Wunderlich syndrome as a rare complication of polyarteritis nodosa: a case report

Spontaneous subcapsular and perirenal hemorrhage, known as Wunderlich syndrome (WS), is a rare clinical manifestation of polyarteritis nodosa (PAN). We report a case of a 48-year-old male with a history of recurrent episodes of leg muscle tenderness and dysesthesia, bilateral flank pain, painful nodular skin lesions in the lower limbs, weight loss, and difficult-to-control arterial hypertension. The abdominopelvic computed tomography angiography showed a large left perirenal hematoma, leading to the patient's admission to the intensive care unit. After the exclusion of infectious or neoplastic foci, the patient was diagnosed with PAN and started intravenous methylprednisolone pulses with a good response. Since WS is a rare initial clinical manifestation of PAN, an early diagnosis and aggressive treatment will significantly improve clinical outcomes.

Impact de l’infection par le SARS-CoV-2 sur l’activité de la maladie des patients atteints de rhumatisme psoriasique sous bDMARD : données réelles

Introduction

L’infection par le SARS-CoV-2 peut entraîner une inflammation sévère et il a été suggéré d’induire des poussées de rhumatisme psoriasique (RP). Cependant, l’impact sur l’activité de la maladie et la réponse aux DMARD biologiques modificateurs de la maladie (bDMARD) reste inconnu.

Patients et méthodes

Nous avons réalisé une analyse rétrospective incluant tous les patients atteints de RP, répondant aux critères CASPAR et sous biothérapie, suivis dans le service de rhumatologie d’un CHU universitaire tertiaire. Les données démographiques et cliniques, y compris la survenue d’une infection par le SARS-CoV-2, ont été collectées à partir de notre base de données nationale (reuma.pt). L’activité de la maladie (CDAI, SDAI, DAS28 4v, BASDAI, ASDAS) et les réponses aux bDMARD (réponses EULAR, ASDAS, ASAS, ACR et PsARC) ont été évaluées avant et après l’infection par le SARS-Cov-2.

Résultats

Au total, 102 patients atteints de RP ont été inclus. Cinquante-deux étaient des femmes (51 %). L’âge moyen était de 53 ± 11,09 ans et la durée médiane de la maladie était de 15 ans [min 2, max 47]. Au total, 54 (53 %) patients avaient une atteinte axiale prédominante, 26 (26 %) périphérique et 36 (37 %) enthésopathique. Le bDMARD le plus utilisé était l’étanercept (n = 28, 27,5 %) suivi de l’adalimumab (n = 22, 21,6 %) et du sécukinumab (n = 18, 17,6 %). La prévalence de l’infection par le SARS-CoV-2 était de 15,7 % (n = 16). Soixante-trois pour cent ont reçu le vaccin BNT162b2 (Pfizer/BioNtech), 31 % ont reçu l’ARNm-1273 (Moderna), 13 % ont reçu l’AZD1222 (AstraZeneca) et 13 % ont reçu l’AD26.COV2.S (Janssen/Johnson & Johnson). Soixante-trois pour cent étaient infectés avant toute vaccination, 13 % après la première dose et 25 % après la seconde. Les symptômes les plus fréquents étaient l’anosmie (65 %), la dysgueusie (56 %) et la toux (56 %). Tous les patients se sont complètement remis de l’infection, sans nécessiter d’hospitalisation. Quel que soit le score utilisé, la différence entre l’activité moyenne de la maladie après l’infection par le SARS-CoV-2 et celle au départ n’a pas atteint la signification statistique. Au départ et après l’infection, les paramètres moyens de l’activité de la maladie étaient respectivement : CDAI 8,6 ± 5,7 vs 8,6 ± 5,7, p = 0,997 ; SDAI 9,3 ± 6,6 contre 9,2 ± 6,1, p = 0,928 ; DAS 28 4v 2,9 ± 1,2 contre 2,9 ± 1,2, p = 0,818 ; BASDAI 3,6 ± 2,6 contre 3,2 ± 2,7, p = 0,506 ; ASDAS 2,2 ± 1,2 contre 2,2 ± 1, p = 0,721. Le nombre de patients ne répondant pas aux bDMARD (selon EULAR, ASDAS, ASAS, ACR et PsARC) avant l’infection n’était pas différent de celui post-infection.

Conclusion

Notre étude suggère que l’infection par le SARS-CoV-2 n’a aucun impact négatif sur l’activité de la maladie PSA et les réponses bDMARD. Cependant, d’autres études sont encore nécessaires pour mieux comprendre les effets à long terme de l’infection par le SARS-CoV-2.

SAT0320 BONE MINERAL DENSITY AND FRACTURE RISK IN A COHORT OF PORTUGUESE SYSTEMIC SCLEROSIS PATIENTS

Background:

Although poorly understood, patients with Systemic Sclerosis (SSc) seem to have higher prevalence of low bone mineral density (BMD) and an increased spine fracture risk.

Objectives:

We aim to determine, by conventional densitometry (DXA) and using the fracture risk assessment tool (FRAX), the prevalence of low BMD and the fracture risk, respectively, in our SSc cohort and its potential determinants.

Methods:

Observational transversal study was performed including consecutive patients with the diagnosis of SSc. We collected data regarding demographics, BMD (lumbar spine and femoral neck) and occurrence of fracture. Ten-year risk of osteoporotic fracture was estimated using FRAXv4.1with the Portuguese population reference. Statistical analysis was performed using SPSS 23.0; p<0.01 was considered statistically significant.

Results:

Median age of patients (n=97) was 62 years old [56, 70], 88.7% females (n=86). Seventy-eight patients (80.4%) had limited cutaneous form, 5 (5.2%) presented a diffuse cutaneous form and 13 (13.4%) an overlap syndrome. Regarding clinical features: digital ulcers in 30 patients (30.9%), interstitial lung disease (ILD) in 16 (6.5%), gastrointestinal involvement in 16 (16.5%), miositis in 4 (4.1%) and pulmonary arterial hypertension in 3 (3.1%). Anti-topoisomerase I antibody (anti-Scl70) positivity was present in 15 patients (15.5%) and anti-centromere antibody (ACA) positivity in 63 (64.9%). Nine patients (9.3%) were smokers and 6 (6.2%) reported an alcohol consumption of 3 or more units/day. Median body mass index (BMI) was 25.4 Kg/m2[21.4, 29.1], with 5 patients (5.2%) being underweight. Vitamin D insufficiency was reported in 19 patients (19.6%). Twenty-one patients (21.6%) have been exposed to oral glucocorticoids (GCT) for more than 3 months at a dose of 5mg daily or more. Eleven patients (11.3%) had previous low impact fractures: 10 of which were vertebral and 1 wrist fracture. Regarding the prescribed anti-osteoporotic treatment (AOP), we found: alendronate (n=7, 7.2%), zoledronic acid (n=7, 7.2%), denosumab (n=2, 2.1%) and teriparatide (n=1, 1%).

Low BMD was present in 45 patients (46.4%); median femoral neck BMD (FN-BMD) was 0.827 [0.709, 0.893].Ten year probability of fracture (%) was: median risk for major fracture was 5.1 [3.5, 9.7] and 3.8 [2.5, 8], with and without FN-BMD, respectively; for hip fracture the estimated risk was 1.2 [0.6, 3.1] and 1.0 [0.4, 2.5], with and without FN-BMD, respectively. According to FRAX thresholds for the Portuguese population, 25 patients (25.8%) met criteria to start AOP treatment. Among them, only 10 patients (40%) started it, as the agreement between the indication to treat by FRAX and the onset of treatment was weak (k= 0.338). A strong agreement was found between FRAX risk threshold with DXA and World Health Organization (WHO) threshold for starting AOP (k= 0.814) and no agreement was found between FRAX risk without DXA and WHO threshold.

FN-BMD presented a weak correlation with BMI (r = 0.393), a moderate inverse correlation with major fracture risk with and without FN-BMD (r = -0.704, r=-0.412, respectively) and with hip fracture risk with and without FN-BMD (r = -0.799, r=-0.412, respectively). Major fracture risk with and without FN-BMD presented a moderate correlation with spine fractures (r = 0.350; r=0.397, respectively).

No correlation was found between WHO threshold and spine fractures. No correlations were found between FN-BMD or fracture risk estimated by FRAX and disease manifestations, anti-Scl70 or ACA positivity, vitamin D insufficiency, smoking or GCT use.

Conclusion:

In our cohort, low BMD was prevalent and had correlation with BMI. FRAX appears to be an useful instrument as it correlated with spine fractures, contrary to what was verified when we used the WHO threshold. Early monitoring of BMD and estimating fracture risk using FRAX appear to be useful tools for the prevention of fractures in this population.

Disclosure of Interests:

Salomé Garcia: None declared, Bruno Miguel Fernandes: None declared, Sara Ganhão: None declared, Maria Rato: None declared, Filipe Pinheiro: None declared, Georgina Terroso: None declared, Miguel Bernardes Speakers bureau: Abbvie, Amgen, Biogen, Eli-Lilly, Glaxo-Smith-Kline, Pfizer, Janssen, Novartis, Lúcia Costa: None declared

AB0825 TIME-COURSE CHANGE IN AXIAL MOBILITY IN PSORIATIC ARTHRITIS PATIENTS UNDER bDMARD

Background:

Spinal mobility is assessed frequently in patients with psoriatic arthritis (PsA) usingBath Ankylosing Spondylitis Metrology Index(BASMI) to provide baseline measurement, monitor changes over time and to assess the impact of clinical interventions. BASMI comprises 4 measures of spinal mobility (cervical rotation, tragus-to-wall distance, modified Schober’s test and lumbar lateral flexion) and one hip mobility measurement (intermalleolar distance).

Objectives:

The aim of this study is to investigate the time-course change of BASMI in PsA patients after 6 months ofBiologic Disease-modifying Antirheumatic Drug(bDMARD) therapy. The authors also pretend to evaluated, at baseline and after 6 months of treatment, the association between BASMI, disease activity scores and physical function.

Methods:

An observational retrospective study was performed in patients with PsA under bDMARD followed in the Rheumatology department of a tertiary university hospital. Were included patients treated with only one bDMARD. Demographic and clinical data were collected from the Rheumatic Diseases Portuguese Register. For spinal mobility calculation BASMI was used. Disease activity was evaluated withAnkylosing Spondylitis Disease Activity Score(ASDAS) andBath Ankylosing Spondylitis Activity Index(BASDAI). Physical function was assessed withBath Functional Index(BASFI). The variation of BASMI, ASDAS, BASDAI and BASFI was calculated as the difference between values registered at 6 months and at baseline and presented as Δ. Correlations between ΔBASMI, ΔASDAS and ΔBASFI was calculated using Pearson test.

Results:

A total of 55 patients were included. Thirty patients were males (54.5%). The mean age at diagnosis was 44.6 ± 12.6 years and the median disease duration at start of bDMARD was 5.4 years (min: 0.30; max: 25.5). In total, 19 (34.5%) patients had predominant axial involvement, 36 (65.5%) peripheric and 36 (65.5%) enthesopathic. Almost all patients fulfilled the CASPAR criteria for PsA (n=50, 90.9%). According to ASDAS criteria, at the baseline 20 patients (36.4%) had high disease activity and 34 (61,8%) very high. The most used bDMARD was etanercept (n=21, 38,3%) followed by golimumab (n=19, 34.5%) and adalimumab (n=8, 14.5%). Three patients were treated with infliximab, two with certolizumab and other two with secukinumab. Forty-one patients (75.9%) were concomitantly treated with conventional synthetic DMARDs. Axial PsA patients had more limitations in spinal mobility (BASMI mean 4.5 ± 1.5) and more functional limitation (BASFI mean 6.8±1.9) than patients with predominant peripheric involvement (BASMI mean 3.3± 1.2, p=0.004; BASFI mean 5.4±3, p=0,0048). Statistically significant differences in ASDAS and BASDAI in these two groups were not observed (p=0.332 and p=0.605, respectively). For all patients, BASMI did not vary significantly (p=0.691) at baseline (mean 3.7± 1.4) and after 6 months (mean 3.8±1.3) of treatment. Although the ΔBASMI for etanercept was negative (mean -0.12±0.9) and for golimumab positive (0.14±0.8), it was not statistically significant. At baseline there is a significant positive association between BASMI and ASDAS (r=0.435, p=0.001), BASMI and BASDAI (r=0.567, p<0.001) and BASMI and BASFI (r=0.510, p<0.001). However, there was not a statistically significant association between ΔBASMI and: ΔASDAS, ΔBASDAI and ΔBASFI (r=0.158; p=0.269, r=0.019; p=0.096 and r=0.121; p=0.397, respectively).

Conclusion:

In PsA patients treated with bDMARDs, at least in short-term follow-up, BASMI does not improve with time. Changes in BASMI did not correlate with changes in activity disease and in functional outcome. Studies with longer follow-up and with more patients are needed to better evaluate these associations.

Disclosure of Interests:

Maria Rato: None declared, Filipe Pinheiro: None declared, Salomé Garcia: None declared, Bruno Miguel Fernandes: None declared, Sara Ganhão: None declared, Rita Gaio: None declared, Miguel Bernardes Speakers bureau: Abbvie, Amgen, Biogen, Eli-Lilly, Glaxo-Smith-Kline, Pfizer, Janssen, Novartis, Alexandra Bernardo: None declared, Lúcia Costa: None declared

AB0769 THE IMPACT OF BODY MASS INDEX ON DISEASE ACTIVITY AND ENTHESITIS IN PSORIATIC ARTHRITIS

Background:

Overweight/obesity has increased exponentially in the last decades, becoming a huge Public Health problem. Moreover, an increase in adipose tissue is associated with an increased production of several proinflammatory cytokines and acute phase reactants. Higher BMI has been related with new bone formation including syndesmophytes and enthesophytes. In fact, besides rheumatologic conditions including Psoriatic Arthritis (PsA), enthesopathy can be a consequence of several clinical conditions including metabolic syndrome, mechanical injuries and degeneration.

Objectives:

To evaluate the effect of body mass index (BMI) on disease activity scores and enthesitis scores in Psoriatic Arthritis.

Methods:

Retrospective study including all the patients with PsA meeting the CASPAR criteria, beginning first-line biologic therapy at our centre. Demographic and clinical data were collected from the Portuguese database Reumapt. Statistical analysis was performed with SPSS. Continuous variables were compared through Spearman/Pearson correlations.

Results:

The mean BMI was 26.8 (SD 0.5). In our sample of 119 PsA patients, 21.5% were overweight and 8.3% were obese. The mean age of patients was 46.3 ± 1.03 years; 60 female and 59 male. The median disease duration was 6.8 (0.3-33.8) years. At baseline mean (SD) disease activity variables were: DAS 28 4vESR 4.9 (0.2), ESR 33.2 (2.3) mm/h; CRP 2.35 (0.3) mg/dL, BASDAI 6.6 (0.2), ASDAS 3.9 (0.1), BASMI 3.7 (0.2), BASFI 5.8 (0.3), MASES 1.9 (0.3), SPARCC 2.3 (0.3). There were statistically significant positive correlations between BMI and MASES at baseline (p=0.024, r=0.411) but there weren’t with SPARCC, DAS 28 4vESR, ESR, CRP, BASDAI, ASDAS, BASMI and BASFI.

Conclusion:

The data showed that patients with higher BMI values had higher enthesitis scores suggesting that overweight/obesity may have a negative impact on enthesopathy. Further studies are still needed to further understand that possible relationship.

References:

[1]Bakirci S, Dabague J, Eder L, McGonagle D, Aydin SZ. The role of obesity on inflammation and damage in spondyloarthritis: a systematic literature review on body mass index and imaging. Clin Exp Rheumatol. 2019 Apr 29.

Disclosure of Interests:

Sara Ganhão: None declared, Bruno Miguel Fernandes: None declared, Salomé Garcia: None declared, Filipe Pinheiro: None declared, Maria Rato: None declared, Eva Mariz: None declared, Miguel Bernardes Speakers bureau: Abbvie, Amgen, Biogen, Eli-Lilly, Glaxo-Smith-Kline, Pfizer, Janssen, Novartis, Lúcia Costa: None declared

SAT0478 OSTEOPOROSIS TREATMENT IN PORTUGUESE PATIENTS WITH PSORIATIC ARTHRITIS – WHAT IS THE VALUE OF THE FRACTURE RISK ASSESSMENT TOOL (FRAX)?

Background:

Few studies have evaluated the prevalence and treatment of osteoporosis (OP) in patients with psoriatic arthritis (PsA), and many of these patients are not screened using dual-energy X-ray absorptiometry (DXA). FRAX makes it possible to stratify the risk and define which patients may benefit from anti-osteoporotic treatment, but its usefulness in this population is not well established.

Objectives:

The aim of this study was to determine whether the application of FRAX changes the indication for anti-osteoporotic treatment in PsA patients, according to the Portuguese guidelines.

Methods:

In this cross-sectional study, we evaluated PsA patients from a tertiary hospital, registered in a national database (Reuma.pt), aged between 40 and 90 years and with a last consultation in 2019. FRAX was applied in all of them, regardless of being under anti-osteoporotic treatment and, when DXA was available, the femoral neck bone mineral density was used. Patients were stratified according to the risk of fracture, and those at high risk were considered candidates for anti-osteoporotic treatment, according to national guidelines [FRAX ≥11% for major osteoporotic fracture (MOF) or ≥ 3% for hip fracture (HF) without DXA; FRAX ≥9% for MOF or ≥ 2.5% for HF, with DXA].

Results:

We included 100 patients, 52 females, with a mean age of 54,4 ±8,9 years and a median disease duration of 10 (6-17) years. Only 43 had already performed DXA and 6 had OP according to World Health Organization criteria. Seven patients were identified as having a high risk of fracture; applying femoral neck bone mineral density, 2 more patients with indication for treatment were recognized, totalizing 9 patients. There was a low agreement between the indication for treatment based only on DXA and FRAX (Cohen’s k 0.066). There was a moderate and significant correlation between percentage of risk of MOF by FRAX with and without DXA (Spearman’s ρ 0.804, p <0.001); for the risk of HF by FRAX with and without DEXA the correlation was weaker but still significant (Spearman’s ρ 0.439, p = 0.004). There was no association between the indication for treatment by FRAX and the performance of DXA (chi-square test, p = 0.597), nor the fact of performing DXA significantly affected the risk of MOF (Wilcoxon test, p = 0.185) or of HF (Wilcoxon test, p = 0.785) by FRAX.

Conclusion:

In line with Portuguese guidelines, FRAX seems to be, in itself, a very useful tool in patients with PsA, and the performance of DXA does not significantly alter the indication for anti-osteoporotic treatment.

References:

[1]Rodrigues AM, Canhao H, Marques A, Ambrosio C, Borges J, Coelho P, et al. Portuguese recommendations for the prevention, diagnosis and management of primary osteoporosis - 2018 update. Acta Reumatol Port. 2018;43(1):10-31.

[2]Del Puente A, Esposito A, Parisi A, Atteno M, Montalbano S, Vitiello M, et al. Osteoporosis and psoriatic arthritis. J Rheumatol Suppl. 2012;89:36-8.

[3]Gulati AM, Michelsen B, Diamantopoulos A, Grandaunet B, Salvesen O, Kavanaugh A, et al. Osteoporosis in psoriatic arthritis: a cross-sectional study of an outpatient clinic population. RMD Open. 2018;4(1):e000631.

[4]Adami G, Fassio A, Rossini M, Caimmi C, Giollo A, Orsolini G, et al. Osteoporosis in Rheumatic Diseases. Int J Mol Sci. 2019;20(23).

[5]Kanis JA, Harvey NC, Johansson H, Oden A, Leslie WD, McCloskey EV. FRAX Update. J Clin Densitom. 2017;20(3):360-7.

Disclosure of Interests:

Filipe Pinheiro: None declared, Maria Rato: None declared, Bruno Miguel Fernandes: None declared, Salomé Garcia: None declared, Sara Ganhão: None declared, Pedro Madureira: None declared, Miguel Bernardes Speakers bureau: Abbvie, Amgen, Biogen, Eli-Lilly, Glaxo-Smith-Kline, Pfizer, Janssen, Novartis, Lúcia Costa: None declared

THU0387 THE IMPACT OF TREATMENT WITH A BIOLOGICAL DISEASE-MODIFYING ANTIRHEUMATIC DRUG ON SPINAL MOBILITY AND ITS CORRELATION WITH DISEASE ACTIVITY IN PATIENTS WITH SPONDYLOARTHRITIS

Background:

Bath Ankylosing Spondylitis Metrology Index (BASMI) is an instrument developed to assess spinal and hip mobility. The relationship between BASMI and disease activity is not always linear and, above all, the data that correlate the variation in BASMI values (ΔBASMI) with the variation in disease activity scores and response to treatment are not unanimous.

Objectives:

Explore the effect of biological disease-modifying antirheumatic drugs (bDMARD) in spine mobility (as assessed by BASMI) and the associations between ΔBASMI and disease activity.

Methods:

Observational retrospective study was performed including consecutive patients with the diagnosis of Spondyloarthritis (SpA) followed at our Rheumatology Department. Demographic, clinical, including Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), BASMI, Ankylosing Spondylitis Disease Activity Score with erythrocyte sedimentation rate and C-reactive protein (ASDAS ESR and ASDAS CRP, respectively), and laboratorial data were collected from our national database at baseline, 6 and 12 months after initiation of a bDMARD. The variation of each parameter was calculated as the difference between the levels recorded at 6 and 12 months and the reference level and presented in the form of Δ. Statistical analysis was performed using SPSS 23.0. Correlations between variables were studied using Spearman correlation analysis and comparison between groups was performed using Wilcoxon and Kruskal-Wallis tests.

Results:

Median age of patients (n=178) was 42 years old [34, 50], 92 (51.7%) were males with a median disease duration of 4.9 [1.0, 10.3] years. One hundred and twenty-six patients (70.8%) had Ankylosing Spondylitis, 15 (8.4%) Inflammatory Bowel Disease related SPA and 30 (16.9%) Undifferentiated SpA. Fifty four (30.3%) patients were taking glucocorticoids and regarding conventional synthetic disease-modifying anti-rheumatic drugs use before starting the bDMARD: Sulfasalazine (52, 29.2%), Methotrexate (31, 17.4%) and Leflunomide (3, 1.7%). Regarding the bDMARD, only one patient started Secukinumab and the others a Tumor necrosis factor inhibitor (TNFi) [Golimumab (n= 64, 36.0%), Adalimumab (n=36, 20.2%), Infliximab (n= 35, 19.7%), Etanercept (n= 32, 18.0%) and Certolizumab (n= 10, 5.6%)].

The majority of the patients had very high disease activity at baseline (86.0%, n=153); median ESR was 29 mm/h [15, 47], median CRP was 13.7 mg/L, [6.60, 27.3], median ASDAS CRP was 7.6 [6.0, 9.0] and median BASMI was 8.0 [7-0, 9.0]. After 6 and 12 months of treatment, mean ESR, CRP, ASDAS-CRP and BASMI were significantly lower than mean baseline values (p<0.01), with median ASDAS-CRP at 12 months of 2.20 [1.50, 2.90] and median ΔBASMI of -4.10 [-5.50, -2.40].

BASMI at baseline showed a moderate correlation with ASDAS CRP (r=0.468, p<0.01), BASDAI (r=0.496, p<0.01) and patient visual analogic scale (VAS) (r=0.563, p<0.01). No correlations were found between BASMI and CRP, ESR, physician VAS or the consumption of nonsteroidal anti inflammatory drugs at baseline.

A significant positive correlation was found between ΔBASMI and ΔASDAS at 6 months and 12 months (r=0.243, p=0.02; r=0.286; p<0.01) and also between ΔBASMI and ΔBASDAI at 6 and 12 months (r=0.183, p=0.04; r=0.291, p=0.02). No correlations were found between ΔBASMI and ΔCRP or ΔESR. No differences were observed in ΔBASMI, regarding the bDMARD of choice.

Conclusion:

In our cohort, starting a bDMARD improved BASMI scores through a 12 month period and there was a correlation between the variation of BASMI and disease activity improvement. As such, a TNFi may retard the progression of spinal mobility dysfunction in SpA patients. We cannot draw conclusions regarding differences between TNFi and interleukin 17 inhibitors and further work is needed to clarify possible differences in their impact in improving spine mobility.

Disclosure of Interests:

Salomé Garcia: None declared, Bruno Miguel Fernandes: None declared, Sara Ganhão: None declared, Maria Rato: None declared, Filipe Pinheiro: None declared, Georgina Terroso: None declared, Miguel Bernardes Speakers bureau: Abbvie, Amgen, Biogen, Eli-Lilly, Glaxo-Smith-Kline, Pfizer, Janssen, Novartis, Lúcia Costa: None declared

SAT0465 FRACTURE RISK ASSESSMENT BY FRAX IN A SYSTEMIC LUPUS ERYTHEMATOSUS PORTUGUESE COHORT

Background:

Osteoporosis is commonly seen in patients with Systemic Lupus Erythematosus (SLE), even in pre-menopausal patients. The etiology is multifactorial and chronic glucocorticoid therapy seems to play a central role.

Objectives:

To investigate the ten-year risk of fracture assessed by Fracture Risk Assessment Tool (FRAX), with and without dual-energy X-ray absorptiometry (DXA) and to determine possible demographic or clinical factors associated with an increased risk of fracture in a SLE population.

Methods:

Retrospective study including all the over 40 years-old patients with the diagnosis of SLE (2012 SLICC classification criteria) followed at our Rheumatology Department registered in our national database. Demographic, clinical and laboratorial data were collected at the last follow-up visit. Data from the last DXA (until 3 years prior to the last visit) were collected. Indication for pharmacological treatment by FRAX was assessed according to the national recommendations: estimated fracture risk, without DXA, ≥11% for major osteoporotic fracture or ≥3% for hip fracture and/or estimated fracture risk, with DXA, ≥9% for major osteoporotic fracture or ≥2.5% for hip fracture.

Results:

We included 104 patients, 101 (97.1%) females, aged 54.5±9.9 years, with a median disease duration of 19.3 years [4.3-51.6]. Twelve patients (11.5%) were current smokers, 31 (29.8%) had elevated anti-dsDNA antibodies (≥100 IU/mL) and 27 (26.0%) had complement consumption (C3c<83mg/dL or C4<12mg/dL). 73 patients (70.2%) were taking glucocorticoids with a mean daily prednisolone equivalent dosage of 4.4±5.2 mg/day. Regarding SLE treatment, 69 patients (66.3%) were under hydroxychloroquine, 22 (21.2%) under azathioprine, 16 (15.4%) under mycophenolate mofetil, 5 (4.8%) under belimumab, 4 (3.8%) under methotrexate, 1 (1.0%) under leflunomide and 1 (1.0%) under rituximab.

Ten patients (9.6%) had previous fragility fractures, 54 patients (51.9%) had DXA in the last 3 years and 81 (77.9%) were taking calcium and/or vitamin D supplements.

Sixteen (15.4%) had indication for treatment by FRAX without DXA and 8 of these (50%) were under treatment. Moreover, thirteen (12.5%) had indication for treatment by FRAX with DXA and 8 of these (61.5%) were under treatment.

Five patients (4.8%) were reclassified in FRAX with DXA: 3 patients (2.9%) had no indication for treatment by FRAX without DXA but conquered it by FRAX with DXA and 2 patients (1.9%) had indication for treatment by FRAX without DXA but lost it by FRAX with DXA. We found a good level of agreement in the indication for treatment between FRAX with and without DXA (kappa=0.741; p<0.001).

There was no significant difference in the risk of fracture estimated by FRAX with or without DXA, both for major osteoporotic fracture and for hip fracture. Correlations between fracture risk and some clinical variables can be seen in table 1.

Table 1.

Correlations between the risk of fracture estimated by FRAX and disease related features.

Age at SLE diagnosisDisease DurationESRSLEDAIEstimated fracture risk by FRAX:without DXAmajor osteoporotic fracturer=0.483p<0.001n.s.r=0.249p=0.012r=-0.586p=0.028hip fracturer=0.481p<0.001n.s.r=-0.552p=0.041n.s.with DXAmajor osteoporotic fracturer=0.386p=0.005r=0.299p=0.033n.s.n.s.hip fracturer=0.338p=0.015n.s.n.s.n.s.

Conclusion:

A higher number of patients had indication for pharmacological treatment by FRAX with DXA in comparison with FRAX without DXA. However, we found no statistically significant difference in the estimated fracture risk with and without DXA. This, together with the good level of agreement between FRAX with and without DXA, suggests that the fracture risk estimation, even without DXA, may be an appropriate approach. The low number of patients with indication for pharmacological treatment by FRAX, with and without DXA, may be explained by their low mean age and the high number of them under vitamin D/calcium supplementation.

Disclosure of Interests:

Bruno Miguel Fernandes: None declared, Salomé Garcia: None declared, Sara Ganhão: None declared, Maria Rato: None declared, Filipe Pinheiro: None declared, Miguel Bernardes Speakers bureau: Abbvie, Amgen, Biogen, Eli-Lilly, Glaxo-Smith-Kline, Pfizer, Janssen, Novartis, Lúcia Costa: None declared

SAT0416 ENTHESITIS AND CLINICAL RESPONSE IN PSORIATIC ARTHRITIS: REAL-LIFE DATA

Background:

Psoriatic arthritis (PsA) is an inflammatory arthritis that is characterized by a broad spectrum of clinical conditions, including axial skeletal involvement, enthesitis, dactylitis, uveitis and arthritis. Among those, enthesitis, the inflammation of the junction where the tendon, ligament or joint capsule inserts into the bone, is assigned to be the hallmark, affecting 35–50% of patients. Several clinical methods have been developed to measure it, including The Maastricht AS Enthesitis Score (MASES) index, which tests 13 entheses and the Spondyloarthritis Research Consortium of Canada (SPARCC) index that assesses 16.

Objectives:

To assess the relationship between enthesitis and clinical response in psoriatic arthritis.

Methods:

Retrospective study including all the patients with PsA meeting the CASPAR criteria, beginning first-line biologic therapy at our centre. Demographic and clinical data including age, gender, body mass index (BMI), smoking status, physical examination findings such as presence of enthesitis, dactylitis, chronic back pain, tender and swollen joint counts (TJC/ SJC), ESR, CRP, DAS 28 4vESR, BASDAI, BASFI, BASMI, ASDAS, HAQ, patient VAS score, MASES and SPARCC were collected from the Portuguese database Reumapt. Statistical analysis was performed with SPSS. Continuous variables were analysed through Spearman correlations.

Results:

We included 119 patients with PsA (60 female), of which 14.9% were active smokers. The mean age of patients was 46.3 ± 1.03 years. The median disease duration was 6.8 (0.3-33.8) years and the mean BMI was 26.8 ± 0.5 Kg/m2.

Enthesitis, dactylitis, inflammatory back pain, peripheral arthritis, ungueal distrophy, and psoriasis were present in 53 (45.7%), 45 (38.8%), 76 (65.5%), 109 (94%), 45 (38.8%), 104 (89.7%) patients, respectively.

At baseline, mean (SD) disease activity parameters were: DAS 28 4vESR 4.9 (0.2), ESR 33.2 (2.3) mm/h; CRP 2.35 (0.3) mg/dL, HAQ 1.3 (0.1), BASDAI 6.6 (0.2), ASDAS 3.9 (0.1), BASMI 3.7 (0.2), BASFI 5.8 (0.3), MASES 1.9 (0.3), SPARCC 2.3 (0.3). Median (min-max) values of TJC, SJC and patient VAS score at baseline were 4 (0-28), 3 (0-19), 76 (0-100), respectively.

There were statistically significant positive correlations (0-12 months) between ΔMASES and ΔDAS 28 4vESR (p=0.02, rho=0.432), Δpatient VAS score (p=0.027, rho=0.307), ΔHAQ (p=0.02, rho=0.411), ΔBASDAI (p=0.025, rho=0.326), ΔBASFI (p=0.037, rho=0.315), ΔASDAS (p=0.023, rho= 0.331). Correlations between ΔSPARCC and ΔDAS 28 4vESR (p=0.023, rho=0.332), Δpatient VAS score (p=0.003, rho=0.402), ΔHAQ (p=0.012, rho=0.440), ΔBASDAI (p=0.011, rho=0.368), ΔBASFI (p=0.001, rho=0.445), ΔASDAS (p=0.002, rho= 0.437), ΔCDAI (p=0.039, rho=0.320) and ΔSDAI (p=0.039, rho=0.319), were also significant. However, there weren’t strong correlations between ΔMASES neither ΔSPARCC and PsARC response at 12 months.

Conclusion:

Our results suggest that enthesitis is correlated with clinical response in PsA, supporting the idea that it is a major determinant of disease activity. It should be given more importance, namely by incorporating it in daily clinical practice, due to its major role, both in establishing an early diagnosis and in assessing treatment response.

References:

[1]Sunar I, Ataman S, Nas K, Kilic E, Sargin B, Kasman SA, et al. Enthesitis and its relationship with disease activity, functional status, and quality of life in psoriatic arthritis: a multi‑center study. Rheumatol Int. 2019 Nov 26. doi: 10.1007/s00296-019-04480-9.

Disclosure of Interests:

Sara Ganhão: None declared, Salomé Garcia: None declared, Bruno Miguel Fernandes: None declared, Maria Rato: None declared, Filipe Pinheiro: None declared, Eva Mariz: None declared, Miguel Bernardes Speakers bureau: Abbvie, Amgen, Biogen, Eli-Lilly, Glaxo-Smith-Kline, Pfizer, Janssen, Novartis, Lúcia Costa: None declared

SAT0449 SPONDYLOARTHRITIS AND FRACTURE RISK: DOES DXA REALLY HAVE AN IMPACT IN THE RISK OF FRACTURE ESTIMATED BY FRAX?

Background:

Low bone mineral density (BMD) is common in ankylosing spondylitis (AS). The fracture risk (FR) is increased and its reduction with pharmacologic therapy is not clearly defined in this population. However, early screening and bisphosphonates as first-line treatment are recommended.

Objectives:

To investigate the influence of dual-energy X-ray absorptiometry (DXA) in the ten-year risk of fracture assessed by FR Assessment Tool (FRAX) and to determine possible demographic or clinical factors associated with an increased FR in a spondyloarthritis (SpA) population.

Methods:

Retrospective study including all the over 40 years-old SpA patients (ASAS classification criteria) followed at our Rheumatology Department and registered in the national database. Demographic, clinical and laboratorial data were collected at the time of the last follow-up visit. Data from the last DXA (until 3 years prior to the last visit) were collected. Indication for pharmacological treatment by FRAX was assessed according to the national recommendations.

Results:

A total of 231 SpA patients were included: 126 males (54.5%), 53 (22.9%) smokers; 171 (74%) had AS, 23 (10%) had Inflammatory Bowel Disease Associated SpA and 37 (16%) had Undifferentiated SpA. At the last follow-up visit, the mean age was 52.9 years (±9.6) and the median disease duration was 21.9 years [1.0-55.5]. The mean ASDAS-CRP was 2.5 (±0.9) and the majority of patients had moderate (25.5%) or high (48.5%) disease activity (according to ASDAS). One hundred and thirty patients (56.3%) were taking NSAIDs, 45 (19.5%) were taking glucocorticoids, 85 (36.8%) were under csDMARDs and 170 (73.6%) under bDMARDs [157 (68%) under TNFi, 11 (4.8%) under secukinumab and 2 (0.9%) under ustekinumab].

Eleven patients (4.8%) had previous fragility fractures, 118 (51.1%) had DXA in the last 3 years and 167 (72.3%) were taking calcium and/or vitamin D supplements.

Sixteen patients (6.9%) had indication for treatment by FRAX without DXA and 9 of these (56.3%) were already under treatment. Similarly, 16 (6.9%) had indication for treatment by FRAX with DXA and 13 of these (81.3%) were already under treatment. Ten patients (4.3%) were reclassified in FRAX with DXA: 7 (3%) had no indication for treatment by FRAX without DXA but obtained it by FRAX with DXA and 3 (1.3%) had indication for treatment by FRAX without DXA but they lost it by FRAX with DXA. We found a moderate level of agreement in the indication for treatment between FRAX with and without DXA (kappa=0.595; p<0.001). The use of DXA in FRAX estimated a significant higher median FR, both for major osteoporotic fracture (2.4% [0.8-31.0] vs 1.8% [0.6-20.0]; p<0.001) and for hip fracture (0.5% [0.0-23.0] vs 0.2% [0.0-14.0]; p<0.001).

We found significant correlations between FR and some disease-related variables (table 1).

Table 1.

Correlations between the risk of fracture estimated by FRAX and disease-related variables.

Disease durationBASDAIASDAS-CRPBASMIBASFIEstimated fracture risk by FRAX:without DXAmajor osteoporotic fracturer=0.352p<0.001r=0.204p=0.002r=0.214p=0.001r=0.301p<0.001r=0.317p<0.001hip fracturer=0.389p<0.001r=0.142p=0.034r=0.170p=0.011r=0.305p<0.001r=0.275p<0.001with DXAmajor osteoporotic fracturer=0.227p=0.014r=0.314p=0.001r=0.356p<0.001r=0.293p=0.002r=0.379p<0.001hip fracturen.s.r=0.197p=0.036r=0.269p=0.004r=0.271p=0.004r=0.258p=0.006

Conclusion:

Our results showed that a similar number of patients had indication for pharmacological treatment by FRAX both with and without DXA. Although the inclusion of DXA resulted in a higher estimated FR by FRAX, the observed moderate level of agreement between FRAX with and without DXA suggests that the FR estimation by FRAX, even without DXA, may be a reasonable approach in SpA patients. In line with literature, we found significant associations between the estimated risk fracture by FRAX and some disease activity and function measures.

Disclosure of Interests:

Bruno Miguel Fernandes: None declared, Salomé Garcia: None declared, Sara Ganhão: None declared, Maria Rato: None declared, Filipe Pinheiro: None declared, Miguel Bernardes Speakers bureau: Abbvie, Amgen, Biogen, Eli-Lilly, Glaxo-Smith-Kline, Pfizer, Janssen, Novartis, Lúcia Costa: None declared

SAT0482 FRAX 10-YR FRACTURE RISK IN RHEUMATOID ARTHRITIS ASSESSED WITH AND WITHOUT BONE MINERAL DENSITY – ARE WE TREATING OUR PATIENTS UNDER bDMARDs?

Background:

Patients with rheumatoid arthritis (RA) have a higher risk of osteoporosis not only due to chronic inflammation status, but also due to the treatment with glucocorticoids. FRAX is a computer-based algorithm developed by the World Health Organization for estimation of the 10-year risk of a hip or major osteoporotic fracture. Inclusion of femoral neck bone mineral density (BMD) in the estimation is optional.

Objectives:

The study aimed to identify the RA patients under treatment with biological disease-modifying antirheumatic drug (bDMARD), who have FRAX scores, calculated with and without BMD, classified as high fracture risk and evaluate if they are receiving treatment for osteoporosis. The authors also investigated the intra-individual agreement between FRAX fracture risk calculated with and without BMD.

Methods:

Demographic and clinical data and BMD results from RA patients followed in a tertiary university hospital and registered in the Rheumatic Diseases Portuguese Register were used for analysis. Patients under 40 years of age at the last visit were excluded. McNemar test was applied for the identification of discordance of risk categories. The Wilcoxon test was used to characterize the intraindividual differences between paired FRAX risks with and without BMD. Correlations between pairs of variables were evaluated by the Spearman test. For independent variables Mann-Whitney test was used.

Results:

A total of 303 patients were included, 244 were females (80.5%) and 49 current smokers (16.2%). Mean age was 59.5 ± 9.54 years and mean disease duration 18.5 ± 10.4 years. Two hundred and twenty patients (72.4%) and 243 (80.2%) were RF and ACPA positive, respectively, and 51.5% had erosive disease. Mean disease activity score (DAS28-4V-CRP) was 3.08 ± 1.18 and mean femoral neck BMD 0.84 ± 0.12 g/cm2. One hundred and seventy nine patients (58.9%) were concomitantly treated with conventional synthetic DMARDs and 215 (70.7%) with glucocorticoids. Among all the patients, 35 (11.6%) had previous fractures and 19 (6.3%) have family history of fracture. The median 10-year risk of a major fracture and a hip fracture, calculated without BMD, was 6.0 (1.2-50) and 1.5 (0.1-39), respectively; with BMD it was 6.9 (1.3-61) and 1.7 (0-49). When FRAX score is calculated without BMD (n=303), 76 (25.1%) patients were categorized as high fracture risk. Among them, only 41 (54%) were receiving osteoporosis treatment. FRAX assessment with BMD (n=231) identified 99 (32.7%) patients with high fracture risk, 51 (51,5%) in treatment for osteoporosis. Thirty patients (21%) previously classified as low fracture risk using FRAX without BMD were recategorized as high risk (p<0.001). Despite that, there was a strong correlation between fracture risks assessed with and without BMD for both major and hip fracture (r = 0.867, p < 0.0001 and r = 0.728, p < 0.0001, respectively). ACPA and RF positive patients did not have higher FRAX scores (including or not BMA). Patients with erosive disease had a higher 10-year probability of major fracture evaluated by FRAX when it includes BMD (p=0.041).

Conclusion:

It is very important to accurately assess the risk of osteoporotic fractures in RA patients to treat them properly. The authors highlight the high number of patients who are not receiving treatment according to FRAX categorization. In spite of the correlation between estimated fracture risk by FRAX with and without BMD, there is a discordance in fracture risk categorization, as one fifth of patients of low risk were reclassified as high risk. For the RA population treated with bDMARDS, our findings raise the need to request a DXA not only for patients classified as having an intermediate risk of fracture, but also for low-risk patients.

Disclosure of Interests:

Maria Rato: None declared, Filipe Pinheiro: None declared, Salomé Garcia: None declared, Bruno Miguel Fernandes: None declared, Sara Ganhão: None declared, Rita Gaio: None declared, Miguel Bernardes Speakers bureau: Abbvie, Amgen, Biogen, Eli-Lilly, Glaxo-Smith-Kline, Pfizer, Janssen, Novartis, Alexandra Bernardo: None declared, Lúcia Costa: None declared

FRI0299 EVALUATION OF ENTHESITIS INDICES AND RESPONSE TO BDMARD THERAPY IN PORTUGUESE PATIENTS WITH SPONDYLOARTHRITIS

Background:

Enthesitis is a hallmark clinical feature of spondyloarthritis (SpA), but to date, few studies have investigated how the overall response to biological treatment relates to the evolution of enthesitis counts.

Objectives:

Assess whether the variation in enthesitis indices reflects the overall response to bDMARD therapy in SpA.

Methods:

This longitudinal, retrospective study included patients who met Assessment of Spondyloarthritis international Society (ASAS) criteria for SpA followed at the Rheumatology Department of a tertiary hospital, under bDMARD therapy. Demographic, laboratorial and clinical data were collected, including Bath Ankylosing Spondylitis Metrology Index (BASMI), Bath Ankylosing Spondylitis Functional Index (BASFI), Bath Ankylosing Spondylitis Activity Index (BASDAI), Ankylosing Spondylitis Disease Activity Score-C-reactive protein (ASDAS-CRP), Maastrich Ankylosing Spondylitis Enthesitis Score (MASES), Leeds Enthesitis Index (LEI) and Spondyloarthritis Research Consortium of Canada (SPARCC) scores. All were evaluated at baseline and at 6, 12, 18 and 24 months after starting the first biological therapy. The variation in each parameter compared with the baseline values was calculated at 6, 12, 18 and 24 months and represented in the form of delta. Correlations between variables were assessed using Spearman test and comparison between groups using Wilcoxon, Mann-Whitney U and Kruskal-Wallis tests.

Results:

We included 273 patients, 123 (45,1%) females, aged 42,0±12,3 years and with diagnosis of SpA for 15,4±11,2 years at the start of bDMARD therapy. Eighteen (6,6%) had depression. At baseline, mean BASDAI was 6,43 ±1,62, ASDAS-CRP was 4,01 ± 0,86, median MASES was 1 (0-4), LEI 0 (0-1,75) and SPARCC 1 (0-4). Seventy-two patients (26,4%) started golimumab, 71 (26,0%) adalimumab, 66 (24,2%) infliximab, 54 (19,8%) etanercept, 9 (3,3%) certolizumab and 1 (0,4%) secukinumab. Enthesitis indices were significantly higher at baseline in females [median MASES-females 2 (0-5) vs 0 (0-2), p<0,001; LEI-females 0 (0-2) vs 0 (0-1), p=0,03; and SPARCC-females 2 (0-5) vs 0 (0-2), p<0,001], and remained so at 24 months [median MASES-females 1 (0-3,5) vs 0 (0-0), p<0,001; LEI-females 0 (0-0,5) vs 0 (0-0), p<0,001; and SPARCC-females 1 (0-3) vs 0 (0-0), p<0,001]. MASES and SPARCC, but not LEI, at baseline were significantly higher in patients with depression [median MASES-depression 3,5 (2-6) vs 1 (0-4), p=0,01; SPARCC-depression 4 (0-8) vs 1 (0-3), p=0,03], but at 24 months no differences were observed. There was a significant difference between each of the 3 scores of enthesitis when assessed at 6, 12, 18 and 24 months, compared to baseline (p <0.004). No differences were observed regarding the choice of bDMARD. At baseline, MASES had a significant correlation with patient visual analogic scale (VAS) (r=0,18; p=0,01), BASDAI (r=0,36; p<0,001) and BASFI (r=0,21; p=0,003); LEI had a significant correlation with BASDAI (r=0,31; p<0,001) and BASFI (r=0,21; p=0,003); SPARCC had a significant correlation with patient VAS (r=0,19; p=0,01), BASDAI (r=0,37; p<0,001) and BASFI (r=0,26; p<0,001). ΔLEI at 6 months had a significant correlation with ΔBASDAI (r=0,25; p=0,005), ΔASDAS (r=0,190; p=0,03), Δpatient VAS (r=0,23; p=0,01) and Δphysician VAS (r=0,25; p=0,01), but not with ΔESR, ΔCRP and ΔBASMI; no correlation was found at 6 months for ΔMASES or ΔSPARCC. At 12 months, ΔMASES had a significant correlation with ΔBASDAI (r=0,18; p=0,03); ΔLEI with ΔBASDAI (r=0,23; p=0,01) and Δpatient VAS (r=0,19; p=0,03); for ΔSPARCC no significant correlations were found. At 18 months and 24 months, no correlations were found.

Conclusion:

The initiation of bDMARD led to improved enthesitis indices over a 24-month period. ΔLEI correlates better with SpA activity scores and measurements than the other indices, especially at the first 12 months of initiation of bDMARD therapy.

Disclosure of Interests:

Filipe Pinheiro: None declared, Maria Rato: None declared, Bruno Miguel Fernandes: None declared, Salomé Garcia: None declared, Sara Ganhão: None declared, Pedro Madureira: None declared, Miguel Bernardes Speakers bureau: Abbvie, Amgen, Biogen, Eli-Lilly, Glaxo-Smith-Kline, Pfizer, Janssen, Novartis, Lúcia Costa: None declared

The role of hybridization and introgression in maintaining species integrity and cohesion in naturally isolated inselberg bromeliad populations

Hybridization is a widespread phenomenon present in numerous lineages across the tree of life. Its evolutionary consequences range from effects on the origin and maintenance, to the loss of biodiversity. We studied genetic diversity and intra- and interspecific gene flow between two sympatric populations of closely-related species, Pitcairnia flammea and P. corcovadensis (Bromeliaceae), which are adapted to naturally fragmented Neotropical inselbergs, based on nuclear and plastidial DNA. Our main results indicate a strong reproductive isolation barrier, although low levels of interspecific gene flow were observed in both sympatric populations. The low rates of intraspecific gene flow observed for both P. corcovadensis and P. flammea populations corroborate the increasing body of evidence that inselberg bromeliad species are maintained as discrete evolutionary units despite the presence of low genetic connectivity. Nuclear patterns of genetic diversity and gene flow revealed that hybridization and introgression might not cause species extinction via genetic assimilation of the rare P. corcovadensis. In the face of reduced intraspecific gene exchange, hybridization and introgression may be important aspects of the Pitcairnia diversification process, with a positive evolutionary impact at the bromeliad community level, and thus contribute to increasing and maintaining genetic diversity in local isolated inselberg populations.

Development and characterization of microsatellite loci for Tabebuia cassinoides (Bignoniaceae)

Tabebuia cassinoides (Lam.) DC., popularly known as caxeta, is a tree species that belongs to the plant family Bignoniaceae. This species is endemic to the Brazilian Atlantic Forest and is widely exploited commercially. To date, little is known about its genetic structure, preventing the establishment of adequate management plans for this taxon. The objective of this study was to construct a microsatellite-enriched genomic library for T. cassinoides to select polymorphic loci, and standardize polymerase chain reaction amplification conditions. Of the 15 loci examined, 5 were polymorphic. The number of alleles per locus ranged from 2 to 8, with a mean of 4.4. The microsatellite loci described here represent the basis for detailed population genetic studies of this species, which will greatly contribute for the development of better conservation strategies for this taxon.

Simple-sequence repeat markers of Cattleya coccinea (Orchidaceae), an endangered species of the Brazilian Atlantic Forest

Microsatellite markers were developed for the endangered Brazilian orchid species Cattleya coccinea to describe its genetic diversity and structure and to support conservation studies. Nine microsatellite loci were isolated and characterized using an enriched genomic library. All loci are polymorphic at least in the 2 populations sampled, except for loci Cac05 and Cac09 for the Petrópolis population. The mean number of alleles per locus was 8.8 between populations. The mean values of the observed and expected heterozygosities were 0.541 (ranging from 0 to 1) and 0.639 (ranging from 0 to 0.9), respectively. Cross-amplifications were performed in 7 additional Epidendroideae species, and at least 2 loci were successful in 3 additional Cattleya species, Epidendrum secundum, and Brasiliorchis gracilis. All markers described herein will be useful in further studies evaluating the genetic diversity, population dynamics, and conservation genetics of C. coccinea and related species.

Phylogeographical patterns shed light on evolutionary process in South America

The South American continent is composed of several biogeographical regions harbouring the highest biodiversity on the globe, encompassing five of the world's biodiversity 'hot spots'. Nonetheless, the patterns and processes responsible for shaping its astonishing species diversity are largely unknown. Here, we present a review of current South American phylogeographical knowledge based on published articles on this topic. An appraisal of the literature reveals emerging phylogeographical patterns in the biota of South America. The striking phylogeographical divergence observed among organism lineages in South American studies is suggestive of high levels of undocumented species diversity. The interplay between Pleistocene climatic oscillations and Pliocene/Miocene orogenic events has contributed to shaping the current diversity and distribution of modern lineages in both the tropical and temperate regions of South America. Although older divergence times were observed for a range of species, most herpetofauna underwent an intraspecific lineage split much earlier than other organisms. The geographical ranges of species associated with forest habitats were reduced mainly during glacial cycles, whereas species associated with open vegetation domains have shown variable responses to climatic oscillations. The results suggest a highly complex mosaic of phylogeographical patterns in South America. We suggest future research directions to promote a better understanding of the origin and maintenance of the South American biota.

Is Drosera meristocaulis a pygmy sundew? Evidence of a long-distance dispersal between Western Australia and northern South America

BACKGROUND AND AIMS

South America and Oceania possess numerous floristic similarities, often confirmed by morphological and molecular data. The carnivorous Drosera meristocaulis (Droseraceae), endemic to the Neblina highlands of northern South America, was known to share morphological characters with the pygmy sundews of Drosera sect. Bryastrum, which are endemic to Australia and New Zealand. The inclusion of D. meristocaulis in a molecular phylogenetic analysis may clarify its systematic position and offer an opportunity to investigate character evolution in Droseraceae and phylogeographic patterns between South America and Oceania.

METHODS

Drosera meristocaulis was included in a molecular phylogenetic analysis of Droseraceae, using nuclear internal transcribed spacer (ITS) and plastid rbcL and rps16 sequence data. Pollen of D. meristocaulis was studied using light microscopy and scanning electron microscopy techniques, and the karyotype was inferred from root tip meristem.

KEY RESULTS

The phylogenetic inferences (maximum parsimony, maximum likelihood and Bayesian approaches) substantiate with high statistical support the inclusion of sect. Meristocaulis and its single species, D. meristocaulis, within the Australian Drosera clade, sister to a group comprising species of sect. Bryastrum. A chromosome number of 2n = approx. 32-36 supports the phylogenetic position within the Australian clade. The undivided styles, conspicuous large setuous stipules, a cryptocotylar (hypogaeous) germination pattern and pollen tetrads with aperture of intermediate type 7-8 are key morphological traits shared between D. meristocaulis and pygmy sundews of sect. Bryastrum from Australia and New Zealand.

CONCLUSIONS

The multidisciplinary approach adopted in this study (using morphological, palynological, cytotaxonomic and molecular phylogenetic data) enabled us to elucidate the relationships of the thus far unplaced taxon D. meristocaulis. Long-distance dispersal between southwestern Oceania and northern South America is the most likely scenario to explain the phylogeographic pattern revealed.

Sympatric bromeliad species (Pitcairnia spp.) facilitate tests of mechanisms involved in species cohesion and reproductive isolation in Neotropical inselbergs

The roles of intra- and interspecific gene flow in speciation and species evolution are topics of great current interest in molecular ecology and evolutionary biology. Recent modelling studies call for new empirical data to test hypotheses arising from the recent shift from a 'whole-genome reproductive isolation' view to a 'genic' view of species and speciation. Particularly scarce (and thus of particular interest) are molecular genetic data on recently radiated, naturally hybridizing species in strongly structured and species-rich environments. Here, we studied four sympatric plant species (Pitcairnia spp.; Bromeliaceae) adapted to Neotropical inselbergs (isolated outcrops resembling habitat 'islands' in tropical rainforests) using nuclear and plastid DNA. Patterns of plastid DNA haplotype sharing and nuclear genomic admixture suggest the presence of both, incomplete lineage sorting and interspecific gene flow over extended periods of time. Integrity and cohesion of inselberg species of Pitcairnia are maintained despite introgression and in the face of extremely low within-species migration rates (N(e)m < 1 migrant per generation). Cross-evaluation of our genetic data against published pollination experiments indicate that species integrity is maintained by the simultaneous action of multiple prezygotic barriers, including flowering phenology, pollinator isolation and divergent mating systems. Postzygotic Bateson-Dobzhansky-Muller incompatibilities appear to contribute to isolation, as suggested by asymmetric introgression rates of single loci. Our results suggest that incomplete lineage sorting, hybridization and introgression form integral aspects of adaptive radiation in Neotropical inselberg 'archipelagos'. Inselbergs with multiple closely related co-occurring species should be of special interest to students of speciation in mountain systems, and to ongoing conservation programmes in the Atlantic Rainforest biodiversity hotspot.

Epidemiology of infectious disease: the example of measles

The situation of unacculturated Brazilian Amazon tribes is described. The isolation of these populations has been sufficiently tight that they have been free of most epidemic diseases of the cosmopolitan world, although diseases associated with persistent infection have a high prevalence. The history of measles epidemics in Amerind populations is reviewed and it is concluded that most deaths can be prevented by basic nursing care but that there is a residual excess mortality characteristic of these populations. Three Brazilian virgin-soil populations and one experienced tribe in Chile, the Mapuche, were vaccinated against measles. Elevated febrile responses were observed in the three virgin-soil populations relative to the fevers seen in the Mapuche and in cosmopolitan populations. Nutritional status, immunological experience, humoral immune response and genetic characters have been examined for an explanation of this phenomenon. The most pronounced correspondence detected so far is a high degree of homozygosity in HLA loci of the virgin populations.

Chemoprevention of preneoplastic liver foci development by dietary mushroom Agaricus blazei Murrill in the rat

The chemopreventive potential of an Agaricus blazei (Ab) Murrill mushroom meal was investigated in a medium-term rat liver carcinogenesis assay. Male Wistar rats initiated for hepatocarcinogenesis with diethylnitrosamine (DEN, 200 mg/kg i.p.) were fed during a 6-week period with the dry powdered mushroom strains Ab 29 or 26, each one with opened (OB) or closed basidiocarp (CB), mixed at 10% level in a basal diet. All experimental animals and controls were subjected to partial hepatectomy at week 3 and killed at week 8. Chemopreventive activity of the mushroom meal was observed for the Ab 29 (OB and CB) and Ab 26 (CB) strains in terms of the number of putative preneoplastic altered foci of hepatocytes which express either the enzyme glutathione S-transferase, placental form (GST-P+) or the transforming growth factor-alpha, and for the Ab 29 (OB) and Ab 26 (CB) strains on the size of GST-P+ foci. This was associated with inhibition of foci cell proliferation in the animals fed the Ab 29 (OB) and Ab 26 (CB) strains. The results suggest that the protective influence of the Ab meal against the DEN potential for rat liver carcinogenicity depends on both the strain and period of mushroom harvest.

Allelic distribution of four tetranucleotide repeat loci (D3S1358, D18S51, D19S253, and FGA) in a population from Porto (North Portugal)

Allele frequencies for four short tandem repeat loci were determined in a population sample from Porto (North Portugal), using the polymerase chain reaction (PCR), in order to investigate possible genetic differences between populations from the center and north of Portugal. After denaturing PAGE electrophoresis, nine alleles were identified for D3S1358 (n = 256), 13 alleles for D18S51 (n = 235), 10 alleles for D19S253 (n = 238), and 15 alleles for FGA (n = 181). No deviations from Hardy-Weinberg equilibrium were found. The allele frequencies observed are similar to those of the Portuguese population compared except for the D3S1358 system.

Rodent-borne emerging viral zoonosis. Hemorrhagic fevers and hantavirus infections in South America

Hantaviruses and arenaviruses are naturally occurring viruses of rodents. Four South American hemorrhagic fevers caused by arenaviruses have emerged in the last 5 decades. All have similar clinical manifestations, with a case-fatality rate as high as 15% to 30%. Hantavirus infections have been increasingly recognized in South America since the description in 1993 of Hantavirus pulmonary syndrome. Given the diversity of rodent species in the region, it can be foreseen that many other viruses will be discovered, and some of them will be causing human illnesses of high public health impact.

[Anti-Hantavirus antibodies in school children in Salvador, Bahia]

Hantavirosis are emerging diseases in the Americas. Although considered rare in children, among the five cases diagnosed in Brazil, one was in this age group. To know the serum-prevalence of hantavirosis in the pediatric group (schoolchildren) of low social economic level in Salvador, Bahia State, and to associate demographic, socio-economic and environmental factors to the serologic results, a standard questionnaire was applied and blood samples were collected from 379 students of two public schools. Sera were tested by indirect Immunofluorescent Antibody (IFA) IgG for Hantaan Virus (HTN) and Immunoenzymatic test (ELISA) for Sin Nombre viruses. Ages varied from five to seventeen years with a mean age of 10.2 years. The proportion of sera positive to HTN virus was 13.2%, and there were no positive antibodies to SN virus. The frequency of positivity was higher in the older group, similar among sexes and racial groups, and there was no association with the exposure to urban rodents. The antibodies anti-HTN serum-prevalence in low social economic level school children is high and confirm the circulation of hantaviruses in Salvador-Bahia, Brazil; the nonobservation of antibodies anti-SN indicates that the species are other than Sin Nombre Virus.

Risk for transfusion-transmitted infectious diseases in Central and South America

We report the potential risk for an infectious disease through tainted transfusion in 10 countries of South and Central America in 1993 and in two countries of South America in 1994, as well as the cost of reagents as partial estimation of screening costs. Of the 12 countries included in the study, nine screened all donors for HIV; three screened all donors for hepatitis B virus (HBV); two screened all donors for Trypanosoma cruzi; none screened all donors for hepatitis C virus (HCV); and six screened some donors for syphilis. Estimates of the risk of acquiring HIV through blood transfusion were much lower than for acquiring HBV, HCV, or T. cruzi because of significantly higher screening and lower prevalence.rates for HIV. An index of infectious disease spread through blood transfusion was calculated for each country. The highest value was obtained for Bolivia (233 infections per 10,000 transfusions); in five other countries, it was 68 to 103 infections per 10,000. The risks were lower in Honduras (nine per 10,000), Ecuador (16 per 10,000), and Paraguay (19 per 10,000). While the real number of potentially infected units or infected persons is probably lower than our estimates because of false positives and already infected recipients, the data reinforce the need for an information system to assess the level of screening for infectious diseases in the blood supply. Since this information was collected, Chile, Colombia, Costa Rica, and Venezuela have made HCV screening mandatory; serologic testing for HCV has increased in those countries, as well as in El Salvador and Honduras. T. cruzi screening is now mandatory in Colombia, and the percentage of screened donors increased not only in Colombia, but also in Ecuador, El Salvador, and Paraguay. Laws to regulate blood transfusion practices have been enacted in Bolivia, Guatemala, and Peru. However, donor screening still needs to improve for one or more diseases in most countries.

Population study of the HUMTH01, HUMVWA31A, HUMF13A1, and HUMFES/FPS STR polymorphisms in the north of Portugal

Allele and genotype frequencies of four short tandem-repeat loci were determined in a population sample from the North of Portugal using the polymerase chain reaction (PCR). After denaturing PAGE, 6 alleles were identified for HUMTH01 (n = 419), 9 alleles for HUMVWA31A (n = 376), 12 alleles for HUMF13A1 (n = 232), and 5 alleles for HUMFES/FPS (n = 409). No deviation from Hardy-Weinberg equilibrium was found. The allele frequencies observed are similar to those of the European populations compared. The combined power of discrimination is 0.999.

Demonstration of yellow fever and dengue antigens in formalin-fixed paraffin-embedded human liver by immunohistochemical analysis

Two immunohistochemical techniques to determine the presence of yellow fever and dengue antigens in fixed tissue samples were developed for the purpose of making retrospective diagnoses of these viral diseases in humans. A horseradish peroxidase label was used for one technique and an alkaline phosphatase label for the other. In the former technique, acid hematin was removed from the tissues, iron-containing pigments were counterstained with Prussian blue, and the product of the diaminobenzidine reaction was enhanced with a dilute solution of osmium tetroxide that differentiated antigen from lipofuscin. In the latter technique, alkaline phosphatase was used as the enzyme labeling system with a red chromogen that contrasted nicely with the pigments in the tissues, as mentioned above. Thus, pigment removal or differentiation from antigen was not required. Replicate sections were cut and mouse polyclonal antibodies for yellow fever and all dengue types were applied to individual sections. On samples positive for dengue antigen, monoclonal antibodies were applied to additional replicate sections to demonstrate antigen of dengue types 1 and 4. In order to test the assay, samples of formalin-fixed liver tissue from Brazilian and Peruvian individuals who had died from a variety of causes as long as eight years earlier were received in a blinded fashion for immunohistochemical analysis. The techniques appeared to be highly reliable for yellow fever diagnosis; however, not enough cases were observed to adequately evaluate the procedures for dengue diagnosis. Both procedures appeared to have similar sensitivity.

Epidemic dengue 1 in Brazil, 1986: evaluation of a clinically based dengue surveillance system

In the last 15 years, dengue fever has emerged as a major health problem in tropical America. Prevention and control of epidemic disease are enhanced by the rapid identification of new or increased dengue activity. Most surveillance systems, however, identify cases by clinical case reports and, therefore, lack the sensitivity needed for early detection. During the 1986 dengue 1 epidemic in Rio de Janeiro, Brazil, the authors evaluated the usefulness of a clinical case definition by comparing it with laboratory-confirmed infection status of residents in two cities. The case definition had a sensitivity of 64% and a false-positive rate of 57%. Thus, for every 100 laboratory-confirmed dengue infections, 230 cases were reported. Both infected and noninfected residents who used medical services and who lived in the city with the highest transmission were more likely to meet the case definition. Thus, factors unrelated to actual infection influenced the sensitivity. With the use of stepwise logistic regression, the authors analyzed combinations of patient symptoms and produced nine new hypothetical case definitions. However, none of the new definitions had a false-positive rate lower than 38%. This study emphasizes the need for laboratory-based dengue surveillance systems.