AB0310 STUDY “AR-CAT INICI”: MANAGEMENT OF EARLY RHEUMATOID ARTHRITIS IN CATALONIA

Background

Given the progressive change in the management of inflammatory diseases,an observational study was conducted on the management of Early Rheumatoid Arthritis (ERA) in Catalonia.

Objectives

To know the management of ERA in Catalonia, to assess whether the recommendations of the EULAR/ACR guidelines are followed and to study the causes of management variability,to set improvement objectives.

Methods

An observational,descriptive,and cross-sectional study was conducted,with data collection from June 15 to 30, 2021.The rheumatologists’ partners of the Catalan Society of Rheumatology were the object of study. An online survey was conducted with 304 members on the management of the ERA. Variables related to the characteristics of the respondents,the derivation and variables of the disease including clinical variables,type of treatment and outcomes used for follow-up including the impact of the SARS-CoV2 pandemic were included.The univariate study was performed using a study of proportions with Pearson’s correlation.

Results

A total of 105 members (34.5%) responded to the survey.11.6%>60 y, only 7.8% <30y. 99% were in public assistance.The number of rheumatologists per service is 7.2[1-17],but 34.2% had< 5 rheumatologists,with a reference population of 200,000-300,000p in 42% of respondents.The number of weekly visits made is 67.5[20-130].42.2% do not have a monographic RA or ERA dispensary and 30.4%not have specialized nursing.Characteristics of ERA:77.5% are derived from primary care(PC),52% have been between 6 weeks,42.1%>3 months.54.9% make a first visit within 2-4 weeks of PC referral and 14.7%> 8 weeks.100%provide previous analysis,only 47% had had RX performed.98% were previously treated(50.4%NSAIDs + CG,36.1%NSAIDs,12.3% CG).4.3% had GC doses>10 mg/day,11.3%> to 20mg/day.The treatment:DMARDs of choice in 100% is MTX,44.1% start doses of 10mg/week and 3.9%7.5 mg/week.The route of choice is oral(55.9% vs 44.1%).92.2% associate GC and 31.7% have not withdrawn them after 6 m.57.8% consider the maximum of MTX 25mg/W.87.1% use doses<10 mg/day,with the most used dose being 5 mg/day(35.6%).Follow-up after the start of DMARDs is performed 72.5% between 4-6 weeks and 12.7% is performed by nursing.100% use DAS 28 and 53.5% also CDAI.31.4% perform PROs(HAQ 83.3%,RAPID 3 14.3%).The use of systematic ultrasound is collected in 33%, being himself who performs it in 59.9% and an expert rheumatologist in 46.1%.Finally, when asked about incidence of pandemic in the follow-up,53.3% consider that it is doing the same as before. 46.1% consider that telephone visits are not suitable for the follow-up of the ERAvs14.7% who consider that Yes.When questioning the situations in which they consider them to be appropriate,75.9% that it was adequate in the control after the beginning of the DMARDs.Regarding the treatment of ERA, 66% delayed the onset of biological DMARDs, 72.1% due to difficulty of follow-up and only 8.8% due to an increased risk of infection. When performing the univariate analysis, it is evident that having a monographic dispensary is associated with earlier onset of MTX(p< 0.001)and at doses≥15 mg/W(p = 0.05),greater nursing intervention(p< 0.001),greater use of PROs(p = 0.008)and there is a tendency to a shorter waiting time for first visits(p = 0.07).It is also associated with not considering telephone visits(p< 0.001), making them in less than 25%(p< 0.0001).Similarly,hospital level is directly proportional to initiation at higher doses of MTX(p< 0.0001),lower use of GC<10mg.Among the rest of the variables, no association has been found.

Conclusion

The recommendations of EULAR/ACR in the treatment and follow-up of ERA are consistently followed,although the wide use of MTX orally is striking.It is evident that the variable that most influences the early onset of FAME and at higher doses,is a monographic dispensary,as well as greater presence of nursing and performance of PROs.

Acknowledgements

Thanks to all the members of the Catalan society of reuamtology who participated in the survey

Disclosure of Interests

None declared

POS1381 ULTRASONOGRAPHIC EVALUATION OF ENTHESOPATHY IN IDIOPATHIC DIFFUSED SKELETAL HYPEROSTOSIS. APPLICABILITY OF THE MASEI INDEX

Background

In Diffuse idiopathic Skeletal Hyperostosis (DISH) o Forestier-Rotés disease the enthesis is also the hallmark of extraspinal manifestations. Despite being a characteristic hallmark of the disease, it has been poorly investigated.

Objectives

To assess the usefulness of the Madrid Sonographic Enthesitis Index (MASEI) to classify patients with DISH and to analyse the ultrasound findings in hyperostotic entheses.

Methods

We recruited 35 patients with DISH, according to Resnick classification criteria, who were compared with 33 healthy patients age, sex and body mass index-matched. An ultrasound was performed strictly following the MASEI protocol. The ultrasound examiners, with extensive experience in musculoskeletal ultrasound (ECOCAT group), were blinded to the diagnosis of the patients. The interobserver reliability of MASEI index measured by an ICC was 0.97 (95%, CI 89-99) [1]. Demographic, cardiovascular risk factors, clinical, radiological and MASEI-related variables were collected. We categorized into MASEI- inflammatory (MASEI-I) and MASEI-damage (MASEI-D) as previously published [2]but also into MASEI-DISH, which included the variables of thickness, structure and calcification. In the statistical analysis, patients’ data were depicted by using descriptive statistics and the comparison between groups with the Chi-square test for categorical variables and the T-Student test for numerical variables. The validity of the index was examined using the area under the ROC curve and its corresponding 95% confidence interval (CI). The optimal cut-off point was defined as the one that maximizes sensitivity (S) and specificity. (Spe). The statistical program used was R software.

Results

In the analysis of the elemental lesions, the alterations in structure, thickness and calcification of the distal quadriceps (DQT) and Achilles tendons (AQT) stood out (p <0.05). In the total MASEI, the ultrasound score of ≥ 16.50 (S80%, Spe 85%), obtained with an AUC of 0.877 (95% CI, 0.79 to 0.96), was the best cut-off to differentiate patients from healthy subjects. In the categorized indices, MASEI-I: cut-off 5.50 (S 89%, Spe 76%) and AUC 0.835 (95% CI 0.73 to 0.94); MASEI-D: 7.50 (S 86%, Spe 76%) and AUC 0.850 (95% CI, 0.75 to 0.94) and MASEI-DISH: 16.50 (S 74%, Spe 91%) and AUC (95% CI 0.76 to 0.95). The total MASEI in the DISH group was 27.46 (SD 14.4) compared to 10.30 (SD 6.4) in healthy controls (p<0.001) as well as in those categorized as MASEI-I, MASEI-D or MASEI-DISH (p <0.001).

Conclusion

Entheses lesions of the AQT and the DQT mark the differences between DISH and healthy patients. The optimal cut-off point was 16.50, and we did not observe any advantages in establishing MASEI categorizations that could be useful in clinical practice. Although the MASEI is an index designed to classify patients with spondyloarthritis, our study shows that it also allows differentiating DISH patients from healthy subjects. It would also be interesting to analyse the capacity of the MASEI to distinguish DISH from spondyloarthritis.

References

[1]Moya Alvarado P, et al. Rheumatol Int. 2020.

[2]Eder L et al. J Rheumatol. 2014; 41(3): 466-72.

This study has received a grant from the Catalan Rheumatology Society (2019)

Acknowledgements

Investigation Unit Sociedad Española de Reumatología

Catalan Rheumatology Society (Grant)

Disclosure of Interests

Teresa Clavaguera Speakers bureau: 2021 Jansen, UCB, Novartis, Marta Valls Speakers bureau: 2021 Lilly, Nordic, Maria Buxó: None declared, MANEL PUJOL BUSQUETS Speakers bureau: abbvie, pfizer, lilly, UCB, Janssen, Novartis, Georgina Salvador Alarcon Speakers bureau: Lilly, Novartis, Roche, abbvie, Sanofi, Eulàlia Armengol Speakers bureau: Novartis, Jansen, Xavier González-Giménez: None declared, Mireia Moreno Speakers bureau: Many: Novartis, MSD, Marta Arévalo: None declared, Vicenç Torrente: None declared, Lourdes Mateo: None declared, Susana Holgado: None declared, Xabier Michelena: None declared, Juan José De Agustín De Oro: None declared, Meritxell Sallés Lizarzaburu Speakers bureau: Lilly, Sanofi, Sonia Mínguez: None declared, ANDRES PONCE FERNANDEZ: None declared, Rosa Morlà: None declared, Paula Estrada: None declared, D Reina-Sanz Speakers bureau: Novartis, UCB, Patricia Moya: None declared, Hector Corominas Speakers bureau: Gebro, Abbvie, Fresenius, Judith Font Urgellés: None declared, Patricia Reyner Speakers bureau: Lilly, Sanofi, Nordic

Clinical factors associated with discontinuation of ts/bDMARDs in rheumatic patients from the BIOBADASER III registry

Biologic and targeted synthetic disease-modifying antirheumatic drugs (ts/bDMARDs) play a pivotal role in the treatment of rheumatoid arthritis (RA), psoriatic arthritis (PsA), and ankylosing spondylitis (AS). Persistence of therapy provides an index of a drug’s overall effectiveness. The objective of the study was to identify factors associated with discontinuation of ts/bDMARDs in a real-world dataset. The study population comprised patients diagnosed with RA, PsA, and AS included in the BIOBADASER registry for whom follow-up data were available until November 2019. Patient features and treatment data were included in the analysis. The Kaplan–Meier method was used to study survival of the different drugs according to the reason for discontinuation. Factors associated with discontinuation were studied using Cox regression models and bivariate and multivariate analyses. P values of less than 0.05 were regarded as statistically significant. The study population comprised 4,752 patients who received a total of 8,377 drugs, of which 4,411 (52.65%) were discontinued. The Kaplan–Meier curves showed that survival for first-line treatment was greater in all 3 groups (p < 0.001). Patients with RA had a greater risk of discontinuation if they were younger (HR, 0.99; 95% CI 0.99–1.00), if they were receiving anti-TNFα agents (HR, 0.61; 95% CI 0.54–0.70), and if they had more comorbid conditions (HR, 1.09; 95% CI 1.00–1.17). Patients with PsA had a higher risk if they were women (HR, 1.36; 95% CI 1.15–1.62) and if they were receiving other ts/bDMARDs (HR, 1.29; 95% CI 1.05–1.59). In patients with AS, risk increased with age (HR, 1.01; 95% CI 1.00–1.02), as did the number of comorbid conditions (HR, 1.27; 95% CI 1.12–1.45). The factors that most affected discontinuation of ts/bDMARDs were line of treatment, age, type of drug, sex, comorbidity and the year of initiation of treatment. The association with these factors differed with each disease, except for first-line treatment, which was associated with a lower risk of discontinuation in all 3 diseases.

Ewe's diet during gestation and lactation affects ready-to-eat meat from light lambs

Maternal grazing may benefit the fatty acid (FA) profile of lamb meat, although any improvement in terms of healthier polyunsaturated FAs (PUFA) may be impaired during subsequent culinary treatments. The objective was to assess the effects of a grass-based ewe diet on the FA profile of the ready-to-eat meat from grain-fed Segureña light lamb. The FA were determined in raw, grilled (G), Sous Vide (SV) cooked and cooked/hot-held (H) lamb leg patties resulting from two maternal rearing systems: grazing (Mediterranean trees, shrubs, herbs, stubble and fallow) or indoors (cereal grain and lucerne pellets). The grass-based ewe diet increased (P < 0.05) levels of n-3 PUFA and total linoleic conjugated acid (CLA), and decreased those of n-6 long chain PUFA and saturated FA (SFA) in the patties from all treatments. These changes in FA slightly increased (P < 0.05) the PUFA/SFA ratio and decreased (P < 0.05) the n-6/n-3 ratio in the raw (from 8.7 to 6.3), SV (from 8.8 to 6.2), G (from 9.0 to 6.3), SV + H (from 8.2 to 6.3) and G + H (from 9.3 to 6.4) patties, improving the atherogenic, thrombogenic and saturation indexes. The effects of the ewe's diet on lamb FA remained unaltered after successive culinary treatments, including aerobically mincing, cooking at an internal temperature of 72 °C and H at 65 °C for 4 h. Heating induced a partial degradation of meat PUFA but also favoured the loss of high saturated melted fat. Both facts balanced the PUFA/SFA ratio in cooked lamb despite the gradual formation of oxidised secondary lipids to the detriment of FA. Grilling or SV cooking did not affect the remaining levels of undegraded FA in the freshly cooked lamb, although SV improved the results obtained for the cooked/H lamb. Maternal diets based on grass result in a healthier ready-to-eat lamb.

AB0907 BONE METABOLISM ASSESSMENT IN PATIENTS WITH RECENT DIAGNOSIS OF GIANT CELL ARTERITIS

Background:

There are several studies assessing bone mass and osteoporosis (OP) development of patients with giant cell arteritis (GCA) during glucocorticoid treatment, however data at time of diagnosis is scarce.

Objectives:

To analyze bone metabolism, bone mineral density (BMD) and trabecular microarchitecture by measuring trabecular bone score (TBS) in patients with recent diagnosis of GCA.

Methods:

Retrospective observational study in which we included all patients with GCA and bone metabolism assessment at diagnosis. We recorded: risk factors for OP (previous fractures and anti-OP treatments), bone metabolism (calcium, phosphate, PTH, 25-vitaminD [25-OHD]) and the DXA results (Lunar, DPX) at the time of diagnosis and during the follow-up. The statistic analysis was made with SPSS.

Results:

36 patients (27 W: 9M) with a mean age of 76±9 years were included. The clinical characteristics of the GCA at diagnoses were: headache (81%), constitutional syndrome (58%), allodynia (42%), visual loss (42%, binocular in 2 patients), jaw claudication (39%), polymyalgic syndrome (28%), amaurosis fugax (25%) and lingular necrosis (n=1, 3%). Additional diagnosis tests included: temporal biopsy (86%, being pathologic in 55%), temporal ultrasound (97%, pathologic 34%), extra-cranial arteries ultrasound (81%, pathologic 7%) and PET/CT (19%, pathologic 86%). Up to 61% received three metilprednisolone bolus (mean dose 1700mg). 7 patients (19%) had previous OP and 3 had already suffered a fragility fracture (Colles, vertebral and femur). Only 4 patients were receiving anti-OP treatment (2 oral bisphosphonate, 2 zoledronate).

At time of diagnosis of GCA, the mean of 25OHD was 17±13ng/mL (88%, <30). BMD showed low bone mass in 80% of patients (47% with OP, 33% osteopenia). The mean TBS was 1.026±0.098 and up to 38% showed poor bone microarchitecture [values <1.23]). No significant differences were observed between patients with or without TBS <1.23. Up to 94% of patients received anti-OP treatment (26 zoledronate, 6 oral bisphosphonate, 1 denosumab, 1 teriparatide). 3 patients had incidental fractures during the follow-up, however no relation was found with BMD or TBS.

Conclusion:

Low bone mass and vitamin D insufficiency are frequent in patients with recent diagnoses of GCA and up to 38% have poor bone microarchitecture at baseline. Thus, it’s important to perform a bone mass assessment in all patients with recent diagnose of ACG and initiate therapeutic or preventive anti-OP treatment if required.

Disclosure of Interests:

None declared

AB0738 SAPHO OR PSORIATIC ARTHRITIS?: EVALUATION OF CASPAR CRITERIA IN A COHORT WITH SAPHO

Background:

SAPHO syndrome (synovitis, acne, pustulosis, hyperostosis and osteitis) is an acronym created with the aim of encompassing within the same entity the findings present in a heterogeneous group of patients with various osteoarticular and cutaneous disorders. For years it has been debated whether it is an entity itself or if, on the contrary, it is a specific phenotype of psoriatic arthritis.

Objectives:

Determine the relationship between SAPHO syndrome and psoriatic arthritis by comparing the classic criteria of SAPHO with CASPAR in patients previously diagnosed with SAPHO.

Methods:

A retrospective study where patients with a diagnosis of SAPHO in the same center (1984-2018) were reviewed. Of a total of 95 patients that met the criteria of Benhamou et al., 46 were excluded due to lack of information to complete the minimum necessary data, so 39 patients were finally included in the study. Demographic data were registered, age at diagnosis, CASPAR criteria (active psoriasis, history of own or familial psoriasis, nail psoriasis, negative RF, dactylitis and new formation/juxta-articular bone proliferation), classical criteria of SAPHO and HLAB27. For the statistical analysis, a Chi-square is applied to determine the differences between the groups with / without CASPAR criteria.

Results:

Of the sample of 39 subjects diagnosed with SAPHO, 15 patients (38%) met CASPAR criteria (4M/11W), with a median age at diagnosis of 42 years (range 21-50). Of them, 8 (60%) had active cutaneous psoriasis, 10 (73%) had a family or personal history of psoriasis, 6 (40%) had psoriatic nail dystrophy, 14 (93%) had negative FR, 3 (20%) had presented some episode of dactylitis and 10 (73%) had juxta-articular new bone formation. Of the 15 patients who met CASPAR criteria, 9 (67%) had synovitis, 2 (13%) acne, 4 (26%) pustulosis, 13 (87%) hyperostosis and 12 (80%) osteitis. HLAB27 was positive in 1 patient (2.5%) of the group that met CASPAR criteria. Of the patients who did not fulfill CASPAR criteria (9M/15W), the median age at diagnosis was 44.5 years (range 10-70). None of them had active cutaneous psoriasis, psoriatic nail distrophy or dactylitis, 1 (4%) had a family or personal history of psoriasis, all had RF- and 3 (12.5%) had juxta-articular bone new formation (Table 1). Synovitis was observed more frequently in patients who met CASPAR criteria than in those who did not (67% vs 25%, p 0.01). In contrast, osteitis was present more frequently in patients who did not meet CASPAR criteria (80% vs 96% p 0.05) and pustulosis, although it was not statistically significant (50% vs 26%, p 0.07). Among patients who did not meet CASPAR criteria only 1 met the 5 classic SAPHO criteria and another 3 met 4.

Table 1.

Conclusion:

Approximately one third (38%) of patients diagnosed with SAPHO meet criteria for psoriatic arthritis, the most notable variables being active psoriasis or a history of psoriasis. Synovitis manifests more frequently in patients with CASPAR criteria and osteitis more present in patients who did not meet them.

Acknowledgments:

Rheumatology Service of the Germans Trias i Pujol Hospital

Disclosure of Interests:

None declared

Adult onset Still's disease: review of 41 cases

OBJECTIVES

To describe the clinical, laboratory and radiological features, treatment and prognosis of patients with adult onset Still's disease (AOSD).

METHODS

Specific clinical features were retrospectively recorded in 41 patients fulfilling the Yamaguchi criteria. Patients were reviewed in two academic hospitals with a referral area of 700,000-1,000,000 inhabitants. Laboratory tests including haemogram, ferritin, biochemistry and autoimmunity were reviewed. Radiological studies, treatment and ACR functional class were determined.

RESULTS

Forty-one patients with AOSD were identified, 25 of whom were female. Mean age at diagnosis: 38.19 years (range 17-68). Feverish polyarthritis was the most common clinical presentation. Acute phase reactants were invariably high in all patients. Serum ferritin levels were elevated in 86% of patients. Anti-cyclic citrullinated peptide antibodies (anti-CCP antibodies) were negative in all patients except one. The course of the disease was monocyclic in 44% of the patients, polycyclic in 26%, and chronic articular in 30%. ACR class was as follows: 29 (72.5%) class I, 7 (17.5%) class II, 2 (5%) class III and 2 (5%) class IV. As for the treatment received, aspirin or NSAIDs controlled the disease in eight patients (19.5%) and high-dose corticosteroids (0.5-1 mg/kg/day) in 32 (78%). Almost half of the patients (49%) required an additional diseasemodifying agent, usually methotrexate. Finally, in seven of them (17%) a biological treatment with TNF-α or specially anti-IL-1 had to be added to control the disease.

CONCLUSIONS

The clinical and laboratory findings were similar to previous studies. Anti-CCP antibodies were almost always negative. A monocyclic course was associated with a good prognosis. Most of the patients were in ACR functional class I and II. Biological agents were required in 7 patients (17%).

Usefulness of bone densitometry in postmenopausal women with clinically diagnosed vertebral fractures

OBJECTIVE

To analyse whether bone mineral density (BMD) assessment is required in postmenopausal women presenting with low trauma vertebral fracture.

METHODS

Women with vertebral fracture diagnosed over a 10 year period were recruited from our database. The following were excluded: (a) patients with high energy trauma; (b) patients with malignancies; (c) patients with a metabolic bone disease other than osteoporosis. All postmenopausal women were included in whom BMD had been evaluated at both the lumbar spine and femoral neck by dual energy x ray absorptiometry during the six months after the diagnosis. Patients with a potential cause of osteoporosis other than age and menopause were not considered. A total of 215 patients were identified.

RESULTS

The mean (SD) age of the patients was 65.9 (6.9) years. BMD at the lumbar spine was 0.725 (0.128) g/cm(2) and the T score was -2.94 (1.22); BMD at the femoral neck was 0.598 (0.095) g/cm(2) and the T score was -2.22 (0.89). The BMD of the patients was significantly lower than that of the general population at both the lumbar spine and femoral neck. When the lowest value of the two analysed zones was considered, six patients (3%) showed a normal BMD, 51 (23.5%) osteopenia, and 158 (73.5%) osteoporosis. The prevalence of osteoporosis at the femoral neck increased with age; it was 25% in patients under 60, 35% in patients aged 60-70, and 60% in patients over 70.

CONCLUSION

These results indicate that bone densitometry is not required in postmenopausal women with clinically diagnosed vertebral fractures if it is performed only to confirm the existence of a low BMD.

Delayed emergence of bovine leukemia virus after vaccination with a protective cytotoxic T cell-based vaccine

In a previous study eight MHC class I-matched sheep were vaccinated with a minimal cytotoxic T lymphocyte (CTL) peptide epitope vaccine and were challenged with the retrovirus, bovine leukemia virus (BLV). Half the vaccinated animals remained PCR negative after challenge, whereas the remaining half and the placebo group became PCR positive within 4 weeks postchallenge (Hislop AD, Good MF, Mateo L, Gardner J, Gatei MH, Daniel RCW, Meyers BV, Lavin MF, and Suhrbier A: Nat Med 1998;4:1193). Here we show that neither epitope mutations nor processing differences explained why half the peptide-vaccinated animals failed to resist the BLV challenge. However, in these animals the development of BLV-induced lymphosarcomas was significantly delayed compared with the placebo group, suggesting a role for CTLs in preventing retrovirus-induced cancers. Importantly, two of the initially protected animals become PCR positive after approximately 1.5 years, indicating extended suppression but not elimination of challenge virus by vaccine-induced CTLs. The late emergence of virus could not be explained by epitope escape mutations or the loss of memory CTL responses. We speculate that high levels of effector CTL may be needed to protect animals from a postchallenge viremia and maintenance of such effector CTLs, rather than memory CTLs, may be required to prevent subsequent emergence of virus from latent pools.

Osteoporotic vertebral fracture in clinical practice. 669 Patients diagnosed over a 10 year period

OBJECTIVE

Few data are available on clinically diagnosed vertebral fracture. Information about osteoporotic vertebral fracture has mainly been obtained via inferences from epidemiological studies of vertebral deformity. We evaluated the characteristics of patients with osteoporotic vertebral fracture diagnosed in a rheumatology department over a 10 year period.

METHODS

Patients with back pain and vertebral fracture diagnosed between January 1990 and December 1999 were recruited from our data base. Patients with high energy trauma, malignancies, and metabolic bone diseases other than osteoporosis were excluded. These variables were analyzed: sex, age at diagnosis, type of osteoporosis (primary vs secondary), number of fractures at diagnosis (single vs multiple), and percentage of admissions and length of stay.

RESULTS

Of the 669 patients, 534 (80%) were women and 135 (20%) were men. Age at diagnosis ranged from 30 to 91 yrs, mean 67.1 +/- 9.1. Secondary osteoporosis was diagnosed in 177 (26%) patients and the frequency was significantly higher in men than women (55% vs 19%; p < 0.001); the most common associations for secondary osteoporosis were oral corticosteroids, chronic obstructive airway disease, and rheumatoid arthritis. At diagnosis, half of the patients presented with multiple fractures. One hundred twenty (18%) patients were admitted; length of stay ranged from 5 to 56 days, mean 15.9 +/- 7.7. The frequency of admissions was higher in men than women (27% vs 16%; p < 0.001), higher in patients with secondary osteoporosis than in those with primary osteoporosis (33% vs 12%; p < 0.001), and higher in patients with multiple fractures than in those with single fractures (27% vs 8%; p < 0.001).

CONCLUSION

Characteristics of patients recruited from a clinical setting differ significantly from those of subjects included in the epidemiological studies. In a rheumatology practice, frequency of secondary osteoporosis, mainly associated with corticosteroid treatment, is notably high. Admission is by no means a rare event.

Weak androgen levels, glucocorticoid therapy, and bone mineral density in postmenopausal women with rheumatoid arthritis

OBJECTIVE

To study dehydroepiandrosterone sulfate (DHEAS) and androstenedione (AND) status in postmenopausal women with rheumatoid arthritis (RA), the effects of glucocorticoid therapy on DHEAS and AND levels, and their relationship with bone mineral density (BMD).

METHODS

Forty-six postmenopausal women with RA were separated into two groups based on whether they had a negative history for glucocorticoid therapy (n = 24) or were currently on glucocorticoid therapy (n = 22). The control group was composed of 39 postmenopausal women who had never received hormone replacement therapy. Serum DHEAS and AND levels were measured using a radioimmunoassay. BMD was determined at the lumbar spine (L2-L4) and femoral neck using a DEXA Hologic QDR-1000 densitometer. Results. RA patients and controls were similar in age, weight, body mass index, and years since menopause. DHEAS and AND levels were lower in the glucocorticoid-treated RA group than in the other two groups. The glucocorticoid-treated RA group also had a significantly lower femoral BMD value than the nonglucocorticoid-treated RA group. Lumbar BMD was similar in the two RA groups and in the controls.

CONCLUSION

Decreases in DHEAS and AND levels in postmenopausal women with RA are probably related to glucocorticoid therapy rather than to the disease itself.

Pyarthrosis in patients with rheumatoid arthritis: a detailed analysis of 10 cases and literature review

OBJECTIVES

1) To analyze the clinical features and outcome of patients with rheumatoid arthritis and pyarthrosis seen in a rheumatology department during a 9-year period; 2) To review the available literature about this association in the last decade.

METHODS

From the database of our department, we collected all hospitalized cases of infectious arthritis in native joints between January 1990 and December 1998. In 10 cases (27%), pyarthrosis occurred in patients with rheumatoid arthritis. A detailed analysis of each patient was performed. The literature was reviewed by using MEDLINE from 1990 to 1999.

RESULTS

The mean age of patients was 63.2 years; six were female. Most patients had long-standing disease and poor functional class, and all received glucocorticoid treatment. Mean diagnostic delay was 7.3 days. Causative organisms were Staphylococcus aureus (4 cases), gram-negative bacilli (3 cases), anaerobic bacteria (2 cases), and Streptococcus pneumoniae (n = 1). Two patients died. In all but two patients who survived, joint function worsened.

CONCLUSIONS

Rheumatoid arthritis is a relevant host-related risk factor for septic arthritis. Pyarthrosis in these patients is associated with considerable morbidity and mortality.

An arthrogenic alphavirus induces monocyte chemoattractant protein-1 and interleukin-8

Cytokines and chemokines play important roles in both autoimmune and infectious arthritides. Here we describe the cytokines and chemokines induced by Ross River (RR) virus infection of synovial fibroblasts and macrophages in vitro. RR virus is the aetiological agent of epidemic polyarthritis (EPA), a principally acute and chronic rheumatic disease affecting up to 7,000 Australians annually. Infected fibroblasts increased expression of mRNA coding for monocyte chemoattractant protein-1 (MCP-1), interleukin-8 (IL-8), and granulocyte-macrophage colony-stimulating factor. MCP-1, IL-8, macrophage inflammatory protein-2, and to a lesser extent interferon gamma-induced protein-10 mRNA were upregulated in infected macrophages. Expression of MCP-1 is consistent with the predominantly monocytic effusion found in EPA synovia.

Bone mineral density in women with ankylosing spondylitis

OBJECTIVE

To determine bone mineral density (BMD) in premenopausal women with early ankylosing spondylitis (AS).

METHODS

Eighteen premenopausal women with AS without syndesmophytes, interapophysiary arthritis, and/or coxofemoral joint destruction were studied. BMD was analyzed at lumbar spine and femoral neck by dual energy x-ray absorptiometry (Hologic QDR 1000). Z scores and T scores related to the general Spanish population were recorded. Comparisons were performed using the Student t test. Pearson's correlation coefficients were used to study the correlation between BMD and the variables. Following the WHO classification, osteopenia was diagnosed in patients with T score between -1 and -2.5 and osteoporosis in those with T score < -2.5 at lumbar spine or femoral neck.

RESULTS

The mean Z score for spine BMD was -0.19+/-0.7, and -0.03+/-0.85 for femoral neck BMD. There were no significant differences of Z score values compared to the general population. No significant correlation was found between BMD and disease duration, radiology sacroiliac score, and spine mobility. Densitometry showed osteopenia in 2 patients and osteoporosis in none.

CONCLUSION

We found a slight reduction in BMD in premenopausal women with early AS, but the difference was not statistically significant. We discuss the factors related to its pathogenesis.

[Study of bone mineral density in postmenopausal women with rheumatoid arthritis treated with low dose glucocorticoids]

BACKGROUND

To study bone mineral density (BMD) in a group of postmenopausal women with rheumatoid arthritis (RA) treated with low doses of corticosteroids.

PATIENTS AND METHODS

One hundred and eleven patients were included. Mean age (SD) was 63.8 (8.8) years, mean duration of postmenopausal period was 16.4 (10.1) years and the mean disease duration was 12.5 (8.2) years.

RESULTS

A significant reduction of lumbar BMD (p < 0.05) and femoral BMD (p < 0.0001) was observed. The prevalence of osteoporosis was of 47%.

CONCLUSIONS

The study supports, in the Spanish population, that postmenopausal women with RA treated with low doses of corticosteroids, have low BMD. We consider that the prevalence of osteoporosis in these patients is high.

H-2 class I knockout, HLA-A2.1-transgenic mice: a versatile animal model for preclinical evaluation of antitumor immunotherapeutic strategies

H-2 class I-negative, HLA-A2.1-transgenic HHD mice were used for a comparative evaluation of the immunogenicity of HLA-A2.1-restricted human tumor-associated cytotoxic T lymphocyte (CTL) epitopes. A hierarchy was established among these peptides injected into mice in incomplete Freund's adjuvant which correlates globally with their capacity to bind and stabilize HLA-A2.1 molecules. Co-injection of a helper peptide enhanced most CTL responses. In contrast, classical HLA class I-transgenic mice which still express their own class I molecules did not, in most cases, develop HLA-A2.1-restricted CTL responses under the same experimental conditions. Different monoepitope immunization strategies of acceptable clinical usage were compared in HHD mice. Recombinant Ty-virus-like particles, or DNA encoding epitopes fused to the hepatitis B virus middle envelope protein gave the best results. Using this latter approach and a melanoma-based polyepitope construct, CTL responses against five distinct epitopes could be elicited simultaneously in a single animal. Thus, HHD mice provide a versatile animal model for preclinical evaluation of peptide-based cancer immunotherapy.

Bone mineral density in patients with peripheral psoriatic arthritis

BACKGROUND

Little information is available on the occurrence of generalized osteopenia in psoriatic arthritis. The only two published studies of bone mass in psoriatic arthritis produced conflicting results.

METHODS

We compared bone mineral density measured at the lumbar spine and femoral neck using dual-energy X-ray absorptiometry in 52 patients with active peripheral psoriatic arthritis and in 52 controls. The psoriatic arthritis group included 19 males, 14 premenopausal women, and 19 post-menopausal women. Controls were matched to the patients on sex, age, and menopausal status.

RESULTS

In the overall study population no significant differences were found between psoriatic arthritis patients and controls. Postmenopausal psoriatic arthritis patients had a lower femoral neck bone mineral density than the relevant subgroup of controls. No significant differences in lumbar spine bone mineral density were found in the analyses of the male, premenopausal female, and postmenopausal female subgroups. Neither was femoral neck density significantly different between male or premenopausal female psoriatic arthritis patients and controls.

CONCLUSION

These results suggest that peripheral psoriatic arthritis is not associated with significant generalized bone loss.

An HLA-A2 polyepitope vaccine for melanoma immunotherapy

Epitope-based vaccination strategies designed to induce tumor-specific CD8 CTL are being widely considered for cancer immunotherapy. Here we describe a recombinant poxvirus vaccine that codes for ten HLA-A2-restricted epitopes derived from five melanoma Ags conjoined in an artificial polyepitope or polytope construct. Target cells infected with the melanoma polytope vaccinia were recognized by three different epitope-specific CTL lines derived from HLA-A2 melanoma patients, and CTL responses to seven of the epitopes were generated in at least one of six HLA-A2-transgenic mice immunized with the construct. CTL lines derived from vaccinated transgenic mice were also able to kill melanoma cells in vitro. Multiple epitopes within the polytope construct were therefore shown to be individually immunogenic, illustrating the feasibility of the polytope approach for melanoma immunotherapy. Tumor escape from CTL surveillance, through down regulation of individual tumor Ags and MHC alleles, might be overcome by polytope vaccines, which simultaneously target multiple cancer Ags.

Immunogenicity of a human immunodeficiency virus (HIV) polytope vaccine containing multiple HLA A2 HIV CD8(+) cytotoxic T-cell epitopes

Compelling evidence now suggests that alphabeta CD8 cytotoxic T lymphocytes (CTL) have an important role in preventing human immunodeficiency virus (HIV) infection and/or slowing progression to AIDS. Here, we describe an HIV type 1 CTL polyepitope, or polytope, vaccine comprising seven contiguous minimal HLA A2-restricted CD8 CTL epitopes conjoined in a single artificial construct. Epitope-specific CTL lines derived from HIV-infected individuals were able to recognize every epitope within the construct, and HLA A2-transgenic mice immunized with a recombinant virus vaccine coding for the HIV polytope also generated CTL specific for different epitopes. Each epitope in the polytope construct was therefore processed and presented, illustrating the feasibility of the polytope approach for HIV vaccine design. By simultaneously inducing CTL specific for different epitopes, an HIV polytope vaccine might generate activity against multiple challenge isolates and/or preempt the formation of CTL escape mutants.

Peptide based cytotoxic T-cell vaccines; delivery of multiple epitopes, help, memory and problems

Synthetic CD8+ cytotoxic T-lymphocyte (CTL) peptide epitope based vaccines are being developed against a number of human diseases. Here we describe extensive preclinical testing of peptide epitope vaccines formulated with a protein as a source of CD4 help and Montanide ISA 720, an adjuvant currently in human clinical trials. Such water-in-oil formulations could effectively co-deliver several peptide epitopes and simultaneously induce multiple independent CTL responses. The efficiency of CTL induction by some peptides was, however, dependent on the aqueous buffer conditions, with poor performance correlating with non-covalent peptide oligomerisation. Any of a number of proteins currently used in human vaccines could supply CD4 help and no difference in CTL induction was obtained if the CD4 response was amnestic or a primary. Peptide immunisation was found to induce long term CTL memory and the recall of protective responses did not depend on an amnestic CD4 response. Slow pyroglutamic acid formation and rapid oxidation of methionine residues was observed in water-in-oil formulations, however, the latter had no effect on CTL induction. These data highlight the need to monitor for potential deleterious chemical events and interpeptide interactions, but illustrate that peptide based vaccination can effectively deliver multiple epitopes, in conjunction with any protein, and induce protective memory.

High serum prolactin levels in men with rheumatoid arthritis

OBJECTIVE

High prolactin (PRL) levels have been reported in systemic lupus erythematosus, Reiter's syndrome, and psoriatic arthritis. However, results of PRL investigations in rheumatoid arthritis (RA) are contradictory. We evaluated the PRL status in men with RA and the possible effect on bone mineral density (BMD).

METHODS

We studied 91 men with RA and 68 controls. PRL serum levels were analyzed under standardized conditions. Sex hormones (testosterone, androstenedione, and DHEAS) were also studied. BMD was analyzed at L2-L4 and the femoral neck by Hologic QDR1000. Comparative tests, linear correlations, and multiple regression analysis were performed.

RESULTS

Serum PRL levels were significantly higher in men with RA (249+/-162 mU/l) than in controls (189+/-85 mU/l) (p=0.0015). High PRL levels were significantly correlated with the duration of RA (r=0.23; p=0.01) and with functional stage according to the Steinbrocker classification (r=0.24; p=0.01). High PRL concentrations were not correlated with the low levels of androgens observed in males with RA. Femoral BMD showed a negative correlation with PRL concentrations (r=0.20; p=0.04). Nevertheless, PRL was not a significant determinant of BMD.

CONCLUSION

Men with RA have high serum PRL levels and concentrations increase with longer disease evolution and worse functional stage. Prolactin levels do not have a direct effect on BMD.

Vaccine-induced cytotoxic T lymphocytes protect against retroviral challenge

The development of prophylactic vaccines against retroviral diseases has been impeded by the lack of obvious immune correlates for protection. Cytotoxic T-lymphocyte (CTL), CD4-lymphocyteS, chemokine and/or antibody responses have all been associated with protection against HIV and AIDS; however, effective and safe vaccination strategies remain elusive. Here we show that vaccination with a minimal ovine CTL peptide epitope identified within gp51 of the retrovirus bovine leukemia virus (BLV), consistently induced peptide-specific CTLs. Only sheep whose CTLs were also capable of recognizing retrovirus-infected cells were fully protected when challenged with BLV. This retrovirus displays limited sequence variation; thus, in the relative absence of confounding CTL escape variants, virus-specific CTLs targeting a single epitope were able to prevent the establishment of a latent retroviral infection.

Salivary testosterone in postmenopausal women with rheumatoid arthritis

OBJECTIVE

To study changes in testosterone concentrations in saliva and total testosterone, free testosterone, and sex hormone binding globulin (SHBG) concentrations in serum in 2 groups of postmenopausal women with rheumatoid arthritis (RA), one group with glucocorticoid treatment and the other without it.

METHODS

The above mentioned hormonal levels were measured in 20 postmenopausal women with RA undergoing glucocorticoid treatment, in 24 postmenopausal women with RA without treatment, and in 36 postmenopausal women without RA.

RESULTS

We observed significantly lower levels of total testosterone in serum, SHBG in serum, testosterone in saliva, and the free testosterone index in the group of patients with RA undergoing glucocorticoid treatment compared to the group without treatment. We did not observe changes in free testosterone concentrations in serum of the groups studied, which is believed due to its lower specificity.

CONCLUSION

Testosterone in saliva is a useful indicator for monitoring androgenic status in women with RA.

The serine proteinase inhibitor (serpin) plasminogen activation inhibitor type 2 protects against viral cytopathic effects by constitutive interferon alpha/beta priming

The serine proteinase inhibitor (serpin) plasminogen activator inhibitor type 2 (PAI-2) is well characterized as an inhibitor of extracellular urokinase-type plasminogen activator. Here we show that intracellular, but not extracellular, PAI-2 protected cells from the rapid cytopathic effects of alphavirus infection. This protection did not appear to be related to an effect on apoptosis but was associated with a PAI-2-mediated induction of constitutive low-level interferon (IFN)-alpha/beta production and IFN-stimulated gene factor 3 (ISGF3) activation, which primed the cells for rapid induction of antiviral genes. This primed phenotype was associated with a rapid development of resistance to infection by the PAI-2 transfected cells and the establishment of a persistent productive infection. PAI-2 was also induced in macrophages in response to viral RNA suggesting that PAI-2 is a virus response gene. These observations, together with the recently demonstrated PAI-2-mediated inhibition of tumor necrosis factor-alpha induced apoptosis, (a) illustrate that PAI-2 has an additional and distinct function as an intracellular regulator of signal transduction pathway(s) and (b) demonstrate a novel activity for a eukaryotic serpin.

Alphavirus-specific cytotoxic T lymphocytes recognize a cross-reactive epitope from the capsid protein and can eliminate virus from persistently infected macrophages

Persistent alphavirus infections in synovial and neural tissues are believed to be associated with chronic arthritis and encephalitis, respectively, and represent likely targets for CD8+ alphabeta cytotoxic T lymphocytes (CTL). Here we show that the capsid protein is a dominant target for alphavirus-specific CTL in BALB/c mice and that capsid-specific CTL from these mice recognize an H-2Kd restricted epitope, QYSGGRFTI. This epitope lies in the highly conserved region of the capsid protein, and QYSGGRFTI-specific CTL were cross reactive across a range of Old World alphaviruses. In vivo the acute primary viraemia of these highly cytopathic viruses was unaffected by QYSGGRFTI-specific CTL. However, in vitro these CTL were able to completely clear virus from macrophages persistently and productively infected with the arthrogenic alphavirus Ross River virus.

Prevalence of antiphospholipid antibodies in patients with ankylosing spondylitis

OBJECTIVE

To establish the prevalence of antiphospholipid antibodies (aPL) in a group of patients with ankylosing spondylitis (AS). The relation of the antibodies with different clinical and analytical features was studied.

METHODS

Eighty-four patients with AS (71 men) and 40 age and sex matched controls were studied. aPL determinations included: anticardiolipin antibodies (aCL) of the IgM, IgG, and IgA classes, the presence of lupus anticoagulant (LAC), and a false positive serologic test for syphilis. Comparisons between variables were done by Student t test, Mann-Whitney test and Chi squared test. Correlations between aPL and clinical variables were performed by Pearson coefficients.

RESULTS

Twenty-four patients with AS (29%) has positive IgG aCL, compared with only 2 cases in the control group (5%) (p < 0.002). There were no differences in other aPL determinations between patients and controls. There was no correlation between the presence of aCL (IgG, IgM, or IgA) and LAC and the different aspects of the disease. Two patients fulfilled the criteria for antiphospholipid syndrome.

CONCLUSION

Our results indicate the presence of IgG aCL in patients with AS higher than in the normal population but their relation with thrombosis and other systemic manifestations seems weak.

Sex hormone status and bone mineral density in men with rheumatoid arthritis

OBJECTIVE

Sex hormone status has been proposed as an important determinant of low bone mineral density (BMD) in both men and women. Our objective was to study the relationship between sex hormones and BMD in patients with rheumatoid arthritis (RA), and how steroid therapy affects both.

METHODS

We studied 99 men with RA to assess their BMD and sex hormone status. A comparative group of 68 age paired men was used. We made comparative tests, linear correlations, and multiple regression analysis.

RESULTS

We found significant reductions in lumbar BMD (p = 0.0005), femoral BMD (p < 0.0005), salivary testosterone (p = 0.01), androstenedione (p = 0.007), and dehydroepiandrosterone sulfate (DHEAS) (p = 0.03) in patients with RA. In contrast, serum testosterone concentrations were normal. Salivary testosterone showed correlation with femoral BMD (r = 0.36; p < 0.001). By multiple regression analysis, weight, serum testosterone concentrations, and the cumulative dose of corticosteroids were significant predictors of lumbar BMD (r = 0.41; p = 0.001). Weight, age, androstenedione concentrations, and the cumulative dose of corticosteroids were the significant predictors of femoral BMD (r = 0.79; p < 0.0005).

CONCLUSION

We confirm there is reduced BMD in men with RA; corticosteroids contribute, but are not the only factor in the pathogenesis of low BMD in patients with RA; we found decreased levels of androstenedione, DHEAS, and salivary testosterone in men with RA; and salivary testosterone, as with free testosterone, is correlated with BMD in patients with RA, with lower levels contributing to low BMD.