Clinical Characteristics of EGPA Patients in Comparison to GPA Subgroup with Increased Blood Eosinophilia from POLVAS Registry

Objective

To characterize the eosinophilic granulomatosis with polyangiitis (EGPA) population from the POLVAS registry depending on ANCA status and diagnosis onset, including their comparison with the granulomatosis with polyangiitis (GPA) subset with elevated blood eosinophilia (min. 400/μl) (GPA HE) to develop a differentiating strategy.

Methods

A retrospective analysis of the POLVAS registry.

Results

The EGPA group comprised 111 patients. The ANCA-positive subset (n = 45 [40.54%]) did not differ from the ANCA-negative one in clinics. Nevertheless, cardiovascular manifestations were more common in ANCA-negative patients than in those with anti-myeloperoxidase (MPO) antibodies (46.97% vs. 26.92%, p = 0.045). Patients diagnosed before 2012 (n = 70 [63.06%]) were younger (median 41 vs. 49 years, p  < 0.01), had higher blood eosinophilia at diagnosis (median 4,946 vs. 3,200/μl, p  < 0.01), and more often ear/nose/throat (ENT) and cardiovascular involvement. GPA HE comprised 42 (13.00%) out of 323 GPA cases with reported blood eosinophil count. Both GPA subsets had a lower prevalence of respiratory, cardiovascular, and neurologic manifestations but more often renal and ocular involvement than EGPA. EGPA also had cutaneous and gastrointestinal signs more often than GPA with normal blood eosinophilia (GPA NE) but not GPA HE. The model differentiating EGPA from GPA HE, using ANCA status and clinical manifestations, had an AUC of 0.92, sensitivity of 96%, and specificity of 95%.

Conclusion

Cardiovascular symptoms were more prevalent in the ANCA-negative subset than in the MPO-ANCA-positive one. Since EGPA and GPE HE share similarities in clinics, diagnostic misleading may result in an inappropriate therapeutic approach. Further studies are needed to optimize their differentiation and tailored therapy, including biologics.

Osteoporosis and diabetes - possible links and diagnostic difficulties

Objectives

In this review, the authors aimed to clarify the relationship between the occurrence of osteoporosis and diabetes, analyze the differences between the pathogenesis of osteoporosis in different types of diabetes and propose the most effective diagnostic strategy and fracture risk assessment in diabetic patients.

Material and methods

A analysis of publications in MEDLINE, COCHRANE and SCOPUS databases was performed, searching for reports on the diagnostics, fracture risk assessment, prevention, and treatment of osteoporosis in patients with diabetes mellitus (DM) published in the years 2016-2022. The key words for the search were: diabetes, osteoporosis, and low-energy fracture.

Results

Bone complications of T1DM are more severe than T2DM, because of the lack of anabolic effect of insulin on bones. In T2DM the risk of fractures is elevated; however, identifying the mechanisms underlying the increased risk of fractures in T2DM is not clear. The FRAX tool is not appropriate for assessing the fracture risk in young patients with T1DM. It is quite useful in older patients with T2DM, but in these patients the calculated fracture risk may be underestimated. In T2DM the fracture risk often does not correspond to BMD value as measured by dual-energy X-ray absorptiometry (DXA). Diagnostic tools such as the trabecular bone score may play a significant role in this group of patients. Conclusions: Optimal strategies to identify and treat high risk individuals require further research and proper definition. The diagnostic criteria for osteoporosis should be clearly defined as well as fracture risk assessment and choice of anti-osteoporotic medication. In all cases of secondary osteoporosis, treatment of the underlying disease is the most important. The relationship between high risk of fractures and diabetes is inseparable, and its full understanding seems to be the key to effective management.

Guidelines for the diagnosis and management of osteoporosis in Poland. Update 2022

Guidelines to provide an update of the previously published Polish recommendations for the management of women and men with osteoporosis have been developed in line with advances in medical knowledge, evidence-based data, and new concepts in diagnostic and therapeutic strategies. A Working Group of experts from the Multidisciplinary Osteoporosis Forum and from the National Institute of Geriatrics, Rheumatology, and Rehabilitation in Warsaw performed a thorough comprehensive review of current relevant publications in the field (including all age groups of people and management of secondary osteoporosis), and they evaluated epidemiological data on osteoporosis in Poland and the existing standards of care and costs. A voting panel of all co-authors assessed and discussed the quality of evidence to formulate 29 specific recommendations and voted independently the strength of each recommendation. This updated practice guidance highlights a new algorithm of the diagnostic and therapeutic procedures for individuals at high and very high fracture risk and presents a spectrum of general management and the use of medication including anabolic therapy. Furthermore, the paper discusses the strategy of primary and secondary fracture prevention, detection of fragility fractures in the population, and points to vital elements for improving management of osteoporosis in Poland.

Seasonally Dependent Change of the Number of Fractures after 50 Years of Age in Poland-Analysis of Combined Health Care and Climate Datasets

Aim: The incidence of fractures correlates with many independent and interrelated factors. The aim of the study was to examine trends in fracture incidence and to find possible reasons for changes. Materials and methods: A complete dataset of Polish population aged above 50 from the National Heath Fund—which is a single, state-owned payer for the health service procedures in Poland—covering the years between 2010 and 2015 was analyzed along with climate dataset. Results: The analysis indicated that there was a substantial and statistically significant decrease in the incidence of forearm and hip fractures (p = 0.007 and 0.007, respectively). On the other side, there was a statistically significant increase in incidence of humerus and lumbar fractures (p = 0.002, p < 0.001, respectively). The observed changes (especially decrease in forearm and hip fracture incidence) happened mostly in the cold season and were correlated to mean-temperature changes during the assessed time period. Conclusion: In the analysis based on the dataset obtained from fracture-related database collected in Poland in the years 2010−2015 in the population of patients over 50 years of age, we observed that the changes of fracture incidence during the observation period are associated with and may be dependent on the season (warmer versus colder) and on mean temperature increase during the observation period.

POS0253 PERSONALIZED RISK EVALUATION FOR OUTCOME PREDICTION IN ANCA ASSOCIATED VASCULITIS (AAV) USING LATENT CLASS ANALYSIS AND MACHINE LEARNING

Background

ANCA associated vasculitides (AAV) are a heterogeneous group of rare diseases with unknown etiology. In the most severe cases AAV can lead to end stage kidney disease or death. Since etiology and detailed pathogenesis of AAV is not known, the prediction of disease outcome at the time of diagnosis is challenging. Thus, there is an unmet need for tools to identify patients with the highest risk of organ dysfunction and death and apply effective personalized therapy.

Objectives

The aim of this work was to search for tools allowing outcome prediction at the time of AAV diagnosis. Early identification of patients, who are likely to develop severe organ dysfunction and death is crucial for appropriate disease management. Induction therapy in AAV relays on immunosuppressive drugs characterized by a high risk of severe side effects. Thus, their administration in high doses should be limited only to individual patients with an especially high risk of poor outcome.

Methods

We applied here two methods of identification of AAV patients at risk to develop severe organ dysfunction and death. First method (latent class analysis [LCA] followed by logistic regression) was meant to subcategorize patients and identify a subgroup at subjects at risk to develop chronic renal replacement therapy (CRRT) and death [1]. Second, served to assess individual poor outcome risk and was based on two machine learning (ML) classifiers, which by analyzing clinical information allow assigning computed risk for CRRT and death in an individual patient allowing to identify subjects with high risk of chronic replacement therapy (CRRT) and death. We have evaluated a number of different approaches to build the ML models (including logistic regression, support vector machines, random forests), and obtained the best results for the gradient boosting algorithm implementation called LightGBM [2]. It works as a sequential ensemble of so-called weak learners (decision trees) finally combined in a one prediction model. Both analyses were based on retrospective data from Polish national AAV registry (POLVAS) [3] including presently 565 GPA and 135 MPA patients. The parameters used were: demographic data and laboratory parameters, specific organ involvement, ANCA specificity and time between selected stages of the disease.

Results

LCA used on our AAV cohort identified four subphenotypes – three already previously proposed - and revealing a fourth clinically relevant subphenotype. This new subphenotype includes only GPA patients, usually diagnosed at a younger age as compared to other groups, and characterized by multiorgan involvement, high relapse rate, relatively high risk of death, but no end-stage kidney disease. Logistic regression analysis revealed significant differences in the risk of CRRT and death between those subphenotypes – the worst prognosis was found for severe MPO AAV. On the other hand, using ML approach we obtained an individual prediction model with potentially relevant clinical performance (ROC AUC of 0.85 for CRRT and 0.82 for death).

Conclusion

We consider results obtained encouraging. They may offer a new insight into AAV course based on data available at diagnosis, and create a solid foundation for potential clinical decision support system.

References

[1]Wójcik K et al. Subphenotypes of ANCA-associated vasculitis identified by latent class analysis. Clin Exp Rheumatol. 2021 Mar-Apr;39 Suppl 129(2):62-68.

[2]Ke G, at al. Light GBM: A Highly Efficient Gradient Boosting Decision Tree. Advances in Neural Information Processing Systems 30 (NIPS 2017), pp. 3149-3157.

[3]Wójcik K et al. Clinical characteristics of Polish patients with ANCA-associated vasculitides-retrospective analysis of POLVAS registry. Clin Rheumatol. 2019 Sep;38(9):2553-2563.

Acknowledgements

This work was supported by a grant from Polish National Science Center UMO-2018/31/B/NZ6/03898

Disclosure of Interests

None declared

AB0083 RELATIONSHIP BETWEEN APOLIPOPROTEIN C-III AND ACTIVATED FACTOR VII-ANTITHROMBIN COMPLEXES IN PATIENTS WITH RHEUMATOID ARTHRITIS AND PSORIATIC ARTHRITIS

Background

Both rheumatoid arthritis (RA) and psoriatic arthritis (PsA) are associated with increased cardiovascular risk and thrombosis. Alterations in plasma lipids levels, including apolipoproteins are recognized as the important risk factors of cardiovascular disorders. Activated Factor VII -anti- Thrombin complex (FVIIa-AT) is a marker of the extrinsic coagulation cascade activation, the pathway accelerated by interaction with plasma apolipoprotein C-III (Apo-CIII) (1).

Objectives

To investigate the associations between plasma FVIIa-AT concentration, lipid profile including apolipoprotein CIII, and markers of disease activity in patients with RA and PsA.

Methods

41 patients with RA, 38 with PsA, and 22 healthy controls, all not taking anticoagulant drugs were selected for the study. The lipid profile comprised triglycerides (TG), total cholesterol (TCh), low (LDL), and high-density lipoprotein (HDL). Serum levels of Apo C-III were measured using a Human ApoCIII ELISA kit CellBiolabs Inc.Austria. FVIIa–AT plasma concentrations were determined using ELISA test. C-reactive protein (CRP) level was measured using the immunoturbidimetric assay. All measurements were performed by a technician blinded to sample origin. The Mann-Whitney test and Kruskal Wallis tests were applied for intergroup comparisons, and correlations were assessed using Spearman’s rank tests, due to data non-normal distribution.

Results

The highest serum levels of Apo C-III were found in RA patients (median: 99.9μg/ml, min.-max. 8.7–199) compared to PsA (30.86μg/ml, 12.4–125.8) and controls (9.5 μg/ml, 3.7–29.2), p<0.001. RA and PsA patients revealed higher FVIIa-AT plasma levels than controls (RA median 153.8 pM, min.—max. 57.0–397.8, PsA 157.6 pM, 64.9– 323.8 vs controls 104.5 pM, 68.9–150.9, p<0.001). In RA and PsA patients ApoCIII correlated positively with TG levels (r=0.35, p=0.027 and r=0.38, p=0.018 respectively). In all patients and controls, Apo C-III levels correlated positively with FVIIa-AT concentrations (r=0.45 p<0.001). No significant differences were found in the serum concentrations of TCh, LDL, HDL, TG, and CRP, between the groups of RA and PsA patients.

Conclusion

Elevated concentrations of both, apolipoprotein CIII and activated FVII-AT complexes in rheumatic patients suggest associations between plasma lipoproteins and activation of coagulation cascade leading to a pro-thrombotic state in patients with RA and PsA. Further studies on these relationships are necessary taking into account various clinical conditions of patients and treatment.

References

[1]Martinelli N et al. Apolipoprotein C-III Strongly Correlates with Activated Factor VII-Anti-Thrombin Complex: An Additional Link between Plasma Lipids and Coagulation. Thromb Haemost. 2019; 119: 192-202.

Disclosure of Interests

None declared

Circulating miRNA Correlates with Lipid Profile and Disease Activity in Psoriatic Arthritis, Rheumatoid Arthritis, and Ankylosing Spondylitis Patients

This study aimed to investigate the associations of microRNA (miRs) signatures with cytokines, serum lipids, and disease activity in patients with psoriatic arthritis (PsA), ankylosing spondylitis (AS), and rheumatoid arthritis (RA). In total, 65 patients (PsA n = 25, AS n = 25, RA n = 15) and 25 healthy controls (HC) were enrolled into the study. The expression of miR-223-5p, miR-92b-3p, miR-485-3p, miR-10b-5p, let-7d-5p, miR-26a-2-3p, miR-146b-3p, and cytokines levels were measured in sera. DIANA-mirPath analysis was used to predict pathways targeted by the dysregulated miRs. Disease activity scores were calculated. Lipid profile, uric acid, glucose level, and C-reactive protein (CRP) concentrations were determined in the blood. Based on lipid profiles, the PsA group had hypertriglyceridaemia, and RA patients revealed mixed dyslipidaemia, while in AS, no specific changes were found. miR expression analysis revealed upregulation of miR-26a-2-3p and miR-10b-5p in PsA, miR-485-3p in AS, and let-7d-5p in RA. Several correlations between disease activity indexes, metabolites levels, and expression of miRs were observed in PsA, RA, and AS patients. Finally, in ROC analysis, miR-26a-2-3p/miR-485-3p, and let-7d-5p/miR-146b-3p tandems revealed high sensitivity and specificity in distinguishing between PsA, AS, and RA. Our study illustrates the superiority of miR expressions in distinguishing between RA, PsA, and AS. In PsA, a unique regulatory pathway exists through miR-26a-2-3p, miR-223-5p, miR-10b-5p, and miR-92b-3p that converges proatherogenic metabolism and disease activity.

Association of antineutrophil cytoplasmic antibody (ANCA) specificity with demographic and clinical characteristics of patients with ANCA‑associated vasculitides

INTRODUCTION

Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is characterized by the presence of proteinase‑3 (PR3) or myeloperoxidase (MPO) ANCA. In over 90% of cases, PR3‑ANCA is associated with granulomatosis with polyangiitis (GPA). However, it is also rarely found in microscopic polyangiitis (MPA) and eosinophilic granulomatosis with polyangiitis (EGPA). On the other hand, MPO‑ANCA being characteristic of MPA (>90% of cases), is also found in about 40% of EGPA and 5% of GPA patients. On the ground of this overlap, clinical importance of ANCA specificity identification has been questioned.

OBJECTIVES

In this study, we analyzed the clinical and demographic characteristics of AAV subgroups identified by ANCA serotype.

PATIENTS AND METHODS

We conducted a multicenter study of AAV patients (417 GPA, 106 MPA, 102 EGPA; diagnosed between 1990 and 2016), included in the POLVAS registry. The data were systematically collected according to a standardized protocol.

RESULTS

In the ANCA-positive group (anti‑MPO, anti‑PR3) a male-to-female ratio was 1:1, whereas in the ANCA-negative group it was 1:2, regardless of AAV diagnosis. Anti‑MPO antibodies were present in significantly older patients. Patients with MPO+GPA and MPO+EGPA were older than those with corresponding ANCA‑negative GPA and EGPA as well as PR3+AAV. Moreover, ANCA‑negative AAV was characterized by a low risk of end‑stage kidney disease and death.

CONCLUSIONS

The presence and specificity of ANCA in AAV patients are related to sex and age, determine their organ involvement and influence mortality as previously shown. Patients with MPO‑ANCA-positive AAV constitute a clinically homogeneous group, whereas PR3‑ANCA-positive patients are much more clinically heterogeneous. ANCA-negative AAV patients are characterized by better prognosis. Thus, ANCA identification is an indispensable element and should not be omitted in establishing AAV diagnosis.

Associations of IL-18 with Altered Cardiovascular Risk Profile in Psoriatic Arthritis and Ankylosing Spondylitis

Objective: To investigate the associations of IL-18 serum levels with serum lipids, cardiovascular risk, and disease activity in patients with ankylosing spondylitis (AS) and psoriatic arthritis (PsA) with axial (axPsA) and peripheral (perPsA) joint involvement. Methods: 155 adult patients (PsA 61/AS 94) were enrolled in the study. Standard disease activity indices, BASDAI, and ASDAS, were calculated for AS and PsA and DAPSA for PsA. Sera from peripheral blood samples were obtained after night fasting. Serum concentrations of cytokines (IL-18, IL-17) were measured by ELISA, while lipid profile with total cholesterol (TC), triglycerides (TG), low-density cholesterol-(LDL), high-density cholesterol (HDL), and C-reactive protein (CRP) concentrations were determined using routine procedures. The atherogenic index was calculated using the standard formula AI = TC/HDL. Results: Patients with PsA and peripheral joint involvement (perPsA) had significantly higher IL-18 serum levels than axial PsA and AS patients (medians 160 vs. 116 vs. 80 pg/mL). In patients with PsA and in the subgroup with PsA+ ischemic heart disease (IHD), IL-18 positively correlated with atherogenic index (AI) (rho = 0.46 and rho = 0.67, respectively) and TG serum concentrations (rho = 0.4 and rho = 0.675), while negatively with HDL levels (rho = −0.37 and rho = −0.608). In PsA + IHD subgroup IL-18 serum levels correlated positively also with disease activity (DAPSA) (rho = 0.613). Importantly, in patients with perPsA, characterized by the highest IL-18 serum levels, cardiovascular risk, and frequency of both hypertriglyceridemia and IHD, positive correlations between IL-18 and IL-17 (rho = 0.47, p = 0.002), TG (rho = 0.45 p = 0.01) levels and AI (rho = 0.63 p = 0.021) were found. Whereas linear regression models revealed that IL-17, TG concentrations and the tender joint count had an impact on IL-18 Conclusions: We confirmed that patients with perPsA are characterized by a more pronounced proinflammatory and proatherogenic cardiovascular risk profile than patients with axPsA and AS. Importantly our study indicates that in PsA, but not in AS, elevated serum concentration of IL-18 is associated with higher disease activity and proatherogenic lipid profile, leading to a higher cardiovascular risk. Thus, our results point out IL-18 as a critical contributor in these pathological processes and possible therapeutic targets.

Trabecular Bone Score (TBS) in Patients with Early Ankylosing Spondylitis-Limited Utility

Purpose: Ankylosing spondylitis (AS) not only results in pathological ossification of the spine, but can also be associated with osteoporosis. Due to the presence of syndesmophytes and possible involvement of the hip joints, classical dual X-ray absorptiometry (DXA) is of limited use in patients with advanced stages of AS. Trabecular bone score (TBS) is a method complementary to DXA, providing additional information about bone microarchitecture. There is a growing body of evidence for the usefulness of TBS in AS patients. The aim of this study was to assess the clinical utility of TBS in patients with AS. Methods: Patients with AS underwent DXA with additional TBS assessment. A cross-sectional analysis of the frequency of osteoporosis and bone microarchitecture deterioration and their association with patients’ characteristics was done. Results: A total of 51 male patients, mean age 40.7 years, were enrolled. Osteoporosis was diagnosed in seven patients (13.7%). Lumbar bone mineral density (BMD) was higher (p < 0.001) than femoral BMD, indicating abnormal BMD readings in the spine caused by syndesmophytes. Patients with DXA-diagnosed osteoporosis had lower TBS (p = 0.03) and TBS T-score (p = 0.043) values compared to patients without osteoporosis. However, disturbed bone microarchitecture (TBS < 1.23) was present in only three patients (5.9%). None of the patients had a history of an osteoporotic fracture. A lower TBS T-score (p = 0.032) was demonstrated in patients with sacroiliitis grade 4 than in patients with sacroiliitis grade 2, with no significant differences in BMD and T-score values. Conclusion: Among patients with early AS, the clinical utility of TBS is limited—it does not add value to DXA.

Diagnostic agreement between radiofrequency echographic multispectrometry and dual-energy X-ray absorptiometry in the assessment of osteoporosis in a Polish group of patients

INTRODUCTION

Osteoporosis is still under-diagnosed in Poland, among others due to limited accessibility to gold standard diagnostic technique, dual X-ray absorptiometry (DXA) of the proximal femur and lumbar spine.  Radiofrequency echographic multispectrometry (REMS) might be of particular interest because the technique is nonionizing, devices are portable and utilization relatively cheap.

OBJECTIVES

The aim of this study was to assess the agreement between a novel quantitative technique REMS, and DXA in bone mineral density evaluation and the diagnosis of osteoporosis.

PATIENTS AND METHODS

All recruited patients (116) underwent DXA and REMS of the proximal femur and lumbar spine. The diagnostic agreement of REMS was assessed through a direct comparison with DXA results, with separate analysis for the proximal femur and lumbar spine scans. Additional sub-analysis of the impact of gender, age, and BMI was performed.

RESULTS

After the exclusion of patients due to significant skeletal impairments, missing results, and erroneous reports, 66 results of the femur and 58 reports of the lumbar spine were analyzed. The diagnostic agreement between DXA and REMS results was 82.8% in the lumbar spine group and 84.8% in the femur group. Strong correlations between REMS and DXA results were found, both in the lumbar spine and femur groups. The correlations between REMS and DXA scores remained strong regardless of gender, age, and BMI.

CONCLUSION

REMS showed a significant diagnostic agreement with the corresponding DXA measurements. The study confirms further the usefulness of REMS in the assessment of osteoporosis.

Clinical Utility of Trabecular Bone Score (TBS) in Fracture Risk Assessment of Patients with Rheumatic Diseases Treated with Glucocorticoids

Chronic glucocorticoid therapy is associated with osteoporosis and can cause fractures in up to 50% of patients. Increased risk of fractures in patients with glucocorticoid-induced osteoporosis does not result only from the decreased bone mineral density (BMD) but also bone microarchitecture deterioration. Trabecular bone score (TBS) is a method complementary to DXA, providing additional information about trabecular bone structure. The aim of this study was to assess the clinical utility of TBS in fracture risk assessment of patients treated with glucocorticoids. Patients with rheumatic diseases treated with glucocorticoids for at least 3 months were enrolled. All recruited patients underwent DXA with additional TBS assessment. We analyzed the frequency of osteoporosis and osteoporotic fractures and assessed factors that might be associated with the risk of osteoporotic fractures. A total of 64 patients were enrolled. TBS and TBS T-score values were significantly lower in patients with osteoporosis compared to patients without osteoporosis. Low energy fractures occurred in 19 patients. The disturbed bone microarchitecture was found in 30% of patients with fractures without osteoporosis diagnosis based on BMD. In the multivariate analysis, only TBS and age were significantly associated with the occurrence of osteoporotic fractures. TBS reflects the influence of glucocorticoid therapy on bone quality better than DXA measured BMD and provides an added value to DXA in identifying the group of patients particularly prone to fractures.

Modulation of T-Cell Activation Markers Expression by the Adipose Tissue-Derived Mesenchymal Stem Cells of Patients with Rheumatic Diseases

Background:

Activated T lymphocytes play an important role in the pathogenesis of rheumatic diseases (RD). Mesenchymal stem cells (MSCs) possess immunoregulatory activities but such functions of MSCs from bone marrow of systemic lupus erythematosus (SLE), systemic sclerosis (SSc), and ankylosing spondylitis (AS) patients are impaired. Adipose tissue–derived MSCs (ASCs) are an optional pool of therapeutically useful MSCs, but biology of these cells in RD is poorly known. This study aimed at investigating the effect of ASCs from RD patients and healthy donors (HD) on the expression of the key T-cell activation markers.

Methods:

ASCs were isolated from subcutaneous abdominal fat from SLE (n = 16), SSc (n = 18), and AS (n = 16) patients, while five human ASCs lines from HD were used as a control. Untreated and cytokine (tumor necrosis factor α + interferon γ)-treated ASCs were co-cultured with allogenic, mitogen (phytohemagglutinin)-stimulated peripheral blood mononuclear cells (PBMCs) or purified anti-CD3/CD28-activated CD4⁺ T lymphocytes. Contacting and noncontacting ASCs-PBMCs co-cultures were performed. RD/ASCs were analyzed in co-cultures with both allogeneic and autologous PBMCs. Flow cytometry analysis was used to evaluate expression of CD25, HLA-DR, and CD69 molecules on CD4⁺ and CD8⁺ cells.

Results:

In co-cultures with allogeneic, activated CD4⁺ T cells and PBMCs, HD/ASCs and RD/ASCs downregulated CD25 and HLA-DR, while upregulated CD69 molecules expression on both CD4⁺ and CD8⁺ cells with comparable potency. This modulatory effect was similar in contacting and noncontacting co-cultures. RD/ASCs exerted weaker inhibitory effect on CD25 expression on autologous than allogeneic CD4⁺ and CD8⁺ T cells.

Conclusion:

RD/ASCs retain normal capability to regulate expression of activation markers on allogeneic T cells. Both HD/ASCs and RD/ASCs exert this effect independently of their activation status, mostly through the indirect pathway and soluble factors. However, autologous CD4⁺ and CD8⁺ T cells are partially resistant to RD/ASCs inhibition of CD25 expression, suggesting weaker control of T-cell activation in vivo.

AB0820 INFLUENCE OF ANCA ANTIBODIES ON DEMOGRAPHIC AND CLINICAL CHARACTERISTIC OF AAV

Background:

ANCA associated vasculitides (AAV) are a heterogeneous group of rare diseases with unknown etiology and the broad clinical spectrum ranging from life-threatening systemic disease, through single organ involvement to minor isolated skin changes. Unfortunately the clinical classification, ANCA specificity or genetic characteristics alone is not able to categorize AAV patients in a satisfactory manner. As a consequence advanced statistical techniques were used to identify and stratify AAV subphenotypes [1, 2]. Here we have analyzed influence of the ANCA type on clinical manifestations and demographic characteristics in various types of AAV, based on data from the POLVAS registry

Objectives:

We decided to retrospectively analyze a large cohort of Polish AAV patients deriving from several referral centers – members of the Scientific Consortium of the Polish Vasculitis Registry (POLVAS) – and concentrate on demographic and clinical characteristics of anti-PR3 and anti-MPO positive patients regardless of their clinical diagnosis.

Methods:

We conducted a systematic multicenter retrospective study of adult patients diagnosed with AAV between Jan 1990 and Dec 2016. Patients were enrolled by 9 referral centers. We analyzed dichotomous variables: gender; ANCA status – anti-PR3+ or anti-MPO+, ANCA negative; organ involvement - skin, eye, ENT, respiratory, heart, GI, renal, urinary, CNS, peripheral nerves and polytomous variable (number of relapses), supported by quantitative covariates (e.g., age at diagnosis, CRP at diagnosis, maximal serum creatinine concentration ever)[3].

Results:

MPO-positive patients (both GPA and EGPA phenotype) were older at the time of diagnosis with a substantial percentage diagnosed > 65 years of age, and with high rate of renal involvement. Interestingly, while in the whole group of patients diagnosed with EGPA male to female ratio was 1:2, the MPO+ EGPA patients showed M:F ratio of 1:1.

The analysis of ANCA negative AAV reveled significant differences in GPA, ANCA negative group is characterized with significantly lower frequency of renal involvement compared to rest GPA (11,5% vs 63,7%) p<0,05 what should be emphasized ANCA negative AAV never lead to ESRD (end stage renal disease) or even transient dialysis.

Conclusion:

ANCA specificity is indispensable as a separate variable in any clinically relevant analysis of AAV subcategories. MPO+ group is characterized by older age at time of diagnosis, male to female ration 1:1, kidney involvement, and shows more homogenous clinical phenotype than PR3+ AAV patients. In our group ANCA negative AAV never lead to ESRD (end stage renal disease) or even transient dialysis.

References:

[1]Mahr A, Specks U, Jayne D. Subclassifying ANCA-associated vasculitis: a unifying view of disease spectrum. Rheumatol Oxf Engl 2019;58:1707–9. https://doi.org/10.1093/rheumatology/kez148.

[2]Wójcik K, Biedroń G, Wawrzycka-Adamczyk K, Bazan-Socha S, Ćmiel A, Zdrojewski Z et al. Subphenotypes of ANCA-associated vasculitis identified by latent class analysis. Clin Exp Rheumatol. 2020 Sep 1. Epub PMID: 32896241.

[3]Wójcik K, Wawrzycka-Adamczyk K, Włudarczyk A, Sznajd J, Zdrojewski Z, Masiak A, et al. Clinical characteristics of Polish patients with ANCA-associated vasculitides—retrospective analysis of POLVAS registry. Clinical Rheumatology. 1 wrzesień 2019;38(9):2553–63.

Disclosure of Interests:

None declared

POS1086 DIFFERENCES IN PROINFLAMMATORY AND LIPID PROFILE BETWEEN PSORIATIC ARTHRITIS, ANKYLOSING SPONDYLITIS AND RHEUMATOID ARTHRITIS

Background:

Patients with rheumatic diseases such as rheumatoid arthritis (RA), psoriatic arthritis (PsA), and ankylosing spondylitis (AS) are at increased risk of developing dyslipidaemia and premature cardiovascular disease (CVD)(1).

Objectives:

To investigate the relationship between proinflammatory cytokines, microRNA, and lipid profile in patients with RA, AS, and PsA.

Methods:

A group of 65 patients (RA15/ AS25/ PsA25) with high disease activity (mean DAS28 5,98 / ASDAS-CRP 3,7/ DAPSA 38,5) and 25 healthy controls (HC) were compared. Lipid profile comprised triglycerides (TG), total cholesterol(TC), low (LDL), and high-density lipoprotein (HDL). Serum concentrations of IL-6, IL-21, IL-17, TNF and osteoprotegerine (OPG) were measured by commercially available enzyme-linked immunosorbent assays. Expression of miR-233-5p,miR-92-3p,miR-485-3p,miR-10b-5p,let-7d-5p, miR-26 -a-2-3p levels in sera was normalized to miR-16a internal control. The Mann-Whitney test was applied for intergroup comparison, the correlation was assessed using Spearman’s Rank test.

Results:

Patients with RA revealed mixed dyslipidemia (mean values:TC196; LDL 117; HDL, 48 TG; 124 mg/dl), PsA revealed hypertriglyceridemia (TC 175; LDL 100; HDL 50; TG137 mg/dl) and in AS no specific profile was found (TC 179; LDL98; HDL55; TG103 mg/dl). Higher expression of miR-485was observed in patients with PsA (4,8-fold) and AS (5,9-fold) compared to RA and HC groups (3,1 and 1,5-fold p=0,02). Similarly, miR-26a revealed higher expression in patients with PsA (28,4-fold) and AS (21,5-fold) than in RA and HC (3,5 and 2,9-fold p<0,00). PsA patients had higher expression of miR-146b than patients with RA, AS and HC (40,9-fold vs 12,6 vs 15,7 vs 3,4-fold p=0,002) and higher miR-10b (11,7 vs 1,4 vs 4,9 vs 1,7-fold p=0,004). Patients with RA showed higher expression of let7-d than patients with PsA, AS and HC (22-fold vs 1,8 vs 2,3 vs1,9 -fold p=0,002). In PsA miR-92b expression correlated negatively with HDL levels (r=-0,62 p=0,02) and positively with fasting glucose (r=0,71 p<0,00). TG levels negatively correlated with TNF (r=-0,47 p=0,01), IL-17 (r=-0,49 p=0,01) and OPG (r=-0,51 p=0,00) serum levels. Let-7d correlated negatively with TC (r=-0,58 p=0,03). In RA IL-21 positively correlated with LDL (r=0,71 p=0,00) and TC (r=0,75 p=0,001) concentrations. TG levels correlated positively with expressions of miR-92b (r=6,9 p=0,02) and miR-26a (r=0,69 p=0,03). In AS expression of let-7d was correlated positively with HDL (r=0,41 p=0,00) and TC (r=0,45 p=0,00) levels and negatively with ASDAS-CRP (r=-0,675 p=0,02) and CRP levels (r=-0,53 p=0,01). There were no significant differences in OPG, IL-21 concentrations or miR-146b, miR-92b,miR-233 expressions.

Conclusion:

Differences in proinflammatory profile in RA, PsA, and AS seem to be associated with different phenotypes of dyslipidemia. In PsA expression of miR-92b and higher levels of TNF, IL-17 and OPG are associated with altered lipid profile and hypertriglyceridemia. High activity of AS is associated with lowered expression of let-7d, possibly influencing TC and HDL levels. Therefore, measuring lipid profile in active disease might be misleading. In active RA increase of TC and LDL levels was associated with high IL-21 concentration, while hypertriglyceridemia with miR-92b and miR-26a expressions.

References:

[1]Bonek K,et al AB0775 Peripheral joint inflammation is associated with more proatherogenic cardiovascular risk profile in patients with psoriatic arthritis.Annals of the Rheumatic Diseases 2020;79:1685-1686

Disclosure of Interests:

None declared.

EULAR/eumusc.net standards of care for rheumatoid arthritis: cross-sectional analyses of importance, level of implementation and care gaps experienced by patients and rheumatologists across 35 European countries

Objective

As part of European League against Rheumatism (EULAR)/European Musculoskeletal Conditions Surveillance and Information Network, 20 user-focused standards of care (SoCs) for rheumatoid arthritis (RA) addressing 16 domains of care were developed. This study aimed to explore gaps in implementation of these SoCs across Europe.

Methods

Two cross-sectional surveys on the importance, level of and barriers (patients only) to implementation of each SoC (0–10, 10 highest) were designed to be conducted among patients and rheumatologists in 50 European countries. Care gaps were calculated as the difference between the actual and maximum possible score for implementation (ie, 10) multiplied by the care importance score, resulting in care gaps (0–100, maximal gap). Factors associated with the problematic care gaps (ie, gap≥30 and importance≥6 and implementation<6) and strong barriers (≥6) were further analysed in multilevel logistic regression models.

Results

Overall, 26 and 31 countries provided data from 1873 patients and 1131 rheumatologists, respectively. 19 out of 20 SoCs were problematic from the perspectives of more than 20% of patients, while this was true for only 10 SoCs for rheumatologists. Rheumatologists in countries with lower gross domestic product and non-European Union countries were more likely to report problematic gaps in 15 of 20 SoCs, while virtually no differences were observed among patients. Lack of relevance of some SoCs (71%) and limited time of professionals (66%) were the most frequent implementation barriers identified by patients.

Conclusions

Many problematic gaps were reported across several essential aspects of RA care. More efforts need to be devoted to implementation of EULAR SoCs.

FRI0223 SUBPHENOTYPES OF ANCA ASSOCIATED VASCULITIS IDENTIFIED BY LATENT CLASS ANALYSIS

Background:

ANCA associated vasculitides (AAV) are a heterogeneous group of rare diseases with unknown etiology and the clinical spectrum ranging from life-threatening systemic disease, through single organ involvement to minor isolated skin changes. Thus there is an unmet need for phenotype identification especially among patients with granulomatosis with polyangiitis GPA, patients with microscopic polyangiitis MPA group seems to be more uniform. Recently, based on previous clustering analysis and clinical, histopathological, serological and prognostic aspects three subcategories of AAV have been proposed and named as: non-severe AAV, severe PR3-AAV and severe MPO-AAV [1].

Objectives:

In line with these attempts to subcategorize AAV we decided to use latent class analysis (LCA) on a large multicenter cohort of polish AAV patients from POLVAS [2] registry to identify potential new subphenotypes or confirm already proposed ones.

Methods:

Latent Class Analysis (LCA) approach was used as a model based clustering method of objects described by dichotomous (e.g., gender; ANCA status – cANCA, pANCA; organ involvement - skin, eye, ENT, respiratory, heart, GI, renal, urinary, CNS, peripheral nerves) and polytomous (number of relapses) variables supported by quantitative covariates (e.g., age at diagnosis, CRP at diagnosis, maximal serum creatinine concentration ever).

Results:

Results of LCA on our AAV group returned four class model of AAV subphenotypes, confirming existence of the previously proposed by Mahr at al. [1] and revealed fourth – previously not described clinically relevant subphenotype. To this fourth class - belong patients only with GPA, diagnosed at young age, with multiorgan involvement, high relapse rate and relatively high risk of death.

Table 1.

AAV subcategorization – summary of clinical characteristics and ANCA specificity

LCA Class 1LCA Class 2LCA Class 3LCA Class 4No of patients13019410297AAV typeMainly GPAMainly GPAmainly MPAOnly GPAAge at diagnosisMiddle ageMiddle ageOldYoungMale/female ratio1:22:11:11:1Main organ involvementENT, respiratory, eyeRenal, respiratory, ENTRenal, respiratory, skinMultiorgan involvementRelapse rateintermediateintermediatelowhighModified class description (based on ref. [1])Non severe AAVSevere PR3 AAVSevere MPO AAVSevere non-renalPR3 AAV

Conclusion:

Based on multiple clinical and serological variables LCA methodology identified 4-class subphenotypes model of AAV. Fourth-class is a new clinically important subphenotype including exclusively PR3-positive young AAV patients with multiorgan involvement, high risk of relapse and distinct mortality.

References:

[1]Mahr A, Specks U, Jayne D. Subclassifying ANCA-associated vasculitis: a unifying view of disease spectrum. Rheumatol Oxf Engl 2019;58:1707–9.https://doi.org/10.1093/rheumatology/kez148.

[2]Wójcik K, Wawrzycka-Adamczyk K, Włudarczyk A, Sznajd J, Zdrojewski Z, Masiak A, i in. Clinical characteristics of Polish patients with ANCA-associated vasculitides—retrospective analysis of POLVAS registry. Clinical Rheumatology. 1 wrzesień 2019;38(9):2553–63.

Disclosure of Interests:

Krzysztof Wójcik: None declared, Adam Ćmiel: None declared, Anna Masiak: None declared, Zbigniew Zdrojewski: None declared, Radoslaw Jeleniewicz: None declared, Maria Majdan Consultant of: Roche, Amgen, Speakers bureau: Roche, Amgen, Iwona Brzosko: None declared, Marek Brzosko: None declared, Piotr Głuszko: None declared, Małgorzata Stasiek: None declared, Małgorzata Wisłowska: None declared, Joanna Kur-Zalewska: None declared, Marta Madej: None declared, Anna Hawrot-Kawecka: None declared, Hanna Storoniak: None declared, Barbara Bułło-Piontecka: None declared, Alicja Dębska-Ślizień: None declared, Eugeniusz Kucharz: None declared, Katarzyna Jakuszko: None declared, Jacek Musiał: None declared

AB0775 PERIPHERAL JOINT INFLAMMATION IS ASSOCIATED WITH MORE PROATHEROGENIC CARDIOVASCULAR RISK PROFILE IN PATIENTS WITH PSORIATIC ARTHRITIS

Background:

We have previously found that: (i) patients with spondyloarthritis (SpAs) have higher circulating levels of IL-18 and osteoprotegerin (OPG) than healthy controls (1), (ii) psoriatic arthritis (PsA) patients present with more proatherogenic lipid profile and higher IL-18 levels than ankylosing spondylitis (AS) patients (2)

Objectives:

To investigate the relationship between disease phenotype, i.e. peripheral arthritis (perPsA n=45), axial PsA (axPsA n=16) and ankylosing spondylitis (AS n=94), cardiovascular risk factors and serum concentrations of IL-18, IL-17.

Methods:

A group of 155 SpA patients (94 AS/61 PsA), of similar age (44.5 versus 44.9 years), disease duration (4.8 versus 6.8 years), and matched with high disease activity (AS ASDAS-CRP 3.62±0.94; PsA DAPSA 26.75±26.61) were included in the study. The lipid profile comprised triglycerides (TG), total cholesterol (tChol), low- and high-density lipoprotein (LDL and HDL, respectively) measurement. Ischemic Heart Disease (IHD) diagnosis was established from patient’s medical history. Serum concentrations of IL-17AF, IL-18 were measured by specific commercially available enzyme-linked immunosorbent assays (ELISA) and were expressed as medians (pg/ml). The Mann-Whitney test was applied for intergroup comparison, correlation was assessed using Spearman’s Rank tests (r value is shown) with linear regression model.

Results:

Patients with perPsA had higher rate of IHD than axPsA and AS patients (27% vs 0% vs 7.8%, respectively). perPsA patients had significantly higher diastolic blood pressure than AS patients (perPsA 131±13mmHg vs AS 121±14 mmHg), more severe cardiovascular burden than patients with axial disease, were characterised by higher occurrence of obesity (perPsA 42% vs axPsA o 18% vs 18% AS) and hypertriglyceridemia (perPsA 48% vs axPsA 14% vs 16%AS) as well as higher TG concentration (perPsA 165± 87 mg/dl vs axPsA 111± 63mg/dl vs 110± 57 AS mg/dl). Moreover, patients with perPsA had significantly higher serum concentrations of IL-18 than axPsA and AS groups (132.5pg/ml vs 79.2pg/ml vs 84.9pg/ml), but there were no differences between them in IL-17 concentrations. Interestingly, in patients with perPsA, but no other patients’ groups, statistically significant associations between IL-18 concentrations and proatherogenic risk factors were found, as IL-18 correlated positively with TC (r=0.31), TG (r=0.53) atherogenic index (r=0.6), and uric acid (r=0.3) concentrations, while negatively with HDL levels (r=-0.47). Although patients groups differ in cardiovascular risk profiles, there were no significant differences in CV risk estimation using SCORE scale (perPsA 2.3% vs 1.6% axPsA vs 2.1%AS)

Conclusion:

We conclude that in PsA peripheral joints inflammation is associated with more proatherogenic cardiovascular risk profile and higher IL-18 serum levels, that seem to be interrelated, while patient’s disease activity is associated with metabolic syndrome. Generally recommended SCORE scale is practically unable to indicate SpA patients with higher CV risk

References:

[1]Kontny E, et al. PAB0733 Associations of serum osteoprotegerin and IL-18 concentrations with cardiovascular risk in ankylosing spondylitis and psoriatic arthritis patientsAnnals of the Rheumatic Diseases2017;76:1310-1311.

[2]Bonek K et al. ESAT0310 The associations of serumIL-l18 and osteoprotegerin (OPG) levels with the lipid profile in psoriatic arthritis (PSA) patientsAnnals of the Rheumatic Diseases2018;77:1019-1020.

Disclosure of Interests:

None declared

The Phenotype and Secretory Activity of Adipose-Derived Mesenchymal Stem Cells (ASCs) of Patients with Rheumatic Diseases

Mesenchymal stem/stromal cells (MSCs) have immunosuppressive and regenerative properties. Adipose tissue is an alternative source of MSCs, named adipose-derived mesenchymal stem cells (ASCs). Because the biology of ASCs in rheumatic diseases (RD) is poorly understood, we performed a basic characterization of RD/ASCs. The phenotype and expression of adhesion molecules (intracellular adhesion molecule (ICAM)-1 and vascular cell adhesion molecule (VCAM)-1) on commercially available healthy donors (HD), ASC lines (n = 5) and on ASCs isolated from patients with systemic lupus erythematosus (SLE, n = 16), systemic sclerosis (SSc, n = 17) and ankylosing spondylitis (AS, n = 16) were analyzed by flow cytometry. The secretion of immunomodulatory factors by untreated and cytokine-treated ASCs was measured by ELISA. RD/ASCs have reduced basal levels of CD90 and ICAM-1 expression, correlated with interleukin (IL)-6 and transforming growth factor (TGF)-β1 release, respectively. Compared with HD/ASCs, untreated and tumour necrosis factor (TNF) + interferon (IFN)-γ (TI)-treated RD/ASCs produced similar amounts of prostaglandin E2 (PGE2), IL-6, leukemia inhibiting factor (LIF), and TGF-β1, more IL-1Ra, soluble human leukocyte antigen G (sHLA-G) and tumor necrosis factor-inducible gene (TSG)-6, but less kynurenines and galectin-3. Basal secretion of galectin-3 was inversely correlated with the patient's erythrocyte sedimentation rate (ESR) value. IFN-α and IL-23 slightly raised galectin-3 release from SLE/ASCs and AS/ASCs, respectively. TGF-β1 up-regulated PGE2 secretion by SSc/ASCs. In conclusion, RD/ASCs are characterized by low basal levels of CD90 and ICAM-1 expression, upregulated secretion of IL-1Ra, TSG-6 and sHLA-G, but impaired release of kynurenines and galectin-3. These abnormalities may modify biological activities of RD/ASCs.

Link between rheumatoid arthritis and chronic periodontitis

Chronic periodontitis is an infectious disease associated with the progressive destruction of periodontal tissues. In recent years, more and more data indicate an existing relationship between periodontal disease and rheumatoid arthritis. The link between both diseases has been confirmed in multiple studies. Despite the fact that this association might be based on shared environmental and genetic risk factors, a possible causal relation was advocated by experimental, epidemiological and interventional studies, with the leading role of Porphyromonas gingivalis. Individuals with chronic periodontitis are at an increased risk of developing rheumatoid arthritis, as well as rheumatoid arthritis patients are at an increased risk of chronic periodontitis and more severe forms of periodontitis. Furthermore, there is a correlation between the activity in both diseases – patients with more severe periodontitis suffer from more active rheumatoid arthritis. Intervention attempts were also performed, which demonstrated that eliminating periodontal infection and inflammation can affect the severity of rheumatoid arthritis. In this paper, we review the current knowledge about the link between both diseases, focusing on its clinical implications. Will periodontal treatment become a part of standard therapy for rheumatoid arthritis?

Guidelines for the diagnosis and management of osteoporosis in Poland : Update 2017

In the rapidly ageing society in Poland, osteoporosis is a growing epidemiological problem, and osteoporosis-related fractures are a cause of chronic disability and considerable increase of death risk. It turns out that 80 to 90% of patients suffering from osteoporosis, including osteoporosis accompanied by fractures, do not receive adequate pharmacotherapy. In this paper, a Guideline Working Group of experts from the Multidisciplinary Osteoporosis Forum update the existing Polish guidelines concerning the diagnosis and management of osteoporosis (last revised in 2013), taking account of the latest literature, availability and reimbursement of drugs, and current health care organisation. In the revised guidelines, we still postulate that tasks are divided between primary care doctors (stage I) and specialists in osteoporosis management (stage II). We emphasise the necessity of early initiation of pharmacotherapy and rehabilitation in all patients with low-energy fractures. We recommend that the 10-year fracture risk should be estimated in all patients (including those without fractures) who are over 50 years of age, and that the Polish threshold for therapeutic intervention should be adopted: ≥ 10% for FRAX PL calculator. We add strategies of drug choice and therapy monitoring with imaging, and densitometric and biochemical diagnostics. We define basic guidelines concerning prevention of falls, rehabilitation, and dietary procedures, and elimination of environmental and other fracture risk factors. We point to two vital elements for improving osteoporosis management: 1) strategy of supervision over fractures management - Fracture Liaison Service (FLS), and, optimally, 2) strategies of short-term monitoring of the therapeutic efficacy with the use of biochemical markers.

Distinct Secretory Activity and Clinical Impact of Subcutaneous Abdominal Adipose Tissue in Women with Rheumatoid Arthritis and Osteoarthritis

In the general population, low-grade inflammation of adipose tissue accompanies obesity and contributes to cardiovascular disease (CVD) development, but the implication of this tissue in rheumatic disease pathology is unclear. Therefore, we characterized the secretory activity of subcutaneous abdominal adipose tissue (SAAT) of females with rheumatoid arthritis (RA) and osteoarthritis (OA) and searched for its relationship with intensity of systemic inflammation, body composition and comorbidity. The secretion of classical adipokines (leptin, adiponectin), pro- and anti-inflammatory factors, i.e. interleukin (IL)-6, IL-8, IL-10, tumour necrosis factor (TNF), macrophage migration inhibitory factor (MIF) and hepatocyte growth factor (HGF), from SAAT explants was measured by specific enzyme-linked immunosorbent assays. Patients' body composition was evaluated by bioelectric impendence technique. Rheumatoid SAAT secreted more adiponectin, IL-6, IL-10, TNF and MIF but less leptin than respective osteoarthritis tissues. In RA patients, TNF secretion correlated with cachectic body composition, HGF release was linked to secondary amyloidosis and visceral fat rating was an independent risk factor for CVD. In OA, secretion of leptin and HGF positively, while adiponectin inversely, correlated with systemic inflammation markers, and the release of MIF was an independent risk factor for CVD. This study reveals differences between RA and OA patients in SAAT secretory activity and suggests its different clinical impact in these diseases, characterized by high- and low-grade systemic inflammation, respectively. In RA, SAAT may directly or via an effect on body composition contribute to amyloidosis, cachexia or CVD co-occurring, while in OA SAAT-derived adipocytokines may rather regulate intensity of systemic inflammation and redound to CVD emergence.

Polish guidelines for the diagnosis and management of osteoporosis: a review of 2013 update

To decrease the risk of osteoporotic fractures in Poland, the Multidisciplinary Osteoporotic Forum has set up a joint Working Group including the representatives of the Polish Associations of Orthopedics and Traumatology, Rehabilitation, Gerontology, Rheumatology, Family Medicine, Diabetology, Laboratory Diagnostics, Andropause and Menopause, Endocrinology, Radiology, and the STENKO group as well as experts in the fields of rheumatology, obstetrics, and geriatrics to update the Polish guidelines for the diagnosis and management of osteoporosis in men and postmenopausal women in Poland. The assessment of fracture risk and intervention thresholds was made using the FRAX® calculation tool for Poland. The strength of recommendations was evaluated according to the principles of the Scottish Intercollegiate Guidelines Network and the results have been approved by national consultants. Finally, the Working Group has formulated the updated guidelines and recommended two -step diagnostic and therapeutic procedures. The first stage applies to family physicians or general practitioners and involves the assessment of fracture risk using the FRAX®-BMI to identify patients at high risk of fractures. An osteoporotic fracture remains an absolute indication both for the general practitioner and specialist to implement treatment. At the second stage, the specialist (in an osteoporosis or other specialty clinic) should review the primary or secondary causes of fracture risk, confirm the diagnosis, and introduce an appropriate treatment and monitoring. In patients (men aged >50 years and postmenopausal women) without low-energy fractures, the absolute risk of fractures exceeding 10% should be considered an indication for treatment. The Polish guidelines were compared with other international guidelines in terms of diagnostic measures, pharmacotherapy, as well as calcium and vitamin D supplementation.

Plasma asymmetric dimethylarginine in active rheumatoid arthritis: links with oxidative stress and inflammation

INTRODUCTION

 Endothelial dysfunction and accumulation of asymmetric dimethylarginine (ADMA) have been identified as independent predictors of future cardiovascular events in patients with coronary artery disease.

OBJECTIVES

 The aim of the study was to investigate the factors that determine increased accumulation of ADMA, an endogenous inhibitor of nitric oxide synthesis, in patients with rheumatoid arthritis (RA).

PATIENTS AND METHODS

 We studied 46 consecutive patients with RA (39 women, 7 men; mean age, 57 years [range, 23-75 years]) with active disease (mean Disease Activity Score 28 [DAS28], 5.2), without clinically overt cardiovascular disease and 50 controls matched for age, sex, hypertension, blood cholesterol, and glucose. We assessed the plasma levels of ADMA, symmetric dimethylarginine (SDMA), L‑arginine, and the marker of oxidative stress, 8‑iso‑prostaglandin F2α (8‑iso‑PGF2α). 

RESULTS

 ADMA and SDMA levels were significantly higher in the RA group than in controls (0.58 ±0.081 vs. 0.46 ±0.045 μmol/l, P <0.0001; 0.45 ±0.07 vs. 0.36 ±0.046 μmol/l, P <0.0001; respectively). ADMA levels in the RA group correlated positively with fibrinogen (r = 0.70, P <0.00001), C‑reactive protein (CRP; r = 0.88, P <0.00001), DAS28 (r = 0.44, P = 0.002) and Health Assessment Questionnaire scores (r = 0.39, P = 0.008), but not with age, renal function, or the medications used. 8‑iso‑PGF2α correlated positively with ADMA (r = 0.82), SDMA (r = 0.72), CRP (r = 0.76), fibrinogen (r = 0.57) (all, P <0.0001) and DAS28 (r = 0.44, P = 0.003). Regression analysis models showed that CRP was the only independent predictor of 8‑iso‑PGF2α and ADMA levels in RA.

CONCLUSIONS

 Our study is the first to show positive associations between plasma ADMA levels and the production of 8‑isoprostanes and CRP in RA.

Non-steroidal anti-inflammatory drugs and the risk of cardiovascular diseases: are we going to see the revival of cyclooxygenase-2 selective inhibitors?

The use of non-steroidal anti-inflammatory drugs (NSAID) is associated with a number of gastrointestinal and other adverse effects. Introduction of selective cyclooxygenase-2 (COX-2) inhibitors at the end of the 20th century raised hopes for a substantial reduction in the rate of serious events such as upper gastrointestinal ulcers, bleeding and perforations. In 2004 and 2005, predictions of some pharmacologists were confirmed when the Adenomatous Polyp Prevention on VIOXX trial (APPROVE) and other randomized, double-blind, placebo-controlled trials with COX-2 inhibitors showed an increased rate of thrombotic vascular events, including myocardial infarction, in patients treated with coxibs. So far, only limited long-term data on cardiovascular risk associated with non-selective NSAID have been available; however, some studies have suggested that both selective COX-2 inhibitors and traditional NSAID increase the risk of cardiovascular events. For patients at high cardiovascular risk, contradictory warnings and recommendations have been published recently by the American Heart Association, Food and Drug Administration, and by independent experts. The current paper reviews these recommendations and discusses the therapeutic challenge to minimize the risk of serious adverse events associated with the use of NSAID.

[Effects of biologic antirheumatic treatments on bone metabolism in rheumatoid arthritis and ankylosing spondylitis]

Systemic inflammatory disorders like rheumatoid arthritis (RA) and ankylosing spondylitis (AS) are characterized by extensive dysregulation of bone metabolism recognized as focal articular bone erosions, juxta-articular and systemic bone loss. The complex interactions between bone cells, osteoprotegerin/RANKL pathway and a variety of inflammatory mediators are involved in the pathogenesis of focal and systemic osteopenia. Treatments with TNF-alpha blockers inhibit inflammation-induced bone resorption and might prevent structural bone damage in RA. In some studies with anti-TNF agents, an increase in BMD has been documented in spondyloarthropathies and in RA. The B-cell depleting antibody rituximab and the T-cell costimulation blocker abatacept are emerging as other effective treatment options in RA. Studies with anti- RANKL antibody Denosumab in RA demonstrate, that treatment targeting RANKL prevents development of erosions but not inflammation. This article reviews recent scientific literature regarding the effects of modern targeted therapies on bone turnover, bone mass and focal damage of joints.

Is Taurolidine a candidate for treatment of rheumatoid arthritis?

OBJECTIVE

To study the therapeutic potential of taurolidine (TRD), a derivative of taurine with known anti-inflammatory and anti-proliferative properties, in various experimental models of synovitis.

METHODS

In vitro: fibroblast-like synoviocytes (RA FLS) isolated from the synovial tissue of patients with rheumatoid arthritis (RA) were cultured in the presence of either TRD or polyvinylpyrrolidine (PVP), the pharmaceutical stabilizer of TRD, which was used as a control. Proliferation of RA FLS and cytokine (IL-6 and IL-8) release were measured. In vivo: (A). The effect of systemic TRD treatment on the development of collagen-induced arthritis (CIA) in female DBA1/J mice was investigated. Mice were treated either with intraperitoneal injections of 1 ml of 2% Taurolin Boehringer Ingelheim (TRD +PVP) or with PVP as placebo. The incidence of arthritis, myeloperoxidase (MPO) activity in periarticular tissue, as well as serum concentration of IgG specific to collagen II (IgG alphaCII) were determined. (B). The effect of intra-articular TRD treatment was studied in rabbits with antigen-induced monoarthritis (AIA). After the induction of AIA of right knees rabbits were treated either with intra-articular injections of 0.5 ml of 2% Taurolin or 0.5ml PVP ( placebo). The animals were examined for clinical signs of arthritis and diameter of joints was measured. After termination of the experiment, the arthritic knees were examined and histopathology of the joints was assessed. In addition, serum amyloid A (SAA) concentration was measured.

RESULTS

n vitro: TRD exerted cytotoxic effect on RA FLS when applied at concentrations >100 microM. TRD at non-cytotoxic concentrations, inhibited PDGF-triggered RA FLS proliferation, reduced IL-1beta - stimulated production of IL-6 and slightly decreased intracellular content of IL-8. In vivo: (A). Intraperitoneal treatment with Taurolin significantly reduced the incidence (30%) of CIA when compared to the control mice (79%). However, Taurolin failed to control the development of CIA in mice with high serum level of IgG alphaCII (>1000 U).(B). Intra-articular application of 2% Taurolin resulted in amelioration of AIA in all treated rabbits (reduced diameter of arthritic joints and smaller rise of SAA level as compared to the control animals). Histopathologic evaluation revealed pannus formation in both groups and extensive necrotic lesions of synovial tissue treated with TRD, suggesting synoviorthesis-like effect.

CONCLUSION

Results from AIA and from in vitro RA FLS studies suggest that intra-articular administration of TRD could be used as a "pharmacological scalpel" to remove the inflamed synovium. Our data confirmed anti-inflammatory and anti-proliferative properties of TRD in all experimental models encouraging further studies which should evaluate its therapeutic potential in RA.

[Atherosclerosis and rheumatoid arthritis]

There is growing evidence that patients with rheumatoid arthritis (RA) are at higher risk of cardiovascular diseases (CVD) including myocardial infarction and stroke. Recent analysis indicate that CVD is the most common cause of death in RA; however research on traditional risk factors such as smoking, hypertension or elevated cholesterol level has shown mixed results. There are many convincing suggestions that RA-specific factors associated with systemic inflammation may play a critical role in endothelial cell damage and accelerated development of atherosclerosis. Since atherosclerosis is currently recognized as a chronic inflammatory condition that can be converted into an acute clinical event by plaque rupture and thrombosis--the interplay between inflammatory mediators including cytokines (TNF-alpha, IL-1, IL-6), C-reactive protein, blood coagulation factors and vessel wall cells attracts much attention. Their pivotal role in the pathogenesis of both diseases, RA and atherosclerosis has been presented and discussed in our review.

[Adaptation of computed tomography and roentgenography to bone density measurements]

The increasing interest in issues connected with osteoporosis has recently caused the development of many new diagnostic methods which allow the measurement of bone density. The DEXA method, performed by specialised densitometers, is one of the most developed and reliable methods. However, the high cost od densitometers and DEXA investigation prevent this method from becoming easily accessible for everyday diagnosis. The adaptation of computerised tomography and rentgenography to densitometric measurements could be one of the methods by which the problem of densitometric diagnosis accessibility could be solved. Both methods are usually applied in the imaging of human tissues, working on the basis of differences in tissue X-ray absorption. X-ray absorption and density are related by linear function in the energy range used in rentgenography and tomography; therefore, quantitative information concerning density should be easily received. The procedure adapting computerised tomography and rentgenography to quantitative measurements of bone density in the lumbar spine is outlined in this work. The quantitative information is obtained from digitalised tomographic and rentgenographic images through use of a personal computer. Both methods were tested using a set of phantoms imitating the lumbar spine and the surrounding tissues. The precision and accuracy of both methods were assessed and compared to the precision and accuracy of the DEXA method. The outlined results confirm the usefulness of the described method in diagnosis.

[Treatment of respiratory tract infections with pefloxacin]

Pefloxacin, a 4-quinolone derivative, was administered in the dose of 800-1200 mg for the mean of 12 days to 24 patients with respiratory tract infection complicating chronic bronchial asthma or chronic obstructive lung disease. Patients with positive sputum culture and bacteria sensitive to pefloxacin were included in the study. Total eradication of the offending microorganisms was achieved in 54% of patients, and partial--in the next 20%. A poor efficacy of pefloxacin against Streptococcus species has been confirmed. In a few cases we have observed the development of resistance of isolated bacteria to pefloxacin during the course of treatment.

[A preliminary assessment of the incidence of atopy at a workplace in Cracow]

Skin tests, IgE level and eosinophils percentage were determined in 337 employees of the "Hydrokop" Works in Cracow. These investigations aimed at seeking more specific markers of allergy than anamnesis and skin tests. Allergy was reported by 108 individuals (38%). Some features of atopy were confirmed in 7.5%. Skin tests were positive in 36 individuals and were related to atopy in 55%. IgE levels were 10 IU/ml--greater than 1000 IU/ml with the distribution similar to log-normal. Mean IgE concentration was relatively high (202 IU/ml, in the individuals with confirmed congenital allergy. Percentage of eosinophils exceeded 3% in 39 subjects out of which 17 reported the symptoms of allergy. IgE level and percentage of eosinophils are controversial as the markers of atopy due to the contribution of various non-allergic factors while skin tests correlate well with allergic diseases which were relatively frequent in the examined group.

[Netilmicin in the treatment of bacterial respiratory tract infections]

Netilmicin - a semisynthetic aminoglycoside - was administered to 33 patients with the acute or chronic lower respiratory tract or pulmonary infections in a daily dose of 5 mg/kg body weight for 10 days. A principle criterium of patients classification to netilmicin therapy were sensitive bacterial strains either in sputum or in BAL liquid. A significant clinical improvement was noted in 88% of the treated patients. However, elimination of pathogens from the sputum was achieved only in 52% of these patients. No improvement was observed in 4% of the treated patients. No adverse reactions were noted. Netilmicin proved safe and effective antibacterial agent in patients with respiratory infections.