The infant-doctor relationship: an examination of infants' distress reactions in the presence of a doctor

Fear of doctors is a common source of distress among infants; however, the underlying sources of this distress are unknown. To investigate the doctor-infant relationship, the behaviors of 61 healthy infants (176-617 days old) were observed in a simulated examination room. Their behaviors and electrocardiograms were recorded. Two groups of infants were analyzed: those who cried and those who did not. When an experimenter dressed in the doctor's attire entered the room, all 9 infants who were crying (14.8% of all infants) stopped crying, all infants gazed at the experimenter, and their mean heart rate (HR) decreased. After the auscultation started, 29.5% of all infants cried, and the HRs of infants who cried were higher than those of infants who did not cry. During the auscultation, 80.0% of infants who cried averted from the experimenter, while 34.4% of infants who did not cry. Within 5 s of gazing at the stethoscope, the number of infants who cried increased from 3 to 12, and their mean HR also increased. Our findings suggest that the fear of doctors is not due to the appearance of doctors but rather to specific actions performed by doctors, such as auscultation. Infants may regard a doctor's appearance as a source of interest. Furthermore, a stethoscope is a possible trigger for infants' crying. These behavioral observations suggest the potential for patient-centered care for infants.

The impact of rare cancer and early-line treatments on the benefit of comprehensive genome profiling-based precision oncology

BACKGROUND

Comprehensive genome profiling (CGP) serves as a guide for suitable genomically matched therapies for patients with cancer. However, little is known about the impact of the timing and types of cancer on the therapeutic benefit of CGP.

MATERIALS AND METHODS

A single hospital-based pan-cancer prospective study (TOP-GEAR; UMIN000011141) was conducted to examine the benefit of CGP with respect to the timing and types of cancer. Patients with advanced solid tumors (>30 types) who either progressed with or without standard treatments were genotyped using a single CGP test. The subjects were followed up for a median duration of 590 days to examine therapeutic response, using progression-free survival (PFS), PFS ratio, and factors associated with therapeutic response.

RESULTS

Among the 507 patients, 62 (12.2%) received matched therapies with an overall response rate (ORR) of 32.3%. The PFS ratios (≥1.3) were observed in 46.3% (19/41) of the evaluated patients. The proportion of subjects receiving such therapies in the rare cancer cohort was lower than that in the non-rare cancer cohort (9.6% and 17.4%, respectively; P = 0.010). However, ORR of the rare cancer patients was higher than that in the non-rare cancer cohort (43.8% and 20.0%, respectively; P = 0.046). Moreover, ORR of matched therapies in the first or second line after receiving the CGP test was higher than that in the third or later lines (62.5% and 21.7%, respectively; P = 0.003). Rare cancer and early-line treatment were significantly and independently associated with ORR of matched therapies in multivariable analysis (P = 0.017 and 0.004, respectively).

CONCLUSION

Patients with rare cancer preferentially benefited from tumor mutation profiling by increasing the chances of therapeutic response to matched therapies. Early-line treatments after profiling increase the therapeutic benefit, irrespective of tumor types.

Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

Physiological arousal explains infant gaze following in various social contexts

Gaze following (GF) is fundamental to central aspects of human sociocognitive development, such as acquiring language and cultural learning. Studies have shown that infant GF is not a simple reflexive orientation to an adult's eye movement. By contrast, infants adaptively modulate GF behaviour depending on the social context. However, arguably, the neurophysiological mechanisms underlying contextual modulation of GF remain somewhat unexplored. In this study, we tested the proposition about whether the contextual modulation of infant GF is mediated by the infant's heart rate (HR), which indicates the infant's physiological arousal. Forty-one 6- to 9-month-old infants participated in this study, and infants observed either a reliable face, which looked towards the location of an object, or an unreliable face, which looked away from the location of an object. Thereafter, the infants watched a video of the same model making eye contact or not making any ostensive signals, before shifting their gaze towards one of the two objects. We revealed that reliability and eye contact acted independently to increase HR, which then fully mediates the effects of these social cues on the frequency of GF. Results suggest that each social cue independently enhances physiological arousal, which then accumulatively predicts the likelihood of infant GF behaviour.

Physiological arousal explains infant gaze following in various social contexts

Gaze following (GF) is fundamental to central aspects of human sociocognitive development, such as acquiring language and cultural learning. Studies have shown that infant GF is not a simple reflexive orientation to an adult's eye movement. By contrast, infants adaptively modulate GF behaviour depending on the social context. However, arguably, the neurophysiological mechanisms underlying contextual modulation of GF remain somewhat unexplored. In this study, we tested the proposition about whether the contextual modulation of infant GF is mediated by the infant's heart rate (HR), which indicates the infant's physiological arousal. Forty-one 6- to 9-month-old infants participated in this study, and infants observed either a reliable face, which looked towards the location of an object, or an unreliable face, which looked away from the location of an object. Thereafter, the infants watched a video of the same model making eye contact or not making any ostensive signals, before shifting their gaze towards one of the two objects. We revealed that reliability and eye contact acted independently to increase HR, which then fully mediates the effects of these social cues on the frequency of GF. Results suggest that each social cue independently enhances physiological arousal, which then accumulatively predicts the likelihood of infant GF behaviour.

O-015 Results of urological consultation in the setting of IVF clinic

Study question

In the management of male infertility, we investigated whether urological consultation could improve the live birth rate, and who should visit urologists in the setting of IVF clinic.

Summary answer

Urologic consultation resulted in improvement of semen quality and live birth rate with more IVF use in those with adverse semen parameters.

What is known already

Male factor infertility exists in about a half of infertility couples. This accounts for about 8% in male reproductive age. Therefore, ideally every male partner of infertility couples attempting conception should have a urological evaluation. However, it is not very easy to access urologists who specialized in reproductive medicine in Japan because we have very few of such urologists. One the other hand, a certain number of couples are wasting their time during IVF failure without urological evaluation.

Study design, size, duration

This is a single-institution retrospective study. We enrolled male partners of infertility couples who visited Kameda IVF clinic Makuhari, Chiba, Japan, between May 2016 and December 2020 and followed at least one year. Live birth rate and the frequency of IVF use were investigated according to semen quality and urological consultation status. Chi-square tests and T tests were used to compare the results between groups.

Participants/materials, setting, methods

Among 2225 couples who visited Kameda IVF clinic Makuhari, 803 male partners (Group A, 36.0%) were evaluated by urologists who were specialized in male reproductive medicine. Remaining 1422 patients did not (Group B, 64.0%). Lifestyle evaluation, physical examination, semen analyses, scrotal ultrasonography, blood test including sexual hormones and zinc concentration were performed in Group A. Semen analyses and lifestyle evaluation were performed in Group B. Urological treatments were done according to factors of male infertility.

Main results and the role of chance

Semen quality was worse in Group A as compared to Group B (sperm motility, 28.5±16.9% vs. 46.0±17.0%; total sperm count, 105±108 million/mL vs. 176±155; total motile sperm count, 34±49 vs.87±98; mean±S.D.; p = 0.0001, 0.0001, 0.0001, A vs. B, respectively). After urologic consultation and managements, sperm motility was improved to 34±18% (p = 0.001). Live birth rate in groups A and B were similar (56.0% vs. 57.2%), however couples who obtained a child in Group A used IVF more often than those in Group B (70% vs. 49.9%, p &lt; 0.001). Among those with adverse semen quality (total motile sperm count less than 15.6 million/mL, n = 472), 350 visited urologists (Group 1, 74.2%) and remaining 122 did not (Group 2, 25.8%). Live birth rate in Group 1 was significantly better than in Group 2 (65.3% vs. 54.1%, p = 0.0359). Use of IVF was significantly more frequent in Group 1 than Group 2 (79.3% vs. 63.6%, p = 0.0359) among who obtained a child. In those with better semen quality (motile sperm count &gt;50 million, n = 900), 119 visited urologist (31.1%, Group 3) and 781 did not (Group 4). Live birth rate and the use of IVF were not different between Groups 3 and 4 (51.1% vs.60.9%; 50.4% vs. 62.9%).

Limitations, reasons for caution

This study is a single-institution, retrospective study in the setting of IVF clinic. There may be a selection bias since men first visit gynecologists. These could affect the study results.

Wider implications of the findings

In the setting of IVF clinic, urologic consultation resulted in improved semen quality and better live birth rate with the use of IVF, especially in those who have adverse semen parameters. The results of this study encourage patients to see urologists and physicians to introduce urologist to patients.

Trial registration number

not applicable

P-152 The first morphokinetic map of human abnormal fertilisation

Study question

What are the similarities and differences between the morphokinetics of abnormal, one- (1PN) and three-pronuclear (3PN) and normal bi-pronuclear (2PN) fertilisation?

Summary answer

The morphokinetic analysis of 1PN/3PN fertilisation reveals novel aspects of abnormal early development.

What is known already

Assisted reproduction technology has allowed the observation of early human development. Initially assessed statically at a single time point, fertilization has revealed its complexity once observed by Time-Lapse Microscopy (TLM). Detailed morphokinetic analysis of fertilisation has been reported in the last few years, unveiling previously unknown cytoplasmic phenomena (e.g. the cytoplasmic wave and halo) and the importance of cell symmetry for embryo development. At present, abnormal fertilization remains neglected, despite potential for understanding the physiology and pathology of early human development.

Study design, size, duration

This retrospective study involved TLM observation of normally (2PN, n = 2,685) and abnormally (1PN, n = 41; 3PN, n = 127) fertilised oocytes generated in ICSI cycles. Oocyte retrievals were carried out after the clomiphene citrate-based minimal ovarian stimulation, between October 2019 and December 2020. Oocytes of patients with different diagnoses of infertility were included in the analysis, while cases involving cryopreserved gametes or surgically retrieved sperm were excluded.

Participants/materials, setting, methods

Microinjected oocytes were assessed by a combined TLM-culture system (Embryoscope). Oocytes not suitable for TLM assessment, due to excess of residual corona cells or inadequate orientation for correct observation, were not analysed. Phenomena, relevant to meiotic resumption, pronuclear dynamics, cytoplasmic/cortical modifications, cleavage pattern, and embryo quality, were annotated and compared between groups.

Main results and the role of chance

Second polar body (PBII) extrusion was observed in all 1PN- and in a majority of 3PN-zygotes (92.1%). A 0.3-hour delay in PBII extrusion was confirmed in 3PN-zygotes (P = 0.0439). In a significant proportion of 3PN-zygotes, a third (female) PN formed from reabsorption of the PBII. The cytoplasmic wave was observed not only in 2PN- and 3PN-, but also in 1PN-zygotes. The presence and position of cytoplasmic halo were comparable among the three classes of zygotes. However, the duration of the cytoplasmic halo was prolonged in 1PN-zygotes (P &lt; 0.0001). PN juxtaposition immediately before PN breakdown was less frequent in 3PN- compared with 2PN-zygotes (P = 0.0159). Furthermore, asynchronous PN breakdown was increased in 3PN- compared with 2PN-zygotes (P = 0.0026). The PN area of 1PN- was larger than that of 2PN-zygotes; however, the PN area of 3PN-zygotes was smaller than that of 2PN-zygotes. In 1PN-zygotes, a developmental delay was observed starting from the disappearance of the cytoplasmic halo, reaching 9 hours at the time of cleavage (P &lt; 0.0001). A higher incidence of abnormal cleavage (P = 0.0019) and blastomere fragmentation (P &lt; 0.0001) was observed in 1PN-zygotes. Cleavage progression was increasingly affected especially in 1PN-zygotes, resulting in blastocyst formation rates of 70.2%, 12.2% and 53.5% in 2PN-, 1PN- and 3PN-zygotes, respectively (P &lt; 0.0001).

Limitations, reasons for caution

The study data derive from treatments carried out in a single centre. The study findings therefore require independent verification from other research groups.

Wider implications of the findings

These observations suggest that 1PN and 3PN fertilisation follow the general pattern of normal fertilization. Crucially, they also shed light on diverse and previously undescribed phenomena - e.g. reabsorption of the PBII in 3PN zygotes - underpinning the origins of abnormal fertilization and potentially clinically relevant.

Trial registration number

not applicable

AB0313 CLINICAL FEATURE OF 100 CASES OF METHOTREXATE ASSOCIATED LYMPHOPROLIFERATIVE DISORDERS WITH RA PATIENT

Background

Lymphoproliferative disorders (LPDs), including malignant lymphoma, are known to occur in RA patients treated with disease modified antirheumatic drugs (DMARDs). In particular, LPD associated with methotrexate (MTX)-treated RA is often referred to as MTX-associated LPD (MTX-LPD). MTX-LPD have various clinical feature and histological findings1). We have accumulated MTX-LPD cases in patients with rheumatoid arthritis (MTX-RA-LPD).

Objectives

We clarified the clinical characteristics of MTX-RA-LPD. In addition, we examine the prognosis of MTX-LPD in RA patients.

Methods

We enrolled 100 RA patients who diagnosed MTX-LPD from 2005 to 2021. We collected as follow data based on clinical reports retrospectively; 1) age, 2) gender, 3) duration from RA onset to LPD onset, 4) total dose of MTX, 5) duration of MTX administration, 6) presence of extranodal lesion 7) histological findings, 8) treatment for LPD, 9) 5-year survival rate.

Results

The mean age of 100 MTX-RA-LPD patients (M:F=30:70) were 66.7 ± 10.7 years old, and the duration from RA onset to LPD onset were 25.2 ± 11.0 years. The total dose of MTX and duration of MTX administration were over 2,600mg and over 5 years, respectively. The extranodal lesions were found in 51%, and diffuse large B cell lymphoma was the most common histological findings. Spontaneous regression was observed in 68%. The 5-year survival rate of MTX-RA-LPD was as high as over 85%.

Conclusion

The clinical features of MTX-RA-LPD were similar to those previous reports. Furthermore, we suggested a good prognosis for MTX-RA-LPD.

References

[1]Harigai M. Lymphoproliferative disorders in patients with rheumatoid arthritis in the era of widespread use of methotrexate: A review of the literature and current perspective. Mod Rheumatol. 2018 Jan;28(1):1-8.

Disclosure of Interests

None declared

POS1220 HUMORAL IMMUNE RESPONSE AGAINST BNT162b2 mRNA COVID-19 VACCINE IN JAPANESE RHEUMATIC DISEASE PATIENTS RECEIVING IMMUNOSUPPRESSIVE THERAPY: A MONOCENTRIC STUDY

Background

Patients with immune-mediated inflammatory diseases are inherently susceptible to infections and are at high risk of developing COVID-19. COVID-19 vaccination in patients with rheumatoid and musculoskeletal disease (RMD) is strongly recommended [1]. BNT162b2 is the most used COVID-19 vaccine in Japan. The safety and efficacy of this vaccine has been demonstrated in the general population [2], but patients receiving immunosuppressive therapy were excluded from the study. Although data on the immunogenicity of COVID-19 vaccine in the immunocompromised adult population is rapidly increasing, the immunogenicity of mRNA COVID-19 vaccine in RMD patients receiving medication has been reported in various and still inadequate ways. Furthermore, the immunogenicity of mRNA COVID-19 vaccine may vary depending on the medication. In addition, most of these data were reported from Western countries, and data on Japanese patients with RMD are limited.

Objectives

To investigate serum antibody titre against SARS-CoV-2 spike protein following BNT162b2 vaccination in Japanese RMD patients on various immunomodulatory treatment.

Methods

Two hundred and twelve RMD outpatients undergoing treatment at Kagawa University Hospital and 43 healthy volunteers, who had received two doses of BNT162b2, were included in the study. Serum sample was collected at least 14 days after the second dose. Antibody titer against SARS-CoV-2 spike protein in serum was measured by ELISA (Elecsys Anti-SARS-CoV-2 S RUO). We analyzed the relationship between clinical characteristics, including the type of disease and treatment of RMD, and antibody titer against SARS-CoV-2 spike protein.

Results

The antibody titer against SARS-CoV-2 spike protein in RMD patients was significantly lower than that in healthy subjects. In the analysis with therapeutic agents, the mean antibody titer in RMD patients treated with rituximab (RTX) was much lower than that in healthy controls. Patients treated with baricitinib, azathioprine, mycophenolate mofetil, abatacept, TNF inhibitors, cyclosporine, IL-6 inhibitors, methotrexate (MTX), or glucocorticoids (GC) had only moderately lower antibody titers. Patients treated with tacrolimus, an immunosuppressive drug commonly used for treatment in Japan, showed a slight decrease in antibody titer, but the difference was not significant compared with healthy subjects. IL-17 and IL-23 inhibitors did not impair the humoral response. In addition, the combination of MTX with various immunosuppressive agents reduced titers, although this was not statistically significant.

Conclusion

Many of the immunosuppressants impaired the immunogenicity to BNT162b2 in Japanese RMD patients. The degree of decline of antibody titers differed according to immunosuppressant. MTX potentially impairs the immunogenicity of BNT162b2 also in the case of concomitant use with other immunosuppressant.

References

[1]Curtis JR, et al. American College of Rheumatology Guidance for COVID-19 Vaccination in Patients With Rheumatic and Musculoskeletal Diseases: Version 3. Arthritis Rheumatol. 2021;73:e60-e75.

[2]Polack FP, et al. Safety and efficacy of the BNT162b2 mRNA Covid-19 vaccine. N Engl J Med. 2020;383:2603–15.

Figure 1.

RMD diagnosis of study patients, n

Table 1.

Serum antibody titre against SARS-CoV-2 spike protein according to the use of immunosuppressive treatments in comparison with controls

Immunosuppressive treatments, nSerum antibody titre, mean±SD, U/mLP valueControl, n=43939 ± 973-Patients with RMD, n=212572 ± 9500.023Without immunosuppressant, n=271074 ± 7580.485IL-17 or IL-23 inhibitors, n=71653 ± 24710.035Tacrolimus, n=32614 ± 9200.095GC, n=103481 ± 9270.009MTX, n=78310 ± 493<0.001IL-6 inhibitors, n=10303 ± 2010.030Cyclosporine, n=8261 ± 2280.035TNF inhibitors, n=26201 ± 252<0.001Abatacept, n=10186 ± 3200.010Mycophenolate mofetil, n=11183 ± 3570.007Azathioprine, n=13150 ± 1590.003Baricitinib, n=6101 ± 970.021RTX, n=620 ± 320.012

Disclosure of Interests

None declared

AB1330 AUTOMATIC SUBPIXEL MEASUREMENT OF RADIOGRAPHIC FINGER JOINT SPACE NARROWING IN RHEUMATOID ARTHRITIS PATIENTS UNDER TOCILIZUMAB TREATMENT

Background

The conventional scoring methods of radiographic joint space narrowing (JSN) in rheumatoid arthritis (RA) such as the Genant-modified Sharp score (GSS) are widely accepted but include subjective and time-consuming nature1. Therefore, we have developed an in-house software equipped with partial image phase-only correlation (PIPOC)2 which can automatically quantify joint space width (JSW) change.

Objectives

The purpose of this study was to investigate whether the in-house software can predict the inhibitory effect of tocilizumab on joint destruction in a short period of time.

Methods

The study included 39 RA patients (35 female) who were treated with tocilizumab (Table 1). Radiological progression of the metacarpophalangeal and the proximal interphalangeal joints was evaluated according to the GSS at 0, 6, and 12 months. Automatic measurement was performed by the in-house software (Figure 1). We then validated in-house software in terms of accuracy in detecting the JSN.

Figure 1.

The algorithm flow of in-house software equipped with PIPOC

Table 1.

Clinical characteristics of RA patients

variablebaseline6 months12 monthsTotal number of patients39Sex, female/male35/4Rheumatoid factor status, positive/negative29/10Age, mean (SD) years61.5 (14.6)Duration of disease, mean (SD) months111.4 (85.0)Swollen joint count, mean (SD)6.0 (4.7)3.5 (3.5)2.9 (4.0)Tender joint count, mean (SD)6.4 (3.5)2.9 (2.2)1.9 (2.0)DAS28-ESR, mean (SD)4.9 (1.2)3.0 (1.1)2.6 (1.0)DAS28-CRP, mean (SD)4.4 (1.1)3.0 (0.9)2.6 (0.8)

RA, rheumatoid arthritis; SD, standard deviation; DAS28, disease activity score with 28 joints; ESR, erythrocyte sedimentation rate; CRP, C-reactive protein

Results

To ensure homogeneity of the subjects, we targeted the joints with GSS = 0 at baseline in the software analysis. The success rate of the in-house software for JSW measurement was 96.8% (449/464). Here, the GSS (+)/PIPOC (+) were defined as joints with JSN progression according to the GSS and the software analysis, respectively. Otherwise, joints were defined as the GSS (-)/PIPOC (-) namely non-progressive JSN. The 0–12-month GSS with the 0–6-month GSS (+) group was significantly more JSN progression than the 0–6-month GSS (-) group (Mann-Whitney U test, p < 0.001). Similarly, the 0–12-month PIPOC with the 0–6-month PIPOC (+) group was significantly more JSN progression than the 0–6-month PIPOC (-) group (p < 0.001). The 0–12-month JSW change of finger joints with the 0–12-month GSS (+) detected by the in-house software was significantly greater than the 0–12-month GSS (-) (p = 0.02).

Conclusion

Our in-house software equipped with PIPOC might be able to predict the subsequent joint destruction with 6 months observations.

References

[1]Genant HK, et al: Assessment of rheumatoid arthritis using a modified scoring method on digitized and original radiographs. Arthritis & Rheumatism: Official Journal of the American College of Rheumatology 1998, 41(9):1583-1590.

[2]Ou Y, et al: Automatic Radiographic Quantification of Joint Space Narrowing Progression in Rheumatoid Arthritis Using POC. In: 2019 IEEE 16th International Symposium on Biomedical Imaging (ISBI 2019). 2019: 1183-1187.

Disclosure of Interests

Taichi Okino: None declared, Yafei Ou: None declared, Masayuki Ikebe: None declared, Akira Furusaki: None declared, Akira Sagawa: None declared, Masaru Kato: None declared, Tatsuya Atsumi: None declared, Tamotsu Kamishima Grant/research support from: Tamotsu Kamishima reports grants from Chugai Pharmaceutical.

POS1362 THE EFFICACY AND CYTOKINE PROFILES DURING TREATMENT WITH APREMILAST IN PATIENTS WITH BEHÇET ‘S DISEASE

Background

Apremilast has been shown to be effective in patients with Behçet’s disease (BD) in domains other than oral ulcers; however, its long-term efficacy is yet to be determined. Although serum cytokine modulation by increasing intracellular cAMP levels has been suggested as a mechanism for the efficacy of apremilast on skin areas of psoriasis [1], the relationship between efficacy and cytokine on various domains in BD has not been fully investigated.

Objectives

This study aims to evaluate the long-term clinical efficacy of apremilast in BD and its effect on serum cytokines.

Methods

In this study, patients with BD who received apremilast for active oral ulcers were included. For 12 months, the improvement rates of oral and genital ulcers, skin lesions, and arthritis were assessed every three months. Serum levels of cytokines, including interferon-gamma (IFN-γ), interleukin 10 (IL-10), and IL-17A were determined using Simple Plex (Protein Simple, CA, USA) at baseline and three months after apremilast treatment. Other cytokines, including tumor necrosis factor-alpha (TNF-a), IL-6, IL-8, and IL-23, were also measured in serum using a multiplex immunoassay (Luminex Assay, R&D Systems).

Results

Fifteen patients were included in this study. Table 1 shows the characteristics of the patients who participated in this study. Oral ulcers disappeared in 66.7% and 92.3% of the patients after 3 and 6 months of apremilast treatment, respectively. Genital ulcers disappeared in all patients after 6 months of apremilast treatment and were maintained for 12 months. The efficacy of apremilast in oral ulcers could be divided between two groups: 8 patients in the oral ulcer remission group (OU-R group) whose oral ulcers completely disappeared after 3 months of apremilast administration and persisted for 1 year, and 7 patients in the oral ulcer non-remission group (OU-NR group) whose oral ulcers persisted after 3 months of apremilast treatment. Genital ulcers improved more rapidly in the OU-R group than in the OU-NR group, and completely disappeared within 3 months. Skin and joint lesions generally improved after 6 months, but recurred after 9 months.

Table 1.

Baseline characteristics of the studied patients with Behçet’s disease

CharacteristicsN = 15Age (years), mean ± SD46.7 ± 13.0Sex (female), n (%)11 (73.3)Disease duration (years), mean ± SD10.4 ± 8.8Active Behçet’s disease manifestation at the time of enrollment, n (%) Oral ulcer15 (100) Genital ulcer5 (33.3) Skin lesion (erythema nodosum or pustules)10 (66.7) Arthralgia9 (60.0) Arthritis5 (33.3) Ocular involvement0 (0) Gastrointestinal involvement1 (6.7) Neurological involvement0 (0) Vascular involvement0 (0)

SD, standard deviation; n, number.

Serum cytokines could be analyzed in seven of the 15 cases. There was no significant association between serum baseline cytokine levels and the presence of lesions or severity of disease. Compared to baseline, TNF-α and IL-23 levels were significantly lower after apremilast treatment and IFN-γ levels were trending upwards; however, IL-6, IL-8, and IL-10 levels showed no constant trend (TNF-α and IL-23: p <0.05, IFN-γ: p = 0.078). In addition, the rate of decrease in serum IL-6, IL-10, and IL-23 levels was significantly greater in the OU-R group than in the OU-NR group (Figure 1). However, the rate of change in serum cytokines was not associated with efficacy of apremilast for skin lesions, arthralgia, or arthritis.

Figure 1.

The rate of change in serum interleukin (IL)-6, IL-10, and IL-23 levels up to 3 months after apremilast treatment in the oral ulcer remission group and the oral ulcer non-remission group.

Conclusion

Apremilast has shown long-term efficacy in the treatment of oral and genital ulcers in patients with BD. The efficacy of apremilast against oral ulcers in BD may be attributed to its modulatory effect on serum cytokines as previously reported. Future exploratory studies for biomarkers associated with the presence of efficacy against genital ulcer and arthritis are needed.

References

[1]Gottlieb AB, Matheson RT, Menter AM, et al. J Drugs Dermatol. 2013;12:888-97.

Disclosure of Interests

None declared

POS0794 PREGNANCY AND CHILDBIRTH IN TAKAYASU ARTERITIS IN JAPAN – A NATIONWIDE RETROSPECTIVE STUDY

Background

Takayasu arteritis (TAK), a granulomatous large vessel vasculitis, mainly involves the aorta and its proximal branches and commonly occurs in young females. However, studies of pregnancy in women with TAK are sparse and limited, probably due to the rarity of the disease.

Objectives

The purpose of this study was to understand the status quo of medical treatments of the primary disease and outcomes of pregnancy in patients with TAK, and birth outcomes of the children in Japan.

Methods

Patients with TAK who conceived after the onset of the disease and were managed at medical facilities participating in the Japan Research Committee of the Ministry of Health, Labour, and Welfare for Intractable Vasculitis (JPVAS) were retrospectively enrolled in this study. The following information was collected from patients who had a live-born baby: age at diagnosis of TAK, disease classification, age at delivery, treatments before and during pregnancy, complications during pregnancy, birth outcomes of the children, and changes in disease activity during pregnancy and after delivery.

Results

Fifty-one cases and 69 pregnancies from 19 ethics committee-approved centers were enrolled during the study period 2019–2021. Of these, 49 cases and 66 pregnancies (95.7%) resulted in delivery and live-born babies. The Numano classification of the 49 cases was as follows: type I, 11; type IIa, 15; type IIb,12; type III, 1; type IV, 1; type V, 9; with type IIa being the most common. The age of diagnosis was 22 years (13–37 years, year of diagnosis 1965–2017), the median age of the delivery of 66 pregnancies was 31 years (year of delivery 1969-2021), and the median duration of illness at delivery was nine years. There were 34 planned pregnancies (51.5%, including four pregnancies by artificial insemination/ovulation induction). Preconception therapy included prednisolone (PSL) in 51 pregnancies (77.3%, median dose 7.5 mg (range 4–30 mg)/day), immunosuppressive drugs in 18 pregnancies (27.3%, azathioprine 8, tacrolimus 7, methotrexate 4, cyclosporin A 1, and colchicine 1), biologics in 12 pregnancies (18.1%, infliximab 6, tocilizumab 5, and adalimumab 1), antihypertensive drugs in 5 pregnancies (7.6%). Surgical treatment had been performed before pregnancy in 6 cases (aortic root replacement 2, subclavian artery dilatation 1, subclavian artery bypass 1, subclavian artery stenting 1, and ascending aorta semicircular artery replacement 1). Medications used during the course of pregnancy included PSL in 48 pregnancies (72.7%, median dose 8 mg (range 4–30 mg)/day, increased in 13 pregnancies, decreased in 1 pregnancy), immunosuppressants in 13 pregnancies (19.7%, azathioprine 6, tacrolimus 6, and cyclosporin A 1), biologics 9 pregnancies (13.6%, infliximab 4, tocilizumab 4, and adalimumab 1). Immunosuppressants and biologics were discontinued in five and four pregnancies after conception. Complications during pregnancy were observed in 20 pregnancies (30.3%), with hypertension being the most common. Complications related to TAK or its treatment were severe infections in two pregnancies and aneurysm enlargement due to increased circulating plasma volume in one pregnancy. Aortic arch replacement was performed after delivery for the latter case. Relapse of TAK was observed in 4 pregnancies (6.1%) during pregnancy and in 8 pregnancies (12.1%) after delivery. One pregnancy resulted in restenosis of subclavian artery for which dilatation procedure was performed prior to the pregnancy. There were 13/66 (19.7%) preterm infants and 17/59 (28.8%) low birth weight infants; all but one had a birth weight of more than 2,000 g and no had serious postnatal abnormalities. Forty-three (82.7%) of the 52 confirmed infants were breastfeed fully or mixed.

Conclusion

Most of the pregnancies in patients with TAK were successfully delivered while they had low disease activity at a dose of less than 10 mg/day of PSL. Relapse occurred during pregnancy and after delivery in some cases. The babies tended to have low birth weight, but 82.7% of them were breastfed without serious complications.

Disclosure of Interests

Takako Miyamae: None declared, Yusuke Manabe: None declared, takahiko sugihara Speakers bureau: TS has received honoraria from Abbvie Japan Co., Ltd., AsahiKASEI Co., Ltd., Astellas Pharma Inc., Ayumi Pharmaceutical, Bristol Myers Squibb K.K., Chugai Pharmaceutical Co., Ltd., Eli Lilly Japan K.K., Mitsubishi-Tanabe Pharma Co., Ono Pharmaceutical, Pfizer Japan Inc., Takeda Pharmaceutical Co. Ltd., and UCB Japan Co., Grant/research support from: TS has received research grants from AsahiKASEI Co., Ltd., Daiichi Sankyo., Chugai Pharmaceutical Co., Ltd., and Ono Pharmaceutical., Natsuka Umezawa: None declared, Hajime Yoshifuji Speakers bureau: HY has received lecture fees from Janssen and Chugai., Naoto Tamura: None declared, Yoshiyuki Abe: None declared, Shunsuke Furuta Speakers bureau: Chugai Pharmaceutical Co.,Ltd.

DaiichiSankyo Co.,Ltd.

Asahi-Kasei Pharma Corporation, Manami Kato: None declared, Takashi Kumagai: None declared, Kaito Nakamura: None declared, Hiroko Nagafuchi: None declared, Jun Ishizaki: None declared, Naoko Nakano: None declared, Tatsuya Atsumi Speakers bureau: Mitsubishi Tanabe Pharma Co., Chugai Pharmaceutical Co., Ltd., Astellas Pharma Inc., Takeda Pharmaceutical Co., Ltd., Pfizer Inc., AbbVie Inc., Eisai Co. Ltd., Daiichi Sankyo Co., Ltd., Bristol-Myers Squibb Co., UCB Japan Co. Ltd., Eli Lilly Japan K.K., Novartis Pharma K.K., Eli Lilly Japan K.K., Kyowa Kirin Co., Ltd.,TAIHO PHARMACEUTICAL CO., LTD., Consultant of: AstraZeneca plc., MEDICAL & BIOLOGICAL LABORATORIES CO., LTD., Pfizer Inc., AbbVie Inc., ONO PHARMACEUTICAL CO. LTD.,

Novartis Pharma K.K., Nippon Boehringer Ingelheim Co., Ltd., Grant/research support from: Astellas Pharma Inc., TAIHO PHARMACEUTICAL CO., LTD.AbbVie Inc., Nippon Boehringer Ingelheim Co., Ltd.,Takeda Pharmaceutical Co., Ltd., Mitsubishi Tanabe Pharma Co., Chugai Pharmaceutical Co., Ltd., Daiichi Sankyo Co. Ltd., Otsuka Pharmaceutical Co., Ltd. and Pfizer Inc. Alexion Inc., TEIJIN PHARMA LIMITED., Kohei Karino: None declared, Koichi Amano Speakers bureau: AbbVie GK, Asahi-Kasei Pharma, Astellas, Chugai Pharmaceutical Co.Ltd., Eisai, Eli Lilly, GlaxoSmithKlein, Janssen Pharma, Pfizer Japan, Grant/research support from: Asahi-Kasei Pharma,Chugai Pharmaceutical Co.Ltd., Takahiko Kurasawa: None declared, Shuichi Ito: None declared, Ryusuke Yoshimi: None declared, Noriyoshi Ogawa: None declared, Shogo Banno: None declared, Taio Naniwa Speakers bureau: Chugai, Tanabe, Abbbvie, Eisai, Grant/research support from: Chugai, Tanabe, Abbbvie, Eisai, Satoshi Ito Speakers bureau: SI has received speaker’s fees from pharmaceutical companies., Akinori Hara: None declared, Shinya Hirahara: None declared, Haruhito A. Uchida: None declared, Yasuhiro Onishi: None declared, Yohko Murakawa Speakers bureau: Astellas, UCB, Chugai, AbbVie, Grant/research support from: Chugai, AbbVie, Yoshinori Komagata: None declared, Yoshikazu Nakaoka: None declared, Masayoshi Harigai Speakers bureau: MH has received speaker’s fee from AbbVie Japan GK, Ayumi Pharmaceutical Co., Boehringer Ingelheim Japan, Inc., Chugai Pharmaceutical Co., Ltd., Eisai Co., Ltd., Janssen Pharmaceutical K.K., Kissei Pharmaceutical Co., Ltd., Novartis Japan, Pfizer Japan Inc., Mitsubishi Tanabe Pharma Co., Teijin Pharma Ltd and UCB Japan., Consultant of: MH is a consultant for AbbVie, Boehringer-Ingelheim, Kissei Pharmaceutical Co., Ltd., and Teijin Pharma.

AB0442 EVEN IN SYSTEMIC LUPUS ERYTHEMATOSUS THAT HAS ACHIEVED SUSTAINED LLDAS, ADDITIONAL ADMINISTRATION OF HYDROXYCHLOROQUINE SHOULD BE CONSIDERED

Background

Hydroxychloroquine (HCQ) therapy is recommended as a baseline treatment for all patients with systemic lupus erythematosus (SLE) due to its various benefits (1). However, it is not clear to what extent HCQ contributes to improvement in SLE patients with stable disease activity. It has also been reported that HCQ is effective in improving the prognosis of life caused by atherosclerotic lesions in SLE, but the mechanism of this effect has not been fully elucidated.

Objectives

The purpose of this study was to determine the benefit of additional HCQ administration in SLE with controlled disease activity, who achieved the sustained LLDAS.

Methods

The study included patients with SLE who started additional HCQ treatment between January 2016 and December 2019 at our institution, those who sustained LLDAS achievement for at least 3 months prior to starting HCQ treatment. These patients did not change their immunosuppressant and glucocorticoid regimens for more than three months after starting HCQ. The effect of HCQ was assessed at the beginning and 3 months after administration. The disease activity was measured by SELENA-SLEDAI, SLE-DAS, and immunoserological parameters including serum complement levels and anti-DNA antibodies. The factors that are known to associated with pathogenesis of atherosclerosis, such as serum TNF-α, IL-6, IL-8, MCP-1, adiponectin, leptin, resistin, S100A8, and S100A9, were measured by ELISA.

Results

Of the 110 SLE patients who received additional HCQ at our institution, 27 patients who had achieved LLDAS from at least 3 months prior to HCQ administration were included in this study. Patient characteristics are represented in Table 1. SLEDAI scores, SLE-DAS scores and serum anti-dsDNA antibodies were observed to be significantly reduced after HCQ treatment compared to baseline. After 3 months of HCQ treatment, serum lipid markers such as triglyceride (TG), low-density lipoprotein (LDL) cholesterol and atherosclerotic index, which are associated with the development of atherosclerosis, were significantly reduced compared to baseline (TG, LDL and atherosclerotic index: p<0.05). Cytokines such as TNF-α, IL-6, MCP-1, S100A8, S100A9, leptin, and resistin were found to be significantly decreased, and serum adiponectin was significantly increased. (TNF-α, IL-6, MCP-1, leptin: p < 0.05. S100A8, S100A9, adiponectin, resistin: p < 0.0001, Figure 1).

Table 1.

Characteristics of patients with SLE enrolled in this study.

CharacteristicsN = 27Female, no. (%)24 (88.9)Age, years, mean ± SD44.4 ± 11.6Disease duration, years, mean ± SD18.3 ± 12.2BMI, mean ± SD21.9 ± 3.0Concomitant immunosuppressive treatmentsPrednisone, no. (%)n = 23Median dosage, mg/day#5 (3.0–5.0)Triglyceride, mg/dL#102 (73–149)High-density lipoprotein cholesterol, mg/dL#59 (43–66.5)Low-density lipoprotein cholesterol, mg/dL#108 (96–122)Arteriosclerotic index#2 (1.7–2.5)Disease activitySLEDAI score#4 (2–4)SLE-DAS score#2.076 (1.12–3.50)Anti-dsDNA antibody, IU/ml#5.2 (5–15.6)dsDNA positive, no. (%)10 (37.0)C3, mg/dL#76 (61–100)C4, mg/dL#14 (10–22)CH50, U/mL#34.1 (29.7–39.6)

#Nonparametric distributions were represented as median (interquartile range). Anti-dsDNA positive means that anti-dsDNA titer increases to >12 IU/mL.

Figure 1.

Serum cytokine levels before and after hydroxychloroquine treatment

Serum levels of the indicated cytokines and factors were measured at baseline and after 3 months (3M) of treatment with HCQ. The gray lines show the values for individual patients, and the thick red line shows the average value. P-values were determined using the Wilcoxon signed-rank test. A p-value of less than 0.05 was considered statistically significant.

Conclusion

The addition of HCQ medication to SLE patients who achieve the clinical therapeutic goal of LLDAS without HCQ may prevent progression of atherosclerosis in addition to further reducing disease activity.

References

[1]Fanouriakis A, Kostopoulou M, Alunno A, et al. Ann Rheum Dis. 2019;78:736-745.

Disclosure of Interests

None declared

AB0201 INTAKE OF FISH RICH IN n-3 POLYUNSATURATED FATTY ACIDS IS ASSOCIATED WITH GOOD RESPONSE TO TREATMENT IN RHEUMATOID ARTHRITIS PATIENTS RECEIVING TARGETED THERAPIES

Background

The management of rheumatoid arthritis (RA) has been transformed by the use of molecular targeted therapies. Early treatment and treat-to-target approach leads to good clinical response and remission (responders), but not in all patients.

Environmental factors including diet contribute to the development, activity and severity of RA. Evidence from clinical trials suggested that dietary interventions, such as Mediterranean diet or supplementation with fish oil rich in n-3 polyunsaturated fatty acids (n-3 PUFA), have positive effects on RA. Japanese and Mediterranean diets are associated with longevity and characterized by high fish intake. Clinical studies have identified predictors of treatment response in individual RA patients, however, the influence of fish consumption on treatment response in RA patients treated with targeted therapies has not been elucidated.

Objectives

To assess whether fish consumption is associated with a good response to targeted therapies in RA patients with Japanese and Mediterranean dietary patterns.

Methods

The study is a collaborative international cross-sectional retrospective study enrolling patients with RA on treatment with biologics or JAK inhibitors attending to Hokkaido University Hospital, Japan or Hospital Virgen de las Nieves, Spain.

Enrolled patients were asked to complete a brief-type self-administered diet history questionnaire (BDHQ) and a detailed fish frequency questionnaire (DFFQ) referring to consumption frequency in the previous month. At study entry, alcohol consumption, tobacco habits, educational level and employment status were recorded and RA disease activity evaluated by qualified rheumatologists. Demographic, clinical/laboratory data were retrospectively extracted from the medical records.

By December 2021, 279 patients (Japan 217, Spain 62) returned the questionnaires. A preliminary analysis was carried out with the first 58 Japanese patients in which all clinical and laboratory data could be collected. A descriptive analysis was performed and the relative risks approximated by odds ratios.

Results

Fifty-eight Japanese RA patients, 45 females, median age at entry 66 yrs [IQR 54-73], median disease duration 11yrs [IQR 7-20] were included in this analysis. Fifty-three (93%) of patients were on biologic therapies and four (7%) on JAK inhibitors with a median treatment duration of 4.5 yrs [IQR 1-7]. Concomitant treatment with conventional DMARDS and glucocorticoids were reported in 69% and 48% of patients, respectively. Forty-two (72%) patients were responders to treatment defined as DASESR ≦3.2. Another systemic autoimmune disease, hypertension, diabetes mellitus, dyslipidemia or gout history were present in 29%, 29%, 9%, 33% and 10% of patients, respectively.

All patients had consumption of fish in the last month and an intake of n3-PUFA rich fish (fatty fish) was indicated by 82% (<1 time/week 34%, ≧ 1 time/week 48%).

The patients’ fatty and non-fatty fish intake scores were calculated with a mathematical formula based on the intake of each of the fish included in the DFFQ and number of responses. In the group of high fatty fish score patients (≧ 1 time/week) 94% were responders to treatment vs. 6% non-responders, [OR 8.75, CI [1.0-73.54, p= 0.022] while only 63% of patients in the high non-fatty fish score group respond to the treatment.

Conclusion

Fatty fish intake associated with a good response to treatment in patients receiving targeted therapies, suggesting that fish consumption may have some beneficial effects on RA treatment.

References

There is no reference.

Acknowledgements

Acknowledgements to Ms. Y. Ikea and S. Kumagai for their enriching support on the nutritional properties of fish. Supported by the Kakenhi C grant number 20K11597 from the Japan Society for the Promotion of Science.

Disclosure of Interests

None declared

POS0822 HYPERTROPHIC PACHYMENINGITIS IN ANTINEUTROPHIL CYTOPLASMIC ANTIBODY-ASSOCIATED VASCULITIS: A MULTICENTER SURVEY IN JAPAN

Background

Hypertrophic pachymeningitis (HP), characterized by an inflammatory disorder indicating intracranial or spinal thickening of dura mater, is found to develop as a neurological involvement in antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV). Meanwhile, the previous studies focusing on HP in AAV have been reported as a single-institution study, and the analyses were performed in a small number of patients because HP is a rare neurological disorder. Therefore, neither etiological nor clinical characteristics of HP in AAV have been adequately elucidated.

Objectives

This study clarified the characteristics of HP in AAV by analyzing the information of multicenter study in Japan (Japan collaborative registry of ANCA-associated vasculitis: J-CANVAS).

Methods

We analyzed the clinical information from 541 Asian patients with AAV enrolled in J-CANVAS. Of them, newly diagnosed and relapsed AAV were included in 448 and 93, respectively. The epidemiological and clinical findings were compared between patients with and without HP. Clinical manifestations related to AAV were evaluated based on the Birmingham Vasculitis Activity Score version 3. To elucidate independent factors in HP development, logistic regression analyses were additionally performed.

Results

Of the total 541 patients (mean age: 71±14 years, M:F = 1:1.2), HP was demonstrated in 28 (5.17%), including 17 (3.79%) in newly diagnosed AAV and 11 (11.8%) in relapsed AAV. The classification of granulomatosis with polyangiitis (GPA) was significantly higher in patients with HP than those without HP (50% vs. 21%, p = 0.0007). In newly diagnosed AAV, patients with HP significantly had higher GPA classification and higher positivity for PR3-ANCA than those without HP (53% vs. 17%, p = 0.001; 29% vs. 9%, p = 0.015, respectively). Conversely, positivity for MPO-ANCA was significantly higher in patients with HP than those without HP in relapsed AAV (91% vs. 55%, p = 0.025), despite not significantly different in the classification of AAV. Headache and cranial neuropathies were significant neurological symptoms in patients with HP compared to those without HP (82% vs. 6.6%, p < 0.0001; 32% vs. 2.9%, p < 0.0001, respectively). Besides, ear, nose and throat (ENT) and mucous membranes/eyes were significantly higher involvements in patients with HP than in those without HP (54% vs. 26%, p = 0.003; 29% vs. 9%, p = 0.003, respectively). Moreover, higher complications of “conjunctive hearing loss” and “sudden visual loss”, which are included in the categories of ENT and mucous membranes/eyes involvement, respectively, were significantly indicated in patients with HP than those without HP (39% vs. 7.2%, p < 0.0001; 21% vs. 1.2%, p < 0.0001, respectively). Multivariable logistic regression analysis identified that ENT (odds ratio [OR] 1.28, 95% confident interval [CI] 1.09 to 1.49, p = 0.002) and mucous membranes/eyes involvement (OR 1.37, CI 1.14 to 1.65, p = 0.0006), as well as conjunctive hearing loss (OR 4.52, CI 1.56 to 13.05, p = 0.005) and sudden visual loss (OR 1.84, CI 1.12 to 3.00, p = 0.015), were independent related factors in patients with HP.

Conclusion

GPA could be significantly classified in patients with HP. Notably, patients with HP significantly showed higher positivity for PR3-ANCA than those without HP in newly diagnosed AAV. Furthermore, sudden visual loss and conjunctive hearing loss might be implicated in HP development.

Disclosure of Interests

None declared

POS0915 MYOSITIS-SPECIFIC AND ASSOCIETED ANTIBODIES, ESPECIALLY ANTI-ARS ANTIBODIES AND ANTI-Ro52 ANTIBODY MAY PREDICT THE CHARACTERISTICS AND FIBROSING PROGRESS OF INTERSTITIAL LUNG DISEASE WITH DERMATOMYOSITIS / POLYMYOSITIS

Background

Myositis-associated antibodies (MAA) and myositis-specific antibodies (MSA) have been associated with clinical manifestations of dermatomyositis and polyneuropathy, including interstitial lung disease (ILD), myopathy, malignancy, arthritis, and skin rashes. Among them, anti-ARS and anti-MDA5 antibodies are strongly associated with complications of ILD that are associated with life expectancy. It has been reported that anti-Ro52 antibody affects severity of myositis and ILD. (1) Based on these findings, it is possible that autoantibodies possessing features of ILD associated with dermatomyositis and polymyositis may be predictive.

Objectives

The purpose of this study is to clarify the relationship between MSA/MAA and clinical features of ILD complicated by dermatomyositis and polymyositis.

Methods

We retrospectively analyzed IIMs patients diagnosed according to Peter & Bohan’s diagnostic criteria in our hospital from 2011 to 2018. The presence of 14 MSA / MAA (Jo1, PL12, PL7, EJ, OJ, KS, Mi2, MDA5, TIF1γ, SRP, PM-Scl70, 100, Ku, Ro52) was measured using ELISA (MESACUP, MBL, Japan) and line blot (EUROLINE myositis profile3, EUROimmun, Germany). Clinical characteristics, including HRCT imaging findings, were extracted from medical records. HRCT imaging findings were analyzed by multiple radiologists. The association between the extracted clinical features and the MSA / MAA held was analyzed.

Results

Seventy-eight cases of IIM were included in the analysis. The frequency of ILD complications was 53/78 (68%), and 60% of ILD complications were ARS antibody positive. The complication rate of ILD in MDA5- and ARS-positive cases was 100% (3/3 cases) and 94% (32/34 cases), respectively. These MDA5- and ARS-positive patients with ILD had rapidly progressive ILD. One of the three MDA5 antibody-positive RPILD cases died, but none of the four ARS antibody-positive RPILD cases died. However, in patients with multiple MSA or MAA including ARS, three case had rapidly progressive ILD, and none died. n the analysis of the presence of Ro52 antibody, it was detected in 46% (36 cases) of all cases, but in 74% of anti-ARS antibody positive cases.

In the analysis of ILD patterns by radiologists using HRCT, fibrosing NSIP (fNSIP), fibrosing OP (fOP), and UIP were the most frequent in that order. analysis of the association between ILD patterns and MSA / MAA showed that there was no MSA / MAA associated with each ILD pattern. No MSA/MAA was found to be associated with each ILD pattern. ARS antibody-associated ILD, the most common type of ILD, had a worse prognosis than other MSA / MAA positive ILD. Death due to ILD was observed in 5 patients (PL7: 3cases, PL12: 1case, PM-Scl75: 1case). Oxygen was required for ILD progression in 3 Jo1-positive patients, 1 PL7-positive patients, and 1 PL12-positive patient, respectively. The frequency of UIP, which is considered to have a poor prognosis in other rheumatic diseases, was higher in patients with anti-ARS and anti-Ro52 antibodies.

Conclusion

The prognosis of anti-ARS antibody-positive lLD associated with dermatomyositis and polymyositis was associated with fibrosis by analysis of HRCT patterns, and the prognosis was confirmed to be poor.In addition, the UIP pattern, which is strongly associated with fibrosis, was found to be associated with anti-Ro52 antibody. In the treatment of ILD, which is strongly associated with the prognosis of dermatomyositis and polymyositis, it may be necessary to consider antifibrotic treatment for patients with anti-ARS antibody and anti-Ro52 antibody positivity.

References

[1]Tamara Vojinovic et al. Predictive Features and Clinical Presentation of Interstitial Lung Disease in Inflammatory Myositis. Clinical Reviews in Allergy & Immunology (2021) 60:87–94

Disclosure of Interests

None declared

AB0625 Association between Cytomegalovirus Reactivation and Renal Prognosis during Remission Induction Therapy for ANCA-Associated Vasculitis

Background

Cytomegalovirus (CMV) has been associated with atherosclerosis in patients with chronic renal failure, and may cause secondary nephrotic syndrome. Therefore, we hypothesized that the reactivation of CMV by immunosuppressive therapy in patients with vasculitis may affect renal function.

Objectives

The purpose of this study was to investigate relationships between CMV infection and renal function during ANCA-associated vasculitis remission induction therapy.

Methods

This retrospective cohort study enrolled microscopic polyangiitis (MPA), granulomatosis with polyangiitis (GPA), and eosinophilic granulomatosis with polyangiitis patients at 25 sites in Japan who had a first or severe relapse between January 2017 and June 2020. Of these, patients with MPA or GPA who had a positive renal lesion score on BVAS (version 3) at baseline, or vasculitis findings on renal biopsy, CMV assayed by 48 weeks of treatment, were included. Patients were divided into two groups based on the presence or absence of a positive CMV antigen test during the remission induction phase (0–48 weeks of treatment). Outcomes were the rate of change in estimated glomerular filtration rate (eGFR) at 48 weeks after initiation of treatment in both groups, as determined by (eGFR at 48 weeks - eGFR at the initiation of treatment)/eGFR at the initiation of treatment; where lower values were associated with worse renal function. General linear models adjusted for age, gender, presence of diabetes or chronic kidney disease, and the use of rituximab or cyclophosphamide were generated.

Results

A total of 387 patients had CMV antigen measured during ANCA-associated vasculitis treatment, of which 164 had renal involvement and eGFR measured at 48 weeks. Seventy-seven (47.0%) were male and the median age was 75 years (range 69–80 years). CMV reactivation was observed in 44 patients (26.8%). The beta coefficient of multiple regression analysis with CMV positive as 1 and negative as 0 was 0.08 (95% confidence interval -0.13 to 0.29) (p = 0.47). The rate of change in eGFR was higher in the CMV positive group, but not statistically significantly.

Conclusion

Contrary to our hypothesis, renal prognoses tended to be better when CMV reactivation was observed. The patients in the CMV reactivation group may have been treated more aggressively, and some patients with a poor prognosis who were not followed up for 48 weeks dropped out. Further research investigating the adjustment of treatment methods is required.

Disclosure of Interests

None declared

POS0247 GLUCOCORTICOID TAPERING STRATEGY FOR ANCA-ASSOCIATED VASCULITIS: ADDRESSING THE GAP BETWEEN RECOMMENDATIONS AND REAL-WORLD PRACTICE

Background

Antineutrophil cytoplasmic antibody -associated vasculitis (AAV) is usually treated with combination of high-dose glucocorticoid (GC) and immunosuppressive agents, followed by tapering GC dose. Although the European League Against Rheumatism (EULAR) has specific recommendations for tapering the GC dose, clinicians often taper it slower than recommended due to concerns of potential disease relapse. However, such slower taper may prolong GC exposure for the patients, increasing the risk of adverse events, particularly infection.

Objectives

The aims of our study were (1) to clarify GC dose tapering in the treatment of AAV in a real-world setting, in contrast to the EULAR recommendation of 2015 and (2) to compare the incidence of AAV relapse and severe infection between patients underdoing EULAR-recommended tapering and those undergoing slower tapering than the recommendation.

Methods

In this multicenter (25 sites in Japan), observational, retrospective study of AAV, 541 patients who had initial or severe relapse were enrolled between January 2017 and June 2020. Of these, 349 patients with microscopic polyangiitis (MPA) or granulomatosis with polyangiitis (GPA) who entered in GC tapering phase after successful induction treatment were included. These patients were then grouped on the pace of GC tapering, defined as the GC dose at 12 weeks after treatment initiation: (1) EULAR group: 7.5-10 mg/day of GC, according to the EULAR recommendation of 2015, and (2) SLOWER group: >10 mg/day of GC. Their baseline characteristics and clinical outcomes were compared. Primary outcome was defined as relapse-free days from treatment initiation, whereas secondary outcome included the incidence of infectious events requiring hospitalization within 48 weeks from treatment initiation. Multivariable analysis was performed to assess the relationship between tapering pace and clinical outcomes.

Results

There were 44 patients (12.6%) in the EULAR group and 290 (83.2%) in the SLOWER group. Regarding baseline characteristics, compared with the EULAR group, the SLOWER group had significantly higher serum C-reactive protein level (EULAR, 5.89 ± 6.89 mg/dL vs SLOWER, 7.56 ± 6.01 mg/dL; p = 0.03), as well as a trend toward higher Birmingham Vasculitis Activity Score (version 3) (EULAR, 11.80 ± 7.01 SLOWER, 13.93 ± 7.06; p = 0.08) We did not observe any significant differences in the frequency of relapses between the two groups (EULAR, 8/44, 18.2% vs SLOWER, 55/290, 19.0%; p = 0.63). Multivariable Cox proportional hazard analysis revealed no relationship GC dose at 12 weeks from treatment initiation and incidence of relapse. However, upon logistic regression analysis, the SLOWER group was found to have significant higher risk of a severe infectious event within 48 weeks from treatment initiation (p = 0.046; hazard ratio, 1.27; 95% confidence interval, 1.004 – 1.601).

Conclusion

Our finding indicates that clinicians tended to taper GC slower for patients with higher disease activity. However, slower GC taper was not found to reduce the frequency of relapse. In addition, slower GC taper was found to increase the risk of a severe infection. Hence, clinicians should pay attention not only relapsing but also late GC taper resulting in the risk of serious infection, especially in patients with higher disease activity of AAV.

References

[1]Eur J Clin Invest 2015;45 (3): 346–368.

[2]Rheumatology (Oxford). 2021 Dec 24;61(1):205-212.

[3]Arthritis Res Ther. 2021 Mar 20;23(1):90.

[4]Scand J Rheumatol. 2022 Jan 20;1-13.

[5]J Rheumatol. 2018 Apr;45(4):521-528.

[6]Rheumatol Adv Pract. 2021 Mar 9;5(3):rkab018.

[7]Ann Rheum Dis. 2016 Sep;75(9):1583-94.

Figure 1.

Acknowledgements

We would like to thank Editage (www.editage.com) for English language editing.

Disclosure of Interests

None declared

AB0438 EFFICACY OF BELIMUMAB TREATMENT FOR SYSTEMIC LUPUS ERYTHEMATOSUS AT OUR HOSPITAL

Background

Belimumab (BEL), a monoclonal antibody against the soluble counterpart of B-cell activating factor (BAFF) has been recommended to be added in patients with SLE who do not respond adequately to standard therapy [1]. In addition to antibody production, belimumab may also affect other functions of B cells, such as antigen presentation and excretion of inflammatory cytokines. Belimumab may also have an effect on immune cells other than B cells, as they express BAFF receptors. These facts suggest that BEL administration in SLE may have an effect on various pathological conditions including cytokine production, not just antibody production. However, there are few reports on whether cytokine production is actually related to the efficacy of BEL administration in SLE.

Objectives

The purpose of this study was to determine the efficacy of BEL administration in patients with SLE and its effect on cytokines.

Methods

Patients with SLE who were started on BEL between December 2018 and December 2021 at our institution were included in this study. We retrospectively analyzed the reasons for additional BEL administration, adverse events, disease activity indicators (SLE Disease Activity Index (SLEDAI)-2K, lupus low disease activity state (LLDAS) achievement rate, anti-dsDNA antibody titer, serum complement titer, and treatment agents including glucocorticoid dose. Serum cytokine (interferon-alpha, interleukin (IL)-6, IL-10, and IL-17A) levels were measured using ELISA at the start of BEL administration, 3 months, and 6 months later.

Results

Five cases of SLE were included in the study. Four of the five patients were female, with a mean age of 51.4±9.6 years and a mean duration of disease of 17.4±10.0 years.

The reasons for additional BEL administration were glucocorticoid reduction in five patients, refractory pericarditis in one patient, skin rash and arthritis in two patients, and immunological activity in two patients. Four of the five patients had decreased renal function below eGFR50 at the baseline. Concomitant medications at the time of BEL induction included steroids in five patients (mean prednisolone dose 12.2±12.2 mg/day), hydroxychloroquine in three patients, mycophenolate mofetil in three patients, tacrolimus in one patient, and methotrexate in one patient. The mean disease activity before the introduction of BEL was SLEDAI 4±4, and LLDAS was achieved in three patients.

Twelve weeks after the start of BEL treatment, two patients had improved SLEDAI, including one patient who achieved LLDAS.

Immunological activity parameters improved in one of the two patients.

However, two patients flared after BEL administration and were treated with increased glucocorticoid doses.

One patient with SLE on hemodialysis had thrombocytopenia, an adverse event that may have been related to belimumab treatment.

Conclusion

At our institution, BEL was additionally administered to SLE patients with refractory disease and was effective; with the exception of one case. Serum cytokine analysis before and after BEL treatment will be included in the discussion.

References

[1]Fanouriakis A, Kostopoulou M, Alunno A, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann. Rheum. Dis. 2019;78:736–745.

[2]Parodis I, Åkerström E, Sjöwall C, et al. Autoantibody and Cytokine Profiles during Treatment with Belimumab in Patients with Systemic Lupus Erythematosus. Int J Mol Sci. 2020;21:3463.

Disclosure of Interests

None declared

AB0397 DISEASE ACTIVITY OF RHEUMATOID ARTHRITIS WERE SIGNIFICANTLY DECREASED BY SWITCHING JAK INHIBITOR TO ANOTHER JAK INHIBITOR

Background

With the availability of multiple Jak inhibitors (JAKi) for treatment, patients with RA who have had inadequate response to conventional therapies, including biologics, can now achieve favorable outcomes such as remission and low disease activity.

However, it is also true that no single JAKi therapy is effective for all RA.

Some RA treatment guidelines recommend a switch strategy from current JAKi to other JAKi or biologics in patients with inadequate response to JAKi therapy [1].

There is insufficient evidence to support the efficacy of switching to another JAKi in patients with inadequate JAKi response (JAKi-IR).

Objectives

The aim of this study is to clarify the effectiveness of the strategy of controlling disease activity by switching to other JAKi in RA cases with JAKi-IR and to analyze the effect on serum cytokines related to the pathogenesis of RA.

Methods

RA patients who switched to other JAKi during treatment with JAKi between September 2017 and January 2022 were included in this retrospective study.

The clinical characteristics of the included RA patients were collected from their medical records.

The efficacy of the JAKi switch strategy was assessed by changes in composite measure scores of disease activity, including DAS28-CRP, SDAI, and CDAI, at 4 and 12 weeks after the switch.

In addition, changes of serum cytokines associated with RA pathogenesis (IL-6, TNF-α) were measured and analyzed by ELISA (Simple Plex, Protein Simple).

Results

Twenty-nine RA patients who received the JAKi switch treatment strategy were included in the analysis. The clinical characteristics of the included patients are shown in Table 1. All patients were receiving JAKi due to inadequate response to biologics. JAKi were switched to control disease activity including 3 cases (10%) who achieved temporary remission.

Table 1.

Baseline characteristics of the 29 patients enrolled this study

Clinical characteristicsn=29Age57 [48.0-66.0]Sex (F/M)22/7 (75.9)Disease duration, years13 [8.6-18.8]RF positive26 (89.7)ACPA positive, (n=22)20(90.0)Concomitant medicationsMethotrexate, dose(mg/week)10 (34.5), 8.0 [6.0-10.5]Corticosteroid, dose(mg/day)17 (59.0), 4.0 [2.0-5.0]Disease activity  DAS28-CRP3.77 [3.2-4.6]  SDAI15.5 [9.8-21.1]  CDAI14.5 [9.5-20.0]Patient global assessment of disease activity (mm)40 [25-58]Provider global assessment of disease activity (mm)32 [15-40]CRP (mg/dl)0.9 [0.1-1.7]TJC/SJC4 [2-5], 2[2-5]Date are n (%) or median [IQR].

Figure 1 shows the effect of the JAKi switch strategy on the disease activity category.

Evaluation using SDAI showed that 65% of patients achieved the immediate treatment goal of low disease activity at 4 weeks after switch, and 69% of patients maintained this goal at 12 weeks. SDAI remission was also observed in 17% of patients at 4 weeks and 31% at 12 weeks, demonstrating the efficacy of the JAKi switch strategy. The efficacy of the JAKi switch strategy was also observed in other measures of disease activity.

Changes in serum cytokines (IL-6, TNF-α) associated with disease activity in RA before and after JAKi switch were analyzed in 10 patients. Regardless of the type of JAKi, serum IL-6 was decreased by JAKi switch in most cases at 12weeks (average change of serum IL-6: -27.25pg/ml).

However, no trend was observed for changes in serum TNF- disease acti（average change of serum TNF-ed for change）.

There was no clear association between changes in these two cytokines and the efficacy of the JAKi switch strategy.

Conclusion

The composite disease activity index showed that about 60% of JAKi-IR patients achieved low disease activity, one of the treatment goals, at 4 weeks after switching to JAKi, and the effect was maintained up to 12 weeks. This effect did not appear to be related to the type of JAKi.

The effects of biologic therapy on serum cytokines associated with RA activity differed from the effects of the JAKi switch strategy.

References

[1]György Nagy, et al. EULAR points to consider for the management of difficult-to-treat rheumatoid arthritis. Annals of the Rheumatic Diseases 2022;81:20-33.

Disclosure of Interests

None declared

AB0689 Clinical courses and pregnancy outcomes of eight cases complicated with Polymyositis/Dermatomyositis (PM/DM) in single center

Background

Pregnancies complicated by a number of rheumatic diseases are known to be at high risk for the occurrence of adverse pregnancy outcomes (APOs). There have been several reports on the risk of APOs in systemic lupus erythematosus and rheumatoid arthritis, but few reports on polymyositis (PM)/dermatomyositis (DM) pregnancies. There are also insufficient reports on changes in the activity of PM/DM during pregnancy. Based on the findings reported in other rheumatic diseases, it is suggested that increased activity during pregnancy is associated with APOs in PM/DM (1-3).

However, the risk factors for pregnancy outcome in pregnancies complicated by PM/DM, including the presence or absence of worsening of disease activity, have not been clarified.

Objectives

The purpose of this study was to analyze a case series of PM/DM complicated pregnancies in a single center to determine the changes in disease activity during pregnancy and pregnancy outcomes.

Methods

PM/DM patients who were managed from pregnancy to delivery at Kagawa University Hospital from March 2006 to May 2021 were included in this study. Clinical indices including duration of illness, disease activity, and treatment were extracted from medical records and retrospectively analyzed for association with pregnancy outcome.

Results

Eight PM/DM pregnancies were included in the analysis. The mean age at delivery was 28.3±3.8 years and the mean duration of disease was 6.3±3.2 years.

Treatment at the time of pregnancy included glucocorticoids (GC) in 7 cases and immunosuppressive drugs in 5 cases.

Creatinine phosphokinase (CK) levels were normal in all patients at the time of pregnancy, but increased during pregnancy in 4 (50%) patients. These 4 patients with elevated CK required treatment with increasing doses of GC, and the mean GC dose during pregnancy was 10.9 ± 6.0 mg/day.

Table 1 shows the pregnancy outcomes of the 8 patients. There was one spontaneous abortion and seven live births. Among the live births, 2 were preterm and 4 were low birth weight. The mean gestational age at delivery was 35.3±5.2 weeks and the mean birth weight was 2297.7±1041.4g.

Table 1.

Pregnancy outcomes of eight cases

Case no.OutcomeMode of deliveryGestational age at delivery (weeks)Birth weight of the newborn (grams)Adverse pregnancy outcomes1Live birthCesarean section26590Preterm birth, LFD, HELLP syndrome2Spontaneous abortion3Live birthTransvaginal delivery301,299Preterm birth, LBW4Live birthCesarean section382,765Hypertensive disorder5Live birthTransvaginal delivery373,290−6Live birthTransvaginal delivery372,492LBW7Live birthTransvaginal delivery393,456−8Live birthTransvaginal delivery402,192LBW7 live births 1 abortion35.3±5.22,297.7±1,041.4

The birth outcomes of the 2 patients who received continuous immunosuppressive therapy were full-term and normal weight infants. APOs, such as preterm delivery and low birth weight, occurred in cases with increased CK levels and increased GC doses.

Conclusion

In pregnancies of PM/DM patients, pregnancy outcome was less than favorable.

An association between disease activity and the development of APOs during pregnancy in PM/DM was suggested. An association was also suggested between GC dose and the risk of developing APOs.

As in other rheumatic disease pregnancies, continued use of pregnancy-appropriate immunosuppressive drugs and control of disease activity with lower glucocorticoid doses in PM/DM pregnancies may be important to achieve good pregnancy outcomes.

References

[1]Nagy-Vincze M, Vencovsky J, Lundberg IE, Danko K (2014) Pregnancy outcome in idiopathic inflammatory myopathy patients in a multicenter study. J Rheumatol 41:2492-2494.

[2]Zhong Z, Lin F, Yang J, Zhang F, Zeng X, You X (2017) Pregnancy in polymyositis or dermatomyositis: retrospective results from tertiary centre in China. Rheumatology (Oxford) 56:1272-1275.

[3]Kolstad KD, Fiorentino D, Li S, Chakravarty EF, Chung L (2018) Pregnancy outcomes in adult patients with dermatomyositis and polymyositis. Semin Arthritis Rheum 47:865-869.

Disclosure of Interests

None declared

AB0497 IMMUNOLOGICAL DISEASE ACTIVITY PARAMETERS AT CONCEPTION ARE RISK FACTORS FOR PRETERM BIRTH AND LOW BIRTH WEIGHT IN PATIENTS WITH SYSTEMIC LUPUS ERYTHEMATOSUS

Background

Women with systemic lupus erythematosus (SLE) are known to have more difficulty in achieving a successful pregnancy than healthy women. They have a higher risk for adverse pregnancy outcomes (APOs) including preterm birth (PB), low birth weight (LBW). (1,2). Many reports revealed that these APOs are related to uncontrolled high disease activity (3,4). Therefore, it is important for SLE women who hope to conceive to control disease activity strictly. However, it is not clear to what extent disease activity should be strictly controlled, including serum parameters such as complement levels and anti-dsDNA antibodies.

Objectives

The purpose of this study was to determine whether disease activity parameters at conception could be a risk factor for PB or LBW among APOs in patients with SLE.

Methods

Disease activity parameters including SLEDAI score, LLDAS achievement rate, serum complement levels (C3, C4, CH50), and anti-dsDNA antibody titer were retrospectively collected from medical records. We then collected information related to each APOs (PB and LBW), and analyzed the association with disease activity parameters.

Results

The subjects were 60 pregnancies of 45 patients. As for a comprehensive disease activity index at conception, SLEDAI score or the rate of LLDAS achievement became risk factors for PB (both of p<0.01, Table 1), and SLEDAI score was also a risk factor for LBW (P=0.04, Table 1). Analysis of immunological disease activity parameters showed that low C3 or high titer of anti-dsDNA antibody were risk factors for PB (P=0.03 and 0.01, respectively, Table 1). In the logistic regression analysis of PB, the cut-off levels of C3 and anti-dsDNA antibody were 62 mg/dl and 5.4 IU/ml, respectively (Figure 1 [1]-A, [1]-D). The risk of PB was significantly higher in the cases with low serum C3 and high anti-dsDNA antibody titer at conception (P=0.02).Similarly, low C3 or CH50 were risk factors for LBW (P=0.02 and 0.03, respectively, Table 1). Logistic regression analysis for LBW showed the cut-off level of C3 as 87 mg/dl, and CH50 as 41.8 IU/ml (Figure 1 [2]-A, [2]-C). Cases with low C3 and low CH50 were at higher risk for LBW (P=0.03).

Table 1.

Association between disease activity parameters and PB or LBW

Preterm birth (PB)Low birth weight (LBW)PB (+)(n = 14)PB (-)(n = 46)P valueLBW (+)(n = 23)LBW (-)(n = 37)P value Achievement of LLDAS, n (%)##5 (41.7)30 (71.4)0.0912 (63.2)23 (65.7)1.00 Achievement of LLDAS without a glucocorticoid dose, n (%)##5 (41.7)37 (88.1)< 0.01*13 (68.4)29 (82.9)0.31 SLEDAI score#3.5±2.91.1±1.3<0.01*2.3±2.11.3±2.00.04* C3, mg/dl#77.3±19.094.7±21.20.03*80.5±16.396.7±22.70.02* C4, mg/dl#16.1±9.019.2±6.30.1617.6±6.319.1±7.40.56 CH50, IU/ml#37.3±10.641.1±8.50.1736.5±6.642.2±9.70.03* Anti-dsDNA antibody, IU/ml#32.5±68.55.5±11.10.01*20.7±55.87.0±12.20.34

(Values are presented as mean ± standard deviation or number (%). #Wilcoxon rank sum test; ##Fisher’s exact test; *P < 0.05.)

Figure 1.

Logistic regression analysis of cut-off value of PB and LBW for C3, C4, CH50 and anti-dsDNA antibody.

(ROC curves based on logistic regression analysis of cut-off levels for disease activity parameters, including C3, C4, CH50, and anti-dsDNA antibody titer. [1] showed ROC curves for PB, and [2] showed those for LBW.)

Conclusion

We revealed that disease activity parameters of SLE at coception are strongly associated with negative pregnancy outcomes; PB and LBW. These include low serum C3 and CH50 levels and high anti-dsDNA antibody titers. In particular, low serum complement is a risk factor for both PB and LBW. Therefore, it is important to strictly control these disease activity parameters at conception in women with SLE.

References

[1]Clowse ME, Jamison M, Myers E, James AH. Am J Obstet Gynecol. 2008;199:127.e1-6.

[2]Bundhun PK, Soogund MZ, Huang F. J Autoimmun. 2017;79:17-27.

[3]Deguchi M, Maesawa Y, Kubota S, Morizane M, Tanimura K, Ebina Y, et al. J Reprod Immunol. 2018;125:39-44.

[4]Clowse ME, Magder LS, Petri M. J Rheumatol. 2011;38:1012-6.

Disclosure of Interests

None declared

Development of a classifier to screen for severe sleep disorders in children

This study aimed to develop an automatic classifier for the identification of severe sleep disorders that require immediate intervention in children. Our study assessed 7,008 children (age: 0-83 months) in Japan, whose parents and nursery teachers recorded their 14-day sleep patterns. Sleep quality was assessed by pediatricians and scored as 1 (no severe sleep disorder) or 0 (severe sleep disorder). Discriminant analysis was performed for each age group using sleep quality (0 or 1) as the dependent variable and variables in the 14-day sleep log as independent variables. A stepwise method was used to select the independent variables to build the best model. The accuracy of the discriminant analysis for the age groups ranged from 71.3 to 97.3%. In summary, we developed an automatic classifier with sufficient application value to screen for severe sleep disorders in children. In the future, this classifier can be used to rapidly determine the presence or absence of severe sleep disorders in children based on their 14-day sleep logs, thus allowing immediate intervention.

Longitudinal Study of Maternal Beliefs About Infant Crying During the Postpartum Period: Interplay With Infant’s Temperament

Infant crying is an important signal for their survival and development, and maternal beliefs about crying predict responsiveness to crying. Most studies have considered caregivers’ reactions to crying to be fixed, and it is unclear how they change with their caregiving experience. Additionally, it has recently been suggested that there is a bidirectional relationship between changes in mothers’ beliefs about crying and infants’ temperament. This study examined that relationship using a longitudinal study design. Maternal beliefs about crying and infant temperament of 339 Asian first-time mothers (mean age = 28.7 years, SD = 4.1) were measured at 1-month intervals over 4 months. There were 289 participants in Wave 2, 240 in Wave 3, and 164 in Wave 4. Prior to the main survey, we conducted a pre-survey to confirm the reliability and validity of the Japanese version of the Infant Crying Questionnaire. The results showed that parent-oriented beliefs, which focus on the caregiver rather than the crying infant, increased in mothers who had infants aged 3 months or older at Wave 1. We also found that the process of change in maternal beliefs was not uniform, and that infants high on surgency predicted changes in maternal beliefs about infant crying. Longitudinal studies of caregivers’ changes, such as the present study, are expected to contribute to understanding the co-development of caregivers and infants.

Intake of Docosahexaenoic Acid-Enriched Milk Beverage Prevents Age-Related Cognitive Decline and Decreases Serum Bone Resorption Marker Levels

The pathogenic mechanism of dementia is still unknown, and the fundamental treatment remains to be established. Thus, there is growing interest in preventing dementia through diet. One of the functional ingredients attracting attention is docosahexaenoic acid. We conducted a 12-month, randomized, double-blind, placebo-controlled clinical trial in healthy elderly Japanese individuals with a Mini-Mental State Examination score of 28 or higher at baseline using a docosahexaenoic acid-enriched milk beverage containing 297 mg docosahexaenoic acid and 137 mg eicosapentaenoic acid. Consumption of a docosahexaenoic acid-enriched milk beverage increased the fatty acid levels of docosahexaenoic acid and eicosapentaenoic acid in erythrocyte membranes, which was the primary outcome of this study. Moreover, intake of this beverage prevented age-related cognitive decline and decreased serum bone resorption marker levels. Our data demonstrate that, even at a low dose, long-term daily intake of docosahexaenoic acid prevents dementia and may show beneficial effect on bone health.

Baby's Online Live Database: An Open Platform for Developmental Science

Efficient data collection in developmental studies is facing challenges due to the decreased birth rates in many regions, reproducibility problems in psychology research, and the COVID-19 pandemic. Here, we propose a novel platform for online developmental science research, the Baby’s Online Live Database (BOLD), which extends the scope of the accessible participant pool, simplifies its management, and enables participant recruitment for longitudinal studies. Through BOLD, researchers can conduct online recruitment of participants preregistered to BOLD simply by specifying their attributes, such as gender and age, and direct the participants to dedicated webpages for each study. Moreover, BOLD handles participant recruitment and reward payment, thereby freeing researchers from the labor of participant management. BOLD also allows researchers the opportunity to access data that were collected from participants in previous research studies. This enables researchers to carry out longitudinal analyses at a relatively low cost. To make BOLD widely accessible, a consortium was formed within the Japan Society of Baby Science, where members from diverse research groups discussed the blueprint of this system. Once in full-scaled operation, BOLD is expected to serve as a platform for various types of online studies and facilitate international collaboration among developmental scientists in the near future.

POS1358 THE EFFECTS AND SAFETY OF APREMILAST AND CYTOKINE EXPRESSION IN BEHCET’S DISEASE PATIENTS

Background:

Apremilast, the small-molecule phosphodiesterase (PDE) -4 inhibitor, was approved for the treatment of recurrent oral ulcers associated with Behcet’s disease (BD) in Japan from September 2019, following the success of the phase 3 RELIEF study (1). However, the efficacy of apremilast on domains other than oral ulcers in BD patients is unclear. On the other hand, it has been reported that apremilast may decrease the production of proinflammatory cytokine and increase the production of anti-inflammatory mediators in psoriasis (PS) and psoriatic arthritis (PsA) (2).

Objectives:

To evaluate the effects and safty of apremilast on clinical symptoms and the changing of serum cytokine expression.

Methods:

BD patients who had treated with apremilast for active oral ulcers were included in the study. We investigated the improvement rate of oral and genital ulcers, skin lesions, arthritis. In addition, serum cytokines (IFN-γ, IL-10, IL-8, and TNF-α) before and after apremilast treatment were measured using a multiplex immunoassay (Luminex Assay, R&D Systems).

Results:

Fourteen patients (3 males and 11 females) were enrolled in this study. The mean age was 46.6 ± 13.0 years and the mean duration of disease was 10.2 ± 8.8 years. All patients had active oral ulcers, five had genital ulcers, six had skin lesions, and four had arthritis. Three months after the treatment with apremilast, oral ulcers improved in 13 patients (92.9%). The improvement rates of genital ulcers, skin lesions and arthritis were 60%, 25% and 25%, respectively. Changes in serum cytokines were different from those previously reported in PS. Adverse events were gastrointestinal symptoms such as nausea and diarrhea in 6 patients and sensorineural deafness in 1 patient. Medication was reduced in 2 patients, and discontinued in 1 patient due to nausea and diarrhea.

Conclusion:

Apremilast is useful not only for oral ulcers, but also for other lesions in BD patients. The effect of apremilast for other domain such as genital ulcers, skin lesions, arthritis was not comparable to that of active oral ulcers. Additionally, BD may have different cytokine profile from PS and PsA.

References:

[1]Hatemi G, Mahr A, Ishigatsubo Y, et al. Trial of Apremilast for Oral Ulcers in Behcet’s Syndrome. N Engl J Med. 2019;381(20):1918-28

[2]Schafer P. Apremilast mechanism of action and application to psoriasis and psoriatic arthritis. Biochem Pharmacol. 2012;83(12):1583-1590

Disclosure of Interests:

None declared

POS0556 USEFULNESS OF FDG-PET/CT FOR PREDICTING SPONTANEOUS REGRESSION IN MTX ASSOCIATED LYMPHOPROLIFERATIVE DISORDER WITH RHEUMATOID ARTHRITIS

Background:

Recently, there are many reports from Japan about methotrexate associated lymphoproliferative disorder (MTX-LPD). We are investigating the predictive factor of spontaneous regression (SR) in MTX-LPD. On the other hand, FDG-PET/CT is used for diagnosis of LPD including malignant lymphoma. In addition, it was reported that imaging biomarkers such as metabolic tumor volume (MTV) and total lesion glycolysis (TLG) could predict the prognosis of malignant tumor (1, 2). However, there is no report that these imaging biomarkers could predict the SR of MTX-LPD.

Objectives:

We investigate the usefulness of FDG-PET/CT for predictive factor of SR in MTX-LPD.

Methods:

We enrolled 24 RA patients who diagnosed MTX-LPD and performed FDG-PET/CT from 2005 to 2019. We divided these cases into spontaneous regression cases (SR group; 15 cases) and cases that treated with chemotherapy after MTX discontinuation (CTx group; 9 cases), and compared the difference as follow subjects between two groups; clinical data including histopathological findings, SUVmax to evaluate malignant tumor activity by FDG-PET/CT, MTV and TLG which refer to metabolically active volume of the tumor segmented FDG-PET/CT. In addition, we analyzed cut off levels, sensitivity and specificity using statistical software JMP.

Results:

Diffuse large B cell lymphoma (DLBCL) and Hodgkin lymphoma (HL) were 5 and 1 cases in SR group, and 1 and 5 cases in CTx group. In addition, MTV and TLG by FDG-PET/CT was significantly lower in SR group, although SUVmax is no difference between two groups (figure 1). Cut off levels of MTV and TLG were 103.12 ml (sensitivity; 88.9%, specificity; 86.7%) and 361.75 ml (sensitivity; 88.9%, specificity; 86.7%), respectively.

Conclusion:

We suggested that MTV and TLG were useful for predict of SR in MTX-LPD.

References:

[1]Chen HH, Chiu NT, Su WC. et al. Prognostic value of whole-body total lesion glycolysis at pretreatment FDG PET/CT in non-small cell lung cancer. Radiology. 2012 Aug;264(2):559-66.

[2]Chu KP, Murphy JD, La TH. et al. Prognostic value of metabolic tumor volume and velocity in predicting head-and-neck cancer outcomes. Int J Radiat Oncol Biol Phys. 2012 Aug 1;83(5):1521-7.

Figure 1.

Comparison of the level of MTV(a) and TLG (b).

Disclosure of Interests:

None declared

AB0443 BIOMARKER SUCH AS IL-17, IL-21 AND TIMP-1, IS USEFUL FOR PREDICTING THE PATHOPHYSIOLOGY OF CONNECTIVE TISSUE DISEASE-ASSOCIATED PULMONARY HYPERTENSION

Background:

Connective tissue disease-associated pulmonary hypertension (CTD-PH) is constructed by a variety of pathologies, including cardiac, pulmonary, and vascular involvement, as well as immune abnormalities. Because of its various constructs, it is difficult for many respiratory physicians, cardiologists, and rheumatologists to determine a treatment strategy for CTD-PH. In addition, CTD-PH has different pathologies from iPAH, and there are cases in which immunosuppressive therapy is effective. These suggests that the two PAHs may have different pathogenesis, including inflammation in the pulmonary artery. However, there are not enough biomarkers to distinguish pathologies. On the other hand, it has been reported that various cytokines such as TIMP-1, Interleukin (IL)-6, IL-17, and IL-21 are involved in the pathogenesis of CTD-PH or vasculitis. (1,2) However, the relationship between these cytokine expression and the pathogenesis or treatment of CTD-PH has not been fully clarified.

Objectives:

To clarify the relationship between cytokine profile and clinical features, change in cytokines and hemodynamics by treatment, association with the effectiveness of immunosuppressive therapy.

Methods:

Patients suspected PH was included. At the time of cardiac catheterization(RHC), sera in pulmonary pre and post-capillary were collected and TIMP-1, MCP-1, IL-17 and IL-21, IL-12p70 and IL-6 were analyzed by ELISA(ABCAM UK, Ella simple plex USA). The following clinical data were collected: age, gender, underlying disease, complication of interstitial lung disease, treatment (immunosuppressant and pulmonary vasodilator), hemodynamics. Furthermore, we investigated the relationship between cytokines and clinical data.

Results:

15 cases of CTD-PH, 13 cases of non-CTD-PH, and 6 cases of non-PH were analyzed. (SSc 12 cases, MCTD 7cases, SLE 2 cases, and others 13 cases) 28 cases were diagnosed with PH by RHC. There was a positive correlation between IL-6 and mean pulmonary arterial pressure in all PH case. In addition, MCP-1, IL-6, and TIMP-1 tend to be high in SSc-PH cases. On the other hand, in Non-SSc-PH, IL-12p70 and IL-17 were high. In cases who pulmonary vascular hemodynamics improved by treatment, IL-17, IL-21, and TIMP-1 decreased.

Conclusion:

Biomarker profiles in pulmonary capillaries may differ depending on the disease. Furthermore, it suggested that IL-17, IL-21 and TIMP-1 may be biomarkers of therapeutic effect.

References:

[1]Hashimoto-Kataoka T. et al. Proc Natl Acad Sci U S A. 2015 May 19;112(20):E2677-86.

[2]Jun Ishizaki et al. Arthritis Res Ther. 2017 Sep 29;19(1):218.

Disclosure of Interests:

None declared.

AB0287 EFFECTS OF HYDROXYCHLOROQUINE ON PERIPHERAL BLOOD CYTOKINE EXPRESSION ASSOCIATED WITH ATHEROSCLEROSIS IN SYSTEMIC LUPUS ERYTHEMATOSUS

Background:

In systemic lupus erythematosus(SLE), a higher frequency of atherosclerotic lesions is associated with a poor life prognosis (1). Hydroxychloroquine (HCQ) has been reported to improve the prognosis of life and dyslipidemia in SLE (2), and the mechanism has been unclear.

Objectives:

To determine the effect of HCQ treatment on serum cytokines associated with atherosclerosis in SLE.

Methods:

SLE patients who received additional HCQ and maintained low disease activity between January 2016 and September 2020 were included in this study. Disease activity was assessed by SLEDAI, CLASI and LLDAS, and serum complement titers, anti-ds-DNA antibodies, serum insulin and serum cytokines (adiponectin, resistin and leptin) were analyzed before and after HCQ treatment.

Results:

Fifty-four patients (3 males, 51 females, mean age 41.9±12.8 years) were included (Table 1). Thirty-two patients achieved LLDAS at baseline. Serum adiponectin and insulin levels were significantly increased after 3 months of HCQ treatment compared to baseline, and serum resistin levels were significantly lower (Figure 1). Patients with a history of renal disease had greater degree of changes in serum adiponectin and resistin levels. Among SLE patients who did not achieve LLDAS at baseline, those who still did not achieve LLDAS after 3 months had significantly lower serum leptin levels before HCQ treatment than those who achieved it after 3 months.

The change of serum resistin levels correlated with those of serum S100A8 levels (r=0.5, p=0.0001).

Conclusion:

Additional HCQ treatment in SLE patients improves lipid abnormalities. HCQ may improve prognosis by controlling disease activity in SLE and reducing risk factors for atherosclerosis.

References:

[1]Gregory Katz, et al. Systemic Lupus Erythematosus and Increased Prevalence of Atherosclerotic Cardiovascular Disease in Hospitalized Patients. Mayo Clin Proc. 2019; 94:1436-1443.

[2]Laura Durcan, et al. Longitudinal Evaluation of Lipoprotein Parameters in Systemic Lupus Erythematosus Reveals Adverse Changes with Disease Activity and Prednisone and More Favorable Profiles with Hydroxychloroquine Therapy. J Rheumatol. 2016; 43: 745–750.

Table 1.

Characteristics of SLE patients enrolled in this study

Characteristicsn=54, no.(%)Female, no(%)51(94)Age, years, mean±SD41.9±12.8Disease duration, years, mean±SD15.1±11.1Past involvementRenal involvement23 (43)NPSLE5 (9)ComplicationAPS10 (19)Dyslipidemia2 (4)Diabetes 1 (2)Concomitant immunosuppressive treatmentsPrednisone No.(%)46 (85) Median Dosage, mg/day (range)5.0 (1-10)Disease activitySLENA-SLEDAI score3.9±2.0 Current skin involvement30 (56) anti-dsDNA positive, no(%)21 (39)low complement, no(%)29 (54)

Anti-dsDNA positive means anti ds-DNA titer increases over 12 IU/ml

Low complement means any of C3, C4 and CH50 decreases to less 68mg/dl, less 12mg/dl, 30U/ml.

APS: Anti-phospholipid antibody syndrome, NPSLE: neuropsychiatric SLE,

Disclosure of Interests:

None declared

AB0390 CHARACTERISTICS AND PROGNOSIS OF AGE-DEPENDED ANCA-ASSOCIATED VASCULITIS IN JAPAN

Background:

It is known that most of ANCA-associated vasculitis (AAV) patients are elderly. A cohort study showed that the mean age of onset was 71.1 years, especially in patients with microscopic polyangiitis (MPA)1). However, the characteristics and prognosis of age-depended AAV patients are still unclear.

Objectives:

To clarify the differences in age-related characteristics and prognosis between Japanese patients with AAV.

Methods:

We enrolled 44 patients with AAV who underwent remission induction therapy at our hospital from January 2016 to December 2020. They were divided with under 70 years old group (<70 yo group, n=12) and over 70 years old group (≥70 yo group, n=32). We investigated between two groups as follows; clinical characteristics and laboratory data at diagnosis, rates of complete remission (CR) at 6 months, defined as Birmingham Vasculitis Activity Score (BVAS)=0 and prednisone ≤7.5 mg/day, adverse events, and relapse free survival.

Results:

Mean age were 61.9 ± 9.74 years old in <70 yo group and 77.5 ± 4.61 years old in ≥70 yo group (p<0.01). There were significantly fewer newly diagnosed cases in the <70 yo group, and half of the patients with relapsing disease. There was no difference in the type of ANCA, organ involvement, or BVAS. Remission induction therapy was performed with CY or RTX, and no difference was observed between these two groups. In addition, there was also no difference in maintenance therapy (Table 1). CR rate in <70 yo group and in ≥70 yo group were 55% and 46 % respectively (p=0.73). Severe infections occurred with no patient (0%) in <70 yo group and with 5 patients (16%) in ≥70 yo group (p=0.30). 5 patients of relapse were observed in the <70 yo group and 1 patient in the ≥70 yo group, and relapse free survival was significantly lower in the <70 yo group (p=0.001) (Figure 1).

<70 yo (n=12)≥70 yo (n=32)p valueAge (year)61.9 ± 9.7477.5 ± 4.61< 0.01*Female, n (%)10 (83)28 (87)0.66AAV typeMPA, n (%) / GPA, n (%)6 (50) / 6 (50)26 (81) / 6 (19)0.06Newly diagnosed, n (%)6 (50)27 (84)0.045*ANCA positivity MPO, n (%) / PR3, n (%)11 (92) / 0 (0)30 (94) / 3 (9)1 / 0.55 negative, n (%)1 (8)1 (3)0.48CRP (mg/dl)3.34 ± 4.018.15 ± 6.860.03*eGFR (mL/min)55.8 ± 25.357.7 ± 24.70.93BVAS12.0 ± 8.014.8 ± 6.80.23Remission induction therapyCY, n (%) / RTX, n (%)5 (42) / 7 (58)16 (50) / 16 (50)0.74Maintenance therapy AZA, n (%)7 (58)14 (44)0.50 RTX, n (%)1 (8)6 (19)0.65 others, n (%)2 (17)3 (9)0.60 without IS, n (%)2 (17)9 (28)0.70

The p-value was estimated using Fisher’s exact or Wilcoxson rank sum test. yo, years old; AAV, ANCA-associated vasculitis; MPA, microscopic polyangiitis; GPA, granulomatosis with polyangiitis; CY, cyclophosphamide; RTX, rituximab; AZA, azathioprine; IS, immunosuppressants. *p<0.05

Conclusion:

There was no difference in remission rate between two groups. Severe infections were observed only in the ≥70 yo group. We suggest that younger AAV patients need attention to relapse after the remission because of lower relapse free survival in <70 yo group.

References:

[1]Sada KE, et al. Arthritis Res Ther 2014; 16: R101.

Figure 1.

Relapse free survival Relapse free survival was calculated by Kaplan-Meier method and compared by log-rank test. *p<0.05

Disclosure of Interests:

None declared

POS0863 DIFFERENTIATING THE DOMINANCE OF PULMONARY VASCULAR DISEASE OR INTERSTITIAL LUNG DISEASE ON HEMODYNAMIC ABNORMALITIES IN SYSTEMIC SCLEROSIS AND CLARIFYING EACH CHARACTERISTIC BY USING QUANTITATIVE EVALUATION OF CHEST CT

Background:

Group 1 and 3 pulmonary hypertension (PH) develop through different pathological mechanisms but have similar hemodynamic abnormalities. Systemic sclerosis (SSc) is associated with both pulmonary vascular disease (PVD) and interstitial lung disease (ILD), making it challenging to differentiate group 1 and 3 PH in those patients. A previous study using quantitative evaluation of chest computed tomography (CT) demonstrated that normal lung volume was inversely correlated with mean pulmonary arterial pressure (mPAP) in patients with group 3 PH (1).

Objectives:

In this study, we aimed to assess the dominance of PVD or ILD in SSc patients by quantitative evaluation of chest CT and to evaluate each characteristic.

Methods:

A total of 76 SSc patients who underwent right heart catheterization (RHC) were included. Chest CT was evaluated by using a software (Synapse Vincent Ver.3.0, Fujifilm) which quantified normal and total area of the lung. Then, we calculated abnormal area by drawing normal area from total area in the lung (%). Pulmonary function test (PFT) and serum biomarkers, such as KL-6 and LDH, were also evaluated. The dominance of PVD or ILD was defined as divergent or parallel change between the first and last assessments, respectively, in mPAP and abnormal area in the lung calculated using the software. Increase or decrease by over 10% in the last assessment compared to the first assessment was considered as a significant change in mPAP or abnormal area in the lung. P values were calculated by Mann-Whitney U test, and correlation coefficients were calculated by direct regression variance.

Results:

The median [range] values of mPAP and abnormal area in the lung at baseline were 23 [9-65] mmHg and 30.2 [0-100] %, respectively. Of 37 SSc and PH patients, 18 were defined as having PVD dominance while 19 as ILD dominance. Abnormal area in the lung at baseline was greater in patients with ILD dominance compared to those with PVD dominance (39.1 [16.3-98.3] v.s. 14.0 [0-99] %, p=0.002), whereas mPAP was higher in patients with PVD dominance than those with ILD dominance (42.5 [23.0-65.0] v.s. 26.0 [16.0-42.0] mmHg, p=0.002). PFT parameters including forced vital capacity were not different between the two groups. The ratio of mPAP/KL-6 showed a great difference between the two groups with its significant elevation in patients with PVD dominance (p=0.007).

Conclusion:

Quantitative evaluation of chest CT showed great efficiency in differentiating the dominance of PVD or ILD in patients with SSc and PH. In addition, the ratio of mPAP/KL-6 may easily be used as a parameter for dominance evaluation.

References:

[1]Iwasawa T, Kato S, Ogura T, Kusakawa Y, Iso S, Baba T, et al. Low-normal lung volume correlates with pulmonary hypertension in fibrotic idiopathic interstitial pneumonia: computer-aided 3D quantitative analysis of chest CT. AJR Am J Roentgenol. 2014;203(2):W166-73.

Disclosure of Interests:

None declared

AB0826 IMPORTANCE OF PRECONCEPTION CARE AND PLANNING FOR PREGNANCY IN WOMEN OF CHILDBEARING AGE COMPLICATED WITH CONNECTIVE TISSUE DISEASES

Background:

Previous reports showed that connective tissue disease (CTD) have a high risk for adverse pregnancy outcomes (APOs) such as preterm birth, light-for-date, or preeclampsia1). It was revealed that these APOs were associated with high disease activity or treatment agents, particularly in glucocorticoid2). Some patients, who have no or insufficient preconception care and became unplanned pregnant, exacerbate the underlying disease, and lead to disappointing pregnancy outcomes. Therefore, preconception care and planning for pregnancy is very important to control disease activities and manage the appropriate treatment agents, including glucocorticoid, immunosuppressants, biologics, hydroxychloroquine, and anticoagulants3).

Objectives:

We investigate whether the presence or absence of preconception care before pregnancy affects clinical disease course and pregnancy outcomes.

Methods:

We examined 200 CTD women who delivered their newborns in our institution from March 2006 to January 2021. We analyzed the association between preconception care and the clinical course of underlying diseases during pregnancy or pregnancy outcomes.

Results:

Of all 200 cases, 133 (55.9%) cases had preconception care in our institution, while the others had no or insufficient preconception care. We showed the comparison of treatment agents and pregnancy outcomes between the cases with and without preconception care in Table 1. There was no significant difference in the rate of glucocorticoid use and the mean prednisolone dose during pregnancy between these two groups. However, the rate of increased dose of glucocorticoid or pulse therapy was significantly higher in the cases without preconception care. As for pregnancy outcomes, there was no significant difference in the live birth rate. On the other hand, the gestational weeks at delivery were significantly shorter, and the rate of preterm birth was higher in the cases without preconception care. In addition, the rate of the hospitalization of neonatal intensive care unit (NICU) was also significantly higher in the cases without preconception care.

Conclusion:

We revealed that preconception care before pregnancy reduced the need for intensified treatment such as increasing dose of glucocorticoid or pulse therapy. The rate of preterm birth and NICU hospitalization was also shown to decrease. Therefore, it is important for our rheumatologists to provide an appropriate preconception care for CTD women of childbearing age and to make a plan for pregnancy.

References:

[1]Tsuda S, Sameshima A, Sekine M, Kawaguchi H, Fujita D, Makino, et al. Mod Rheumatol 2019:24;1-10.

[2]Clowse ME, Magder LS, Petri M. J Rheumaotol 2011;38:1012-1016.

[3]Sammaritano LR, Bermas BL, Chakravarty EE, Chambers C, Clowse MEB, Lockshin MD, et al. Arthritis Care Res 2020;72:461-488.

Table 1.

Comparison of treatment agents and pregnancy outcomes between the cases with and without preconception care

Preconception care (+) (n=113)Preconception care (-) (n=89)P valueTreatment agents during pregnancy Glucocorticoid use (n (%))64 (56.6)50 (56.2)1.00  Mean glucocorticoid dose (mg/day)6.3±3.98.4±6.10.09  Dose-up of glucocorticoid (n (%))11 (9.7)26 (29.2)<0.01*  Glucocorticoid pulse therapy (n (%))0 (0)8 (9.0)0.01* Immunosuppressant (n (%))14 (12.5)4 (4.5)0.08 Hydroxychloroquine (n %))7 (6.2)6 (6.7)1.00 Anticoagulant therapy (n (%))21 (18.8)16 (17.8)1.00Pregnancy outcome Spontaneous abortion (n (%))8 (7.1)6 (6.7)1.00 Live birth (n (%))100 (88.5)78 (87.6)1.00  Gestational weeks at delivery (week)38.7±1.437.3±3.50.01*  Birth weight of newborn (gram)2888.8±453.72678.4±732.60.25 Adverse pregnancy outcomes (n (%))26 (26.0)28 (35.0)0.20  Preterm birth (n (%))5 (5.0)19 (23.8)<0.01*  Light-for-date (n (%))10 (10.0)9 (11.3)0.81  Hypertensive disorder (n (%))5 (5.0)8 (10.0)0.25  NICU management (n (%))13 (13.0)24 (30.0)<0.01*

Disclosure of Interests:

None declared

Is warfarin associated with higher risk of thrombus in left atrial appendage than direct oral anticoagulants?

Funding Acknowledgements

Type of funding sources: None.

Background

Thrombus in left atrial appendage (LAA) is associated with cardiogenic ischemic stroke, and anticoagulation therapy is utilized to prevent thromboembolism.

Purpose

This study is to investigate the incidence of thrombus in left atrial appendage detected by transoesophageal echocardiography (TOE) under anticoagulation therapy with warfarin or direct oral anticoagulants (DOAC).

Methods

Between 2005 and 2016, the patients who underwent TOE under anticoagulation therapy due to atrial fibrillation more than one month were enrolled in this study. The patients were divided into 2 groups according to whether treated with warfarin or DOAC and baseline characteristics and incidence of LAA thrombus were assessed.

Results

Among the 313 study patients, 243 (78%) were treated with warfarin. The patients treated with warfarin were elder (median 73 y vs. 67 y [interquartile range 66 – 78 y vs. 58 – 72 y], P &lt; 0.01), the body mass index was lower (23.2 vs. 24.0 [21.0 – 25.4 vs. 21.3 – 26.9], P = 0.03). The prevalence of male sex (64% vs. 71%, P = 0.26) were similar between the 2 groups. The previous history of hypertension (69% vs. 59%, P = 0.10), diabetes (24% vs. 19%, P = 0.32), vascular disease (30% vs. 26%, P = 0.52), and ischemic stroke were similar between the 2 groups (30% vs. 23%, P = 0.22). The prevalence of CHA2DS2-VASc score &gt; 1 (84% vs. 59%, P &lt; 0.01) and the d-dimer level (0.7 vs. 0.5 mcg/ml [0.5 – 1.8 vs. 0.5 – 0.5 mcg/ml], P &lt; 0.01) were higher in the warfarin groups than those of the DOAC. The velocity of LAA was slower in the warfarin group than those of DOAC (35 vs. 55 cm/s [21 – 54 vs. 38 – 68 cm/s], P &lt; 0.01). The incidence of detection of LAA thrombus was 19% in the warfarin group and 3% in the DOAC group (P &lt; 0.01). In the warfarin group, the PT-INR were lower in the patients with LAA thrombus (1.38 vs. 1.66 [1.11 – 1.92 vs. 1.34 – 2.03], P = 0.03).

Conclusions

The higher risk of ischemic stroke and out of range PT-INR may be the cause of the higher incidence of LAA thrombus in the patients treated with warfarin than those with DOAC.

Abstract Figure.

Comparison of hospital length of stay of acute ischemic stroke patients with non-valvular atrial fibrillation started on rivaroxaban or warfarin treatment during hospitalization

OBJECTIVE

To compare the hospital length of stay (LOS) between rivaroxaban and warfarin in hospitalized acute stroke patients with non-valvular atrial fibrillation (NVAF) in Japan.

METHODS

This was a retrospective, observational study using a Japanese hospital claims database. Data of NVAF patients who were started on oral anticoagulant (OAC) treatment during hospitalization were extracted and LOS-OAC (period from the initiation of index OAC therapy to the end of hospitalization or censoring date) and medical costs were compared between rivaroxaban and warfarin treatments. To compare LOS-OAC, a time-to-event analysis was performed using the Kaplan-Meier method. The analysis period was from April 2012 to December 2015.

RESULTS

This study included 773 rivaroxaban users and 1077 warfarin users. After the propensity score matching, 546 patients for each treatment constituted the matched cohorts. Although the rivaroxaban users had a similar LOS-OAC to warfarin users (median, 18 vs. 19 days, p = .657) in the matched cohorts, 3 days shorter LOS-OAC was observed in the rivaroxaban users (median, 17 vs. 20 days, p = .043) after IPTW adjustment. Subgroup analysis by the severity of stroke after IPTW adjustment demonstrated that rivaroxaban users had a shorter LOS-OAC than warfarin users among patients with mild (median, 10 vs. 14 days) and moderate stroke severity (22 vs. 27 days), but not among those with severe stroke severity (26 vs. 25 days).

LIMITATIONS

It is not possible to say that the only confounder was stroke severity and therefore other possible known and unknown confounders could not be ruled out.

CONCLUSIONS

The rivaroxaban users had a 3-day shorter LOS-OAC after IPTW-adjustment. Using rivaroxaban was associated with 4-5 days shorter LOS-OAC than using warfarin in patients with mild or moderate stroke, though treatment selection did not have a large impact in patients with severe stroke.

Serum interleukin-17A/interferon-gamma ratio as a predictor for the severity of atrial low voltage in atrial fibrillation: from FIB-MARK study

Background

Atrial fibrosis is hallmark of structural remodeling in atrial fibrillation (AF), but the inflammatory mechanism remains unclear. The purpose of the present study was to identify the specific inflammatory biomarkers to atrial fibrosis evaluated by atrial low voltage (LV) in AF patients for clarification of the mechanism.

Methods

Forty inflammatory biomarkers were quantified in 16 consecutive AF patients measured left atrial low voltage during catheter ablation.

Results

Median %LV area was 17%. In Pearson's correlation analysis, interleukin (IL)-17A and interferon (IFN)-γ was the most significant positive and negative correlation with %LV (R=0.35 and 0.43, P&lt;0.001). Furthermore, there was a significant correlation between IL-17A/IFN-γ ratio and %LV (R=0.65, P=0.007). The area under the receiver operator characteristics curve of IL-17A/IFN-γ ratio for significant LV (%LV &gt;10% as a reference standard) was 0.88. IL-17A/IFN-γ ratio was significantly higher in patients with significant LV than those without (1.41 versus 0.97, P=0.01), Furthermore, the sensitivity, specificity, and accuracy for detecting significant LV were 60%, 100%, and 75.0% at the cutoff value of 1.3. The event free survival from recurrent atrial tachyarrhythmias was not significantly different between patients with and without IL-17A/IFN-γ ratio &gt;1.3 (83.3% versus 80.0% at 1-year, P=0.81).

Conclusions

Among inflammatory biomarkers, IL-17A/IFN-γ ratio was a significant predictor for the severity of left atrial low voltage n AF patients. Further study is needed to reveal the association between IL-17A and IFN-γ for development of fibrosis in AF.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): JSPS KAKENHI GrantNumber JP19K17594

Long-term outcomes evaluated by device-monitored physical activity in patients with implantable cardiac defibrillator or cardiac resynchronization therapy device

Background

The patients with implantable cardiac defibrillator (ICD) or cardiac resynchronization therapy device (CRT) have high risk of cardiac events, and lower physical activity has been thought to be associated with higher rate of cardiac events. On the other hand, cardiovascular implantable electronic devices can monitor physical activity through a built-in accelerometer. This study aimed to analyze long-term outcomes by device-based monitoring of physical activity in patients with ICD or CRT.

Methods

We retrospectively reviewed 89 patients with ICD/CRT, (56 males, 66.5 years old; ICD 45, CRT-D 42, CRT-P 2) who survived longer than 6 months after implantation in our institution. We analyzed physical activity by devices at 6th month and divided to 2 groups; In Low activity group (group L; n=38), their physical activity (moving time above 70 steps/min walk level) is less than 2 hours/day, and in Normal activity group (group N; n=51), physical activity is more than 2 hours/day. We evaluated their background characteristics in each group, physical activity at 12th month, and composite outcomes of hospitalization due to worsening of heart failure (HF) and death of any cause.

Results

Mean follow-up period was 57.4 months (median 40 months). In group L, they had higher age (71.1 y.o. vs. 63.2 y.o.; p=0.0003), higher rate of low EF (76.3% vs. 54.9%; p=0.035), and lower rate of attendance to outpatient cardiac rehabilitation program (10.5% vs 27.5%; p=0.043) compared with group N. 85.7% of patients in group L stayed in low physical activity at 12th month, and 87.8% of patient in group N stayed in normal physical activity. Composite outcomes of HF hospitalization and death occurred significantly higher in group L (Log-rank p&lt;0.0001; 29.0% vs. 5.9% at 1 year, and 68.7% vs. 16.2% at 3 year: Figure 1) than in group N. Each event, HF hospitalization and death of any cause were shown significantly higher in group L (Log-rank p&lt;0.0001). In group L, mortality rate of patients who could improve their physical activity from 6th month to 12th month was significantly lower than patients who stayed in low physical activity (Log-rank p=0.038).

Conclusions

Lower level of device-monitored physical activity was associated with higher mortality and higher rate of HF hospitalization in patients with ICD or CRT. Most of the patient in lower physical activity could not improve their activity from 6th month to 12th month. Early and continuous intervention is necessary especially for high risk patients such as high age or low EF.

Figure 1

Funding Acknowledgement

Type of funding source: None

Prognosis and cause of death in patients with left atrial appendage thrombus treated with or without anticoagulation therapy

Background

Thrombus in left atrial appendage (LAA) is associated with cardiogenic ischemic stroke; however, little is known about prognosis of patients with LAA thrombus detected by transoesophageal echocardiography (TOE).

Purpose

This study is to investigate the prognosis of patients with LAA thrombus and their cause of death.

Methods

Between 2005 and 2016, the patients who were performed TOE in our hospital were enrolled in this retrospective observational study. Five-year stroke free and survival curves were constructed by Kaplan-Meir method and cause of death were assessed.

Results

Among the 1263 study patients, LAA thrombus was detected in 146 (12%) patients. The patients with LAA thrombus were elder (74 y [66–79 y] vs. 70 y [62–76 y], P&lt;0.001), than those without LAA thrombus, respectively. The prevalence of male sex (67% vs. 69%, P=0.63) were similar between the 2 groups. The prevalence of CHA2DS2-VASc score ≥2, d-dimer (1.7 mcg/ml [0.9–3.5 mcg/ml] vs. 0.8 mcg/ml [0.5–2.2 mcg/ml], P&lt;0.001), and plasma brain natriuretic peptide (315 pg/ml [128–515 pg/ml] vs. 126 pg/ml [47–284 pg/ml], P&lt;0.001) were higher in the patients with LAA thrombus than those without (89% vs. 78%, P=0.003). The LAA velocity was slower in the patients with LAA thrombus than those without (23 cm/s [15–34 cm/s] vs. 51 cm/s [35–72 cm/s], P&lt;0.001). The prevalence of receiving anticoagulation therapy before (34% vs. 24%, P=0.01) and after (98% vs. 66%, P&lt;0.001) TOE 1 month were higher in the patients with LAA thrombus than those without. The 5-year stroke free rate was lower in the patients with LAA thrombus than those without (82% vs. 93%, P&lt;0.001); however, the 5-year survival were similar between the 2 groups (84% vs. 84%, P=0.93) (Figure). The cause of death as ischemic stroke was only 7% (1/14) and 3% (3/94), (P=0.43); the cardiac cause (14% vs. 43%, P=0.07) and the malignancy (35% vs. 29%, P=0.75) were the frequent cause of death in the patient with LAA thrombus and those without, respectively.

Conclusions

The patients who were detected thrombus in the LAA had higher incidence of ischemic stroke; however, the 5-y survival were similar. The ischemic stroke was not major cause of death in the patients with and without LAA thrombus. The higher rate of receiving anticoagulation therapy may be one of the causes of the discrepancy.

Figure 1

Funding Acknowledgement

Type of funding source: None

Equine non-invasive time-lapse imaging and blastocyst development

In this study we examined the timeline of mitotic events of invitro-produced equine embryos that progressed to blastocyst stage using non-invasive time-lapse microscopy (TLM). Intracytoplasmic sperm injection (ICSI) embryos were cultured using a self-contained imaging incubator system (Miri®TL; Esco Technologies) that captured brightfield images at 5-min intervals that were then generated into video for retrospective analysis. For all embryos that progressed to the blastocyst stage, the initial event of extrusion of acellular debris preceded all first cleavages and occurred at mean (±s.e.m.) time of 20.0±1.1h after ICSI, whereas 19 of 24 embryos that did not reach the blastocyst stage demonstrated debris extrusion that occurred at 23.8±1.1h, on average 4h longer for this initial premitotic event (P<0.05). Embryos that failed to reach the blastocyst stage demonstrated a 4-h delay compared with those that reached the blastocyst stage to reach the 2-cell stage (P<0.05). All embryos that reached the blastocyst stage expressed pulsation of the blastocyst with visible expansion and contraction at approximate 10-min intervals, or five to six times per hour. Using a logit probability method, we determined that 2- and 8-cell stage embryos could reasonably predict which embryos progressed to the blastocyst stage. Together, the results indicate that TLM for equine embryo development is a dynamic tool with promise for predicting successful embryo development.

Integrative and Complementary Health Practices Building a New Health Paradigm

This work arose from the need to broaden the therapeutic approach and offer a differentiated health intervention proposal based on the understanding that the illness process has repercussions on all integrated systems of Being. Since 2019, the Health Center for the Elderly in Blumenau (SC-Brasil), specialized multi-professional service, offering support for biopsychoenergetic transformation with the practice of Yoga and Meditation, through a holistic and comprehensive view of health. It begins with the Multidimensional Assessment of the Elderly, with a guideline in welcoming and qualified listening, which considers the subject and all subjectivity. From there, the expanded diagnosis and the Singular Therapeutic Project are built and the consultations with the team and the 'Re-Conhecer group' begin. The activity is weekly, aimed at the elderly and their family, takes place in an appropriate place and lasts two hours. Welcoming, pranayama, mantras, kriyas and meditation are made, as well as reflections on free themes. The professionals who conduct the practice are the dentist, trained in yoga, and the social worker, the welcoming process continues individually after the activity. Due to subjectivity, results are routinely collected in a qualitative way from the participants' report. There is a perception on the part of the participants, therapists and members of the multidisciplinary team that this work provides improvement in cognitive abilities, self-care, well-being, self-confidence, creativity, improved sleep, autonomy, balance, strengthening bonds, joy, vitality.

Key messages

This initiative builds new models of health care, transcending the traditional biomedical model, according to the operational guideline for comprehensiveness, universal access and equity. Provokes reflections and builds a new perspective of life with quality and participation of the elderly as subjects of their health.