseline disease features between MSUS- and MSUS+ patients at T0.Follow-up MSUS: 14 patients (77.8%) completed the entire study protocol, 4 patients are still ongoing. 7 patients relapsed: 42.9% during tapering, 1 of them relapsed during a VZV infection and was excluded from further analysis. We considered as Tlast-MSUS the last available MSUS before relapse or final MSUS (i.e. three months after MTX withdrawal) for not-relapsed subjects.

At Tlast8 patients had at least 1 Sub-S. Sub-S per patient at Tlastwere more than Sub-S at T0 (2.85 vs 0.53 p=0.03) but the presence of Sub-S was not related with disease flare (50.0 vs 44.4% p=1). MSUS found 27 Sub-S of the small joints (sMSUS): 88.9% were in the feet, they had an OMERACT grading of 1. sMSUS+ patients were older (8.7 vs 3.9, p=0.002) therefore a weight-induced sub-S not related with JIA could be presumed.

Kaplan-Meier curves were analyzed comparing MSUS results at T0 and Tlast, both considering all Sub-S and excluding small feet joints (pMSUS). The best performance was achieved with MSUS at Tlastand pMSUS (figure below, p=0.11).

Conclusion:

•Sub-S are present in 50% of patients in clinical remission >12 months.

•Sub-S in older patients interest often feet small joints; these Sub-S may be of mechanical origin and are not associated with disease flare.

•Sub-S increase during MTX tapering.

Further patients must be enrolled to understand if Sub-S excluding feet small joints may predict disease flare.

References:

[1]Amendment of the OMERACT US definitions of joints’ features in healthy children using the DOPPLER technique. Collado P et al, Pediatr Rheumatol Online J. 2018.

[2]Preliminary Definitions for the Sonographic Features of Synovitis in Children. Roth J, et al; Arthritis Care Res. 2017.

Disclosure of Interests:

Francesco Licciardi: None declared, Marta Dellepiane: None declared, Carlotta Covizzi: None declared, Fabiana Figus: None declared, Irene Azzolin: None declared, Davide Montin Speakers bureau: Not relevant for the topic, Annamaria Iagnocco Grant/research support from: Abbvie, MSD and Alfasigma, Consultant of: AbbVie, Abiogen, Alfasigma, Biogen, BMS, Celgene, Eli-Lilly, Janssen, MSD, Novartis, Sanofi and Sanofi Genzyme, Speakers bureau: AbbVie, Alfasigma, BMS, Eli-Lilly, Janssen, MSD, Novartis, Sanofi

Expanding the mutation spectrum in ICF syndrome: Evidence for a gender bias in ICF2

BACKGROUND

Immunodeficiency, centromeric instability, and facial anomalies (ICF) syndrome is a rare, genetically heterogeneous, autosomal recessive disorder. Patients suffer from recurrent infections caused by reduced levels or absence of serum immunoglobulins. Genetically, 4 subtypes of ICF syndrome have been identified to date: ICF1 (DNMT3B mutations), ICF2 (ZBTB24 mutations), ICF3 (CDCA7 mutations), and ICF4 (HELLS mutations).

AIM

To study the mutation spectrum in ICF syndrome.

MATERIALS AND METHODS

Genetic studies were performed in peripheral blood lymphocyte DNA from suspected ICF patients and family members.

RESULTS

We describe 7 ICF1 patients and 6 novel missense mutations in DNMT3B, affecting highly conserved residues in the catalytic domain. We also describe 5 new ICF2 patients, one of them carrying a homozygous deletion of the complete ZBTB24 locus. In a meta-analysis of all published ICF cases, we observed a gender bias in ICF2 with 79% male patients.

DISCUSSION

The biallelic deletion of ZBTB24 provides strong support for the hypothesis that most ICF2 patients suffer from a ZBTB24 loss of function mechanism and confirms that complete absence of ZBTB24 is compatible with human life. This is in contrast to the observed early embryonic lethality in mice lacking functional Zbtb24. The observed gender bias seems to be restricted to ICF2 as it is not observed in the ICF1 cohort.

CONCLUSION

Our study expands the mutation spectrum in ICF syndrome and supports that DNMT3B and ZBTB24 are the most common disease genes.

Factors useful in predicting the success of oocyte donation: a 3-year retrospective analysis

OBJECTIVE

To establish prognostic relevance of parameters assessed in oocyte donation cycles.

DESIGN

Retrospective analysis.

SETTING

Large university-based donor oocyte program.

PATIENT(S)

All oocyte recipient cycles achieving embryo transfer from September 1995 to October 1998.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Pregnancy.

RESULT(S)

Recipient age and reproductive status, day 9 and 12 serum estradiol (E(2)) levels and a progesterone (P) level obtained 2 days after initiation of hormonal therapy did not correlate with pregnancy. Endometrial thickness, but not endometrial pattern, was useful in predicting pregnancy outcome. The clinical pregnancy and live-birth rate in cycles where the endometrial thickness was less than 8 mm was significantly lower when compared to cycles with an endometrial thickness > or =9 mm. Cycles where optimal quality embryos were transferred had the highest implantation (36%), clinical pregnancy (63%) and live birth (54%) rates and these rates were significantly higher than those of cycles where only poor quality embryos were available for transfer (10% implantation, 17% clinical pregnancy, and 8% live birth rates, respectively; P<.05).

CONCLUSION(S)

The most reliable predictive factors for pregnancy in oocyte donation cycles are the quality of the embryos transferred and the recipient's mid-cycle endometrial thickness. Recipient monitoring should minimally include ultrasound assessment of endometrial thickness.

A two- versus three-embryo transfer: the oocyte donation model

OBJECTIVE

To compare implantation and pregnancy rates in oocyte recipients undergoing a two-embryo versus three-embryo transfer, 3 days after retrieval.

DESIGN

Retrospective comparative analysis.

SETTING

University-based in vitro fertilization center.

PATIENT(S)

All oocyte recipients undergoing embryo transfer from January 1, 1997 through August 31, 1999.

INTERVENTION(S)

Recipients received two or three embryos.

MAIN OUTCOME MEASURE(S)

Implantation, and clinical and multiple pregnancy rates.

RESULT(S)

Seventy-three recipients underwent a two-embryo transfer, and 376 had three embryos replaced. The numbers of oocytes retrieved (12.7 +/- 0.89 vs. 13.1 +/- 0.36) and embryos obtained (8.05 +/- 0.65 vs. 8.77 +/- 0.27) did not differ between the two-embryo and three-embryo transfer groups, nor did the proportion of patients with embryo cryopreservation (54.3% vs. 42.6%, respectively). There was no significant difference in pregnancy or implantation rates when comparing those patients with a two-embryo transfer to those with a three-embryo transfer. Significantly, 13.8% of the pregnancies in the three-embryo transfer group were triplet.

CONCLUSION(S)

Reducing the number of embryos transferred in an oocyte donation cycle can lower the incidence of triplet pregnancies without significantly lowering the overall pregnancy rate.

In vitro fertilization outcome relative to embryo transfer difficulty: a novel approach to the forbidding cervix

OBJECTIVE

To assess the impact of ET difficulty on IVF outcome and to optimize the ET procedure.

DESIGN

Retrospective analysis of IVF outcome by ET catheter type and ET difficulty. Prospective treatment and follow-up of patients with a history of extremely difficult cervical passage.

SETTING

Large university-based IVF program.

PATIENT(S)

All patients < 40 years of age undergoing IVF-ET from September 1995 to May 1998.

INTERVENTION(S)

Surgical correction of cervical stenosis.

MAIN OUTCOME MEASURE(S)

Pregnancy and embryo implantation rates.

RESULT(S)

Only 0.6% of ETs were "extremely difficult." Pregnancy rates were not statistically significantly different among ETs graded easy, moderate, and difficult. In contrast, no pregnancies occurred in the rare "extremely difficult" ET group. Eight patients with a history of extremely difficult cervical passage underwent surgical correction of their cervical stenosis. Twelve postoperative IVF-ET in these women resulted in eight clinical pregnancies, six of which were multiple gestations. The embryo implantation rate of these cycles was 42.2%.

CONCLUSION(S)

Patients with a history of extremely difficult ET may benefit from hysteroscopic evaluation and possible modification of their cervical canal before a future IVF attempt.

Fertility after hysteroscopic resection of submucous myomas

STUDY OBJECTIVE

To analyze fertility outcomes after resection of submucous myomas by operative hysteroscopy in infertile women.

DESIGN

Retrospective analysis (Canadian Task Force classification II-2).

SETTING

Academic tertiary referral center.

PATIENTS

Forty-one women (age 28-42 yrs) old with primary and secondary infertility, and histologically proved submucous myomas. Intervention. Hysteroscopic myomectomy performed with a rigid resectoscope.

MEASUREMENTS AND MAIN RESULTS

Of the 41 patients, 25 (60.9%) became pregnant overall and 20 (48.7%) delivered at term. Seventeen patients delivered a single fetus. Five delivered twins, three at term and two at 33 and 35 weeks. One woman delivered triplets at 31 weeks. The total delivery rate was 56.0%. Two women miscarried, at 6 and 8 weeks. One patient developed postoperative Asherman's syndrome.

CONCLUSION

Our results indicate that hysteroscopic myomectomy improves fertility in previously infertile women. Resection is a viable alternative to abdominal myomectomy for submucous myomas. (J Am Assoc Gynecol Laparosc 6(2):155-158, 1999)

Enhancement or initiation of testicular sperm motility by in vitro culture of testicular tissue

OBJECTIVE

To describe different techniques of testicular tissue culture and their effect on sperm motility, mainly in cases of totally immotile spermatozoa, and to compare the effect of in vitro culture with that of motility stimulants.

DESIGN

Prospective study.

SETTING

University teaching hospital.

PATIENT(S)

Ten patients undergoing testicular biopsy for diagnostic purposes or for intracytoplasmic sperm injection.

INTERVENTION(S)

Dissected testicular biopsy samples and tissue blocks were cultured at 37 degrees C for up to 96 hours. Immediately after dissection, immotile testicular spermatozoa were incubated for 30 minutes in pentoxifylline and 2-deoxyadenosine.

MAIN OUTCOME MEASURE(S)

Sperm motility and vitality.

RESULT(S)

Overall, dissected samples showed improved sperm motility, which peaked within 48 hours of culture. Unlike motility, vitality declined linearly, from 56.3%+/-19% at initial assessment to 18.8%+/-11% at 96 hours. Five samples had initially immotile spermatozoa, of which four acquired motility at 48 hours. In vitro culture showed results comparable with those of incubation with pentoxifylline and 2-deoxyadenosine. Culture of tissue blocks did not improve motility or vitality compared with dissected tissue.

CONCLUSION(S)

The motility of testicular spermatozoa was enhanced or initiated after in vitro culture. Testicular biopsy culture may be an alternative to the use of motility stimulants to obtain motile spermatozoa for intracytoplasmic sperm injection, particularly when oocytes are not immediately available.

Genetic screening of prospective oocyte donors

OBJECTIVE

To report our experience with genetic screening of oocyte donor candidates and to determine the frequency with which significant genetic issues are identified.

DESIGN

Prospective genetic screening of oocyte donor candidates.

SETTING

University hospital oocyte donation program.

PATIENT(S)

Women presenting consecutively as volunteer oocyte donors.

INTERVENTION(S)

Genetic screening was performed by pedigree analysis and laboratory studies.

MAIN OUTCOME MEASURE(S)

Inclusion in the oocyte donor pool based on the results of clinical evaluation and laboratory tests consisting of polymerase chain reaction based mutational analysis for cystic fibrosis carrier status, cytogenetic analysis for karyotype, enzymatic assay for Tay-Sachs disease carrier status, and complete blood count and hemoglobin electrophoresis.

RESULT(S)

Eight (11%) of 73 oocyte donor candidates were excluded from the donor pool because of a potentially serious genetic finding. Cystic fibrosis mutations were identified in 5 candidates (7%), abnormal karyotypes were found in 2 (3.5%), and an autosomal dominant skeletal dysplasia was identified in 1 (1.4%).

CONCLUSION(S)

A significant proportion of women who present as candidates for oocyte donation are inappropriate for donation because of their genetic history or genetic testing results. A thorough genetic evaluation, including a history and laboratory screening, is essential to any oocyte donation program to maximize positive outcomes in pregnancies achieved through assisted means.