Elizabethkingia miricola: an opportunistic pathogen in ICU

Background

The Elizabethkingia genus is formed by a group of bacteria which are widely distributed in nature. Elizabethkingia is not part of human microbiota, therefore is considered to be an opportunistic pathogen. In the last years, it has become a cause of potentially fatal disease, becoming an emerging bacteria of increasing relevance. The objective of this study is to describe the impact of Elizabethkingia bacteria in infected patients in the ICU of a hospital in Granada.

Methods

Descriptive study. Patients who have been isolated in a biological sample of Elizabethkingia miricola throughout the year 2.021 in the ICU of San Cecilio University Hospital in Granada. Date and place of isolation were registered. Other variables registered were sex, age, length of ICU stay, days between ICU admission and bacterium isolation, days between bacterium isolation and death, infection, cause of admission or cause of death.

Results

Bacterium was isolated in 15 patients. Cause of admission was COVID-19 in 73.3% of patients. 73.3% were men and 26.6% women.The average age was 56.9 years. The average length of ICU stay was 43.8 days. 4 patients were diagnosed with ventilator-associated pneumonia and 5 patients were diagnosed with tracheobronchitis.The average days between ICU admission and bacterium isolation was 26,4 days. The average days between mechanical ventilation and bacterium isolation was 25.9 days. 53.3% of patients died. The average days between bacteria isolation and death was 18.2 days.

Conclusions

Elizabethkingia miricola is an emerging bacterium under special vigilance due to its capacity to cause major morbidity and mortality in admitted patients in ICU. The rapid identification and the study of the antibiotic susceptibility is considered of special relevance so they can be correctly managed to avoid infections and complications resulting from this microorganism.

Key messages

• Elizabethkingia is a special surveillance bacterie due to its morbidity and mortality effects.

• Elizabethkingia could be a severity indicator in admitted patients to the ICU.

AB1185 PATIENT-REPORTED EXPERIENCE IN IMMUNE MEDIATED INFLAMMATORY DISEASES (IMID) IN THECONTEXT OF THE COVID-19 PANDEMIC: ACCESSIBILITY AND CONTINUITY OF CARE

Background

The lockdown and mobility restrictions in early COVID19 pandemic had a great impact in chronic patient care due to limited access and scheduled visits. In our hospital, coordinated non-pharmacological interventions (NPI) were designed in Rheumatology and Pharmacy services to maintain the accessibility and continuity of care for patients with IMID.

Objectives

To evaluate the patient reported experience (PRE), health status and quality of life in Rheumatology outpatient IMID subjects since March 14, 2020 when lockdown was imposed and during subsequent restrictions, related to the healthcare team and medications accessibility, and continuity of care.

Methods

Observational study, using a patient survey. Adult patients attending the rheumatology outpatient clinic between Nov 2, 2020 to Feb 13, 2021, with rheumatoid arthritis (RA), psoriatic arthritis (PsA), spondylarthritis (SpA) or systemic autoimmune diseases (SAD), with at least 1 year from diagnosis and 1 month of treatment with conventional synthetic (cs) targeted synthetic (ts) or biological (b) disease modifying antirheumatic drugs (DMARD). Face to face or phone interviews were conducted using an ad hoc designed questionnaire that included COVID19 related questions, the 11 IEXPAC scale items (5 point Likert scale ranging from never to always) (www.iexpac.org), and 4 items (5 points, very good to very bad) of the global scale PROMIS 10 (Patient-Reported Outcomes, PRO). All questions refer to the patient’s experience during the 6 months prior to data collection.

Results

From 174 screening patients, 158 completed the survey, mainly woman (66.5%) with a median age of 60 (IQR 47-69,3) years. The most frequent diagnosis was RA (43%) followed by ESAP (35%), EAS (22%) and PsA (13%). 46.8% of the patients have been prescribed b or ts DMARD and 53.2% sc DMARD, 32.9% in combination. From 158, 39 persons requested healthcare for COVID-19 related symptoms and diagnosis was confirmed in 17 (10,8%). Just 2 patients required hospital admission. Clinical control and continuity of care for COVID19+ patients were carried out from their primary care center and by phone consultation. Some key results of the survey are displayed in Table 1.

Table 1.

PRO and Patients’ perception during COVID19 lockdown and restrictions.

During confinement and restrictions due to covid-19, in the last 6 months …Responses (%)N= 158Your degree of concern about the COVID19 crisis is.High + Quite high (86.7)PRO (PROMIS 10)How good was your health …?Very good (11.4), Good: (43.7)and your emotional/mental health, including mood and ability to think?Very good (10.1)Good (41.1)your quality of life was.Very good (8.25) Good (49,4)Your satisfaction in performing daily tasks (home, work, family) was.Very good (7.8)Good (55.1)Accessibility to care and medicationsI could contact my rheumatologist whenever I needed (email, phone).Always (79.9)My rheumatologist changed my face-to-face visit for a phone callYes (53)I received my medication at home from the hospital pharmacyYes (16)I picked up my medication from the hospital pharmacy, without incident.Yes (21)I maintained the prescribed dose medication…Always + almost always (96,2)At some point I modify a medication by my own decisionYes (6)My doctor changed the dose or route of administrationYes (7)Your satisfaction with the care provided from all professionals in the team wasVery + Quite satisfied (75)PREMS (IEXPAC)Item 2. The professionals … are coordinated to offer me good healthcareAlways (34.18)Item 8. They make sure that I take my medication correctlyAlways (73.42)Item 9. They worry about my welfareAlways (74.68)

Conclusion

Lessons have learned during the COVID19 lockdown and restrictions by assessing patients’ health status and patients-reported experience. Coordinated NPI such as medication monitoring and home delivery, appointment reorganization and protocolized phone visits can result in a good patient perception and medication adherence whilst receiving care in a challenging situation.

Disclosure of Interests

None declared

POS0796 TREATMENT, ADVERSE EVENTS AND FOLLOW UP IN PATIENTS WITH GIANT CELL ARTERITIS IN THE ARTESER MULTICENTER STUDY

Background

Glucocorticoids (GC) are the mainstay therapy in Giant Cell Arteritis (GCA), initially at high doses (40-60 mg/day) followed by gradual glucocorticoid tapering. This treatment, especially in older patients, is associated with numerous adverse effects (AE). In addition, there are frequent relapses. Therefore, conventional synthetic immunosuppressants such as methotrexate (MTX), leflunomide, azathioprine, cyclophosphamide or mycophenolate, have been used with controversial results. Studies with biological immunosuppressants, such as TNFi have been ineffective; in contrast, tocilizumab (TCZ) has obtained positive results and was approved for the treatment of GCA.

Objectives

In the ARTESER study we describe a) treatment with GC, synthetic or biological immunosuppressants; b) AE of CG; and c) evolution.

Methods

ARTESER is a retrospective observational study sponsored by the Spanish Society of Rheumatology. 26 Spanish centers participated and all new patients diagnosed with GCA from June 1, 2013 to March 29, 2019 were included. Data on GC and immunosuppressants were collected at the beginning and during the follow-up of GCA patients. For the calculation of the cumulative dose of GC, an application was developed that, by including the periods of time, dose and type of GC received during follow-up, performs the automatic calculation in mg of prednisone.

Results

Of the 1675 patients included, GC treatment was adequately recorded in 1650 patients (Table 1). All received oral treatment, being prednisone the most frequently drug used (N=1602, 97.09%). In addition, 426 (25.82%) patients received at least one iv pulse of methylprednisolone, being the 1000 mg regimen the most frequent (n=217; 50.9%). The total mean duration of GC treatment was 22.65 months. The mean cumulative dose per patient at the end of follow-up was 8514.98 mg of prednisone.

Table 1.

Corticosteroid treatment and immunosuppressive treatment

Patients taking oral corticosteroid1650 Prednisone, n (%)1602 (97.09) Methylprednisolone, n (%)164 (9.94) Deflazacort, n (%)64 (3.88)Patients receiving intravenous corticosteroid, n (%)426 (25.82)Mean duration of steroid treatment, mean (SD)22.65 (17.36)Mean cumulative dose at the end of follow-up per patient, mg of prednisone, mean (SD)8514.98 (6570.21)Methotrexate at diagnosis*, n (%)165 (9.9)Leflunomide at diagnosis*, n (%)2 (0.1)Azathioprine at diagnosis*, n (%)3 (0.2)Cyclophosphamide at diagnosis*, n (%)7 (0.4)Mycophenolate at diagnosis*, n (%)1 (0.1)Tocilizumab at diagnosis*, n (%)22 (1.3)Methotrexate during follow-up, n (%)532 (31.8)Leflunomide during follow-up, n (%)19 (1.2)Azathioprine during follow-up, n (%)26 (1.5)Cyclophosphamide during follow-up, n (%)10 (0.6)Mycophenolate during follow-up, n (%)10 (0.6)Tocilizumab during follow-up, n (%)153 (9.1)

The most widely used immunosuppressant was MTX both at diagnosis (n=165; 9.9%) and during follow-up (n=532; 31.8%), followed by TCZ, at diagnosis (22; 1.3%) and at follow-up (153; 9.1%).

AE with GC were described in 393 patients (23.8%), highlighting serious infections (n=67; 10.03%) followed by diabetes mellitus (n=63; 9.43%), steroid myopathy (n=53; 7.9%), vertebral fractures (n=47; 7.04%), non-vertebral fractures (n=36; 5.39%), heart failure (n=36; 5.39%), arterial hypertension (n=34; 5.09%) and neuropsychiatric alterations (n=27; 4.04%).

During the follow-up, 334 (19.9%) patients had relapses, 532 (31.8%) were hospitalized on some occasion, and 142 patients (8.48%) died. The main cause of death were infections (n=44; 30.99%), neoplasms (n=23; 16.2%), cardiovascular (n=15; 10.56%), and cerebrovascular (n=10; 7.04%).

Conclusion

The main treatment for GCA was oral GC, which were required for almost two years on average, in a quarter of patients associated with IV pulses. The cumulative steroid dose was high as well as the side effects. MTX was the most widely used immunosuppressant and TCZ was prescribed in 10%. Relapses and admissions at the hospital were relatively frequent.

Acknowledgements

This study has been funded by ROCHE Farma. The funder has not participated in the design, analysis, or interpretation of the results

Disclosure of Interests

None declared

AB1463 CHARACTERISTICS AND MORTALITY OF PATIENTS WITH AUTOIMMUNE RHEUMATIC DISEASES ADMITTED TO THE INTENSIVE CARE UNIT

Background

Autoimmune rheumatic diseases (ARD) are associated with multiple organ dysfunction, which may require admission to Intensive Care Units (ICU), constituting a challenge for rheumatologists and intensivists. The new immunomodulatory treatments may be changing the characteristics and mortality of these patients.

Objectives

The primary objective of the study is to know the mortality and the characteristics related to this event of our patients admitted to the ICU in the last 5 years. The secondary objective is to compare the characteristics of our series with the series of our patients admitted to the ICU in the previous decade.

Methods

We conducted a retrospective transversal observational study using computerized medical records. A database was created with patients with ARD admitted to the ICU of the Princess University Hospital between October 1, 2015 and September 30, 2020, excluding those with a stay of less than 24 hours. Information was collected about the characteristics and treatments of the disease prior to their admission to the ICU, as well as the clinical characteristics and therapeutic measures established in the ICU during their stay.

Statistical analysis was performed using SPSS.

Results

After ruling out admissions of less than 24 hours, a population of 45 patients with a mean age of 65.3 ± 12.2 years and 69% women were included. Connectivopathies (40%) and rheumatoid arthritis (37.8%) were the most prevalent ARDs that required admission to the ICU. Cardiovascular events (51%) were the main reason for ICU admission, followed by infectious processes (27%). The median ICU stay was 5 days. It is striking that 77% of the patients had received glucocorticoids prior to admission throughout their disease. The median score on the severity scales was 34 in SAPS II and 17 in APACHE II. Mortality during the ICU stay was 30.4% and in the multivariate analysis it was associated with the previous administration of glucocorticoid boluses and the APACHE II scale score. This mortality is higher compared to historical series of patients admitted to Spanish ICUs with similar APACHE II severity scores.

In the comparative study with the previous period, similar mortality rates were observed, an increase in the mean age of those admitted, a decrease in patients with vasculitis and an increase in patients with rheumatoid arthritis. Likewise, an increase in cardiovascular events is observed as a fundamental reason for admission to the ICU.

Conclusion

The mortality of our patients with ARD admitted to the ICU in the last five years is 30.4%, similar to the previous decade but higher than the observed in other pathologies with similar severity characteristics. It is related to the APACHE II score and to the prior administration of glucocorticoid boluses. Connectivopathies and rheumatoid arthritis are the diseases that are most frequently admitted to the ICU and the fundamental reasons are cardiovascular events and infections.

Disclosure of Interests

None declared

Sleep Problems Are Related to a Worse Quality of Life and a Greater Non-Motor Symptoms Burden in Parkinson's Disease

INTRODUCTION

The aim of the present study was to examine the frequency of self-reported sleep problems and their associated factors in a large cohort of PD patients.

METHODS

PD patients and controls, recruited from 35 centers of Spain from the COPPADIS cohort were included in this cross-sectional study. Sleep problems were assessed by the Spanish version of the Parkinson's disease Sleep Scale version 1 (PDSS-1). An overall score below 82 or a score below 5 on at least 1 item was defined as sleep problems.

RESULTS

The frequency of sleep problems was nearly double in PD patients compared to controls: 65.8% (448/681) vs 33.5% (65/206) (p < 0.0001). Mean total PDSS score was lower in PD patients than controls: 114.9 ± 28.8 vs 132.8 ± 16.3 (p < 0.0001). Quality of life (QoL) was worse in PD patients with sleep problems compared to those without: PDQ-39SI, 19.3 ± 14 vs 13 ± 11.6 (p < 0.0001); EUROHIS-QoL8, 3.7 ± 0.5 vs 3.9 ± 0.5 (p < 0.0001). Non-motor symptoms burden (NMSS; OR = 1.029; 95%CI 1.015-1.043; p < 0.0001) and impulse control behaviors (QUIP-RS; OR = 1.054; 95%CI 1.009-1.101; p = 0.018) were associated with sleep problems after adjustment for age, gender, disease duration, daily equivalent levodopa dose, H&Y, UPDRS-III, UPDRS-IV, PD-CRS, BDI-II, NPI, VAS-Pain, VAFS, FOGQ, and total number of non-antiparkinsonian treatments.

CONCLUSION

Sleep problems were frequent in PD patients and were related to both a worse QoL and a greater non-motor symptoms burden in PD. These findings call for increased awareness of sleep problems in PD patients.

Osteoporotic patients treated with bisphosphonates do not show the increased mortality observed in those untreated

INTRODUCTION

Osteoporosis has been said to be associated with increased mortality. On the other hand, it is debated whether treatment with bisphosphonates may reduce mortality in osteoporotic patients. To contribute to the clarification of these issues, we have studied in a prospective cohort the mortality in people without osteoporosis and in patients with osteoporosis, untreated or treated with bisphosphonates MATERIAL AND METHODS: At their inclusion in the cohort, four groups of participants were identified: (a) people without osteoporosis (group 1); (b) osteoporotic patients treated with bisphosphonates (group 2); (c) osteoporotic patients who refused to be treated (group 3); and (d) patients who met osteoporosis diagnostic criteria but were not treated because their risk of fracture was considered to be low (group 4). To compare all four groups, unadjusted Kaplan-Meier estimates of survivorship were obtained and they were compared using log-rank test. Hazard ratios were then estimated via Cox regression adjusting for the main confounders. A comparison among the osteoporotic groups was made by means of a Cox regression analysis performed using only these three groups, adjusting for propensity scores.

RESULTS

Two thousand six hundred and sixty-five people were included. In the unadjusted analysis, mortality in group 3 was higher than in the other groups (p < 0.001). Taking group 1 as a reference, Cox regression analysis showed the following mortality HRs for groups 2, 3, and 4 after adjusting for confounding factors: 0.82 (0.41-1.63), 1.37 (0.90-2.10), and 0.69 (0.46-1.02). In the analysis of the osteoporotic groups with the PS generated for them, and taking group 2 as a reference, the HRs were as follows: group 3, 2.38 (1.34-4.22); group 4, 1.45 (0.61-3.43).

CONCLUSION

Mortality in osteoporotic patients who refused treatment is higher than in osteoporotic patients treated with bisphosphonates. In unadjusted analysis, it was also higher than in non-osteoporotic people; however, this difference disappeared after adjustment for confounding factors.

AB0427 ANTI-NOR90 AUTOANTIBODIES: FAVORABLE OR UNFAVORABLE PROGNOSIS?

Background:

Anti-NOR 90 autoantibodies (anti-NOR90 Ab) are autoantibodies that target nucleolar transcription factor 1 or hUBF, involved in transcription of RNA polymerase I. These autoantibodies have been detected in 6.1% of patients with Systemic Sclerosis (SSc), but their clinical or prognostic significance has not been clearly defined. Anti-NOR90 Ab have been mostly associated with limited scleroderma with mild organ involvement and can also be found in other rheumatic diseases such as rheumatoid arthritis, systemic lupus erythematosus or Sjogren’s syndrome.

Objectives:

The aim of this study was to identify the main clinical characteristics of patients with positive anti-NOR90 in our Centre.

Methods:

This is a retrospective, descriptive, cross-sectional study of all patients with positive anti-NOR90 Ab between January 2013 and December 2020 in a single center. Autoantibodies testing was performed using Euroimmun EUROLINE SSc profile IgG autoAb assay kit. Patient demographics, clinical characteristics, associated diagnoses, laboratory and immunological findings were collected.

Results:

We identified a total of 26 patients with at least a positive value for anti-NOR90 Ab (Table 1). In most cases anti-NOR90 patients were ANA positive, predominantly with nucleolar pattern and coexisted with other SSc autoantibodies. 12 patients had rheumatic diseases and two had SSc, both with limited cutaneous SSc and absence of organ involvement. 14 patients had no definite diagnosis. Clinical features of anti-NOR90 patients are represented in Figure 1. Five patients presented Raynaud’s phenomenon, two cases with pathological nailfold capillaroscopy and one patient had SSc. There was no patient with skin ulcers, calcinosis, interstitial lung disease or pulmonary hypertension. Four patients had gastroesophageal reflux disease and one patient presented antral vascular ectasia. Six patients developed some neoplasm.

Figure 1.

Clinical characteristics of anti-NOR90 Ab patients.

Conclusion:

In our case series anti-NOR90 Ab were associated with multiple rheumatic diseases with heterogeneity of clinical manifestations. We did not observe a further progression to SSc or presence of organ involvement or severe scleroderma, so these autoantibodies could be related with a favorable prognosis. In contrast with previous reports, a striking association with cancer has been detected in our population.

Table 1.

Demographic characteristics and main diagnoses of anti-NOR90 positive patients.

CharacteristicsTotal Anti-NOR90: 26 patientsSex, n19 women/ 7 menAge, mean (years)58,9 IQR [46,3-72,2]Race, nAsian: 1; Hispanic: 7; Caucasian: 18Smoker, n3Positive ANA (>1/160), nPattern, n247 Homogeneous, 4 Nucleolar, 4 Speckled, 1 Centromere, 5 Speckled -nucleolar, 3 Homogeneous-nucleolar.Positive ENA, n32 Anti-SSA-Ro52 and Ro60, 1 anti-RNP and anti-SmSystemic sclerosisautoantibodies, n•Anti-Ku: 7•Anti-U3RNP (Fibrilarin): 6•Anti-RNA polymerase III: 5•Anti Th/To: 4•Anti-centromere: 4 (CENP B +/- CENPA)•Anti-topoisomerase I: 2•Anti-Ro52: 3•Anti-PM-Scl: 3Main diagnosis, n12 Rheumatic diseases:2 systemic Sclerosis (2 limited/0 diffuse)1 rheumatoid arthritis1 LES1 Sjögren’s syndrome,3 undifferentiated conective tissue disease2 overlap (1 Sjögren + LES, 1 Sjögren + MCTD 1)s: 1 morphea, 1 cutaneous graft versus host diseaseNeoplasm, n6: 2 solid organ cancer (bladder, kidney), 1 lung adenocarcinoma, 1multiple myeloma, 1 acute myeloid leukemia: 1 basal cell carcinoma.

Abbreviations: LES: systemic lupus erythematosus; MCTD: mixed connective tissue disease

Disclosure of Interests:

None declared

Depression is Associated with Impulse-compulsive Behaviors in Parkinson's disease

BACKGROUND

Depression and impulse control disorders (ICDs) are both common in Parkinson's disease (PD) patients and their coexistence is frequent. Our aim was to determine the relationship between depression and impulsive-compulsive behaviors (ICBs) in a large cohort of PD patients.

METHODS

PD patients recruited from 35 centers of Spain from the COPPADIS cohort from January 2016 to November 2017 were included in the study. The QUIP-RS (Questionnaire for Impulsive-Compulsive Disorders in Parkinson's Disease-Rating Scale) was used for screening ICDs (cutoff points: gambling ≥6, buying ≥8, sex≥8, eating≥7) and compulsive behaviors (CBs) (cutoff points: hobbyism-punding ≥7). Mood was assessed with the BDI-II (Beck Depression Inventory - II) and major, minor, and subthreshold depression were defined.

RESULTS

Depression was more frequent in PD patients with ICBs than in those without: 66.3% (69/104) vs 47.5% (242/509); p<0.0001. Major depression was more frequent in this group as well: 22.1% [23/104] vs 14.5% [74/509]; p=0.041. Considering types of ICBs individually, depression was more frequent in patients with pathological gambling (88.9% [8/9] vs 50.2% [303/603]; p=0.021), compulsive eating behavior (65.9% [27/41] vs 49.7% [284/572]; p=0.032), and hobbyism-punding (69% [29/42] vs 49.4% [282/571]; p=0.010) than in those without, respectively. The presence of ICBs was also associated with depression (OR=1.831; 95%CI 1.048-3.201; p=0.034) after adjusting for age, sex, civil status, disease duration, equivalent daily levodopa dose, antidepressant treatment, Hoehn&Yahr stage, non-motor symptoms burden, autonomy for activities of daily living, and global perception of QoL.

LIMITATIONS

Cross-sectional design.

CONCLUSIONS

Depression is associated with ICBs in PD. Specifically, with pathological gambling, compulsive eating behavior, and hobbyism-punding.

Quality of life and non-motor symptoms in Parkinson's disease patients with subthreshold depression

BACKGROUND

The role of subthreshold depression (subD) in Parkinson's Disease (PD) is not clear. The present study aimed to compare the quality of life (QoL) in PD patients with subD vs patients with no depressive disorder (nonD). Factors related to subD were identified.

MATERIAL AND METHODS

PD patients and controls recruited from the COPPADIS cohort were included. SubD was defined as Judd criteria. The 39-item Parkinson's disease Questionnaire (PDQ-39) and the EUROHIS-QOL 8-item index (EUROHIS-QOL8) were used to assess QoL.

RESULTS

The frequency of depressive symptoms was higher in PD patients (n = 694) than in controls (n = 207) (p < 0.0001): major depression, 16.1% vs 7.8%; minor depression, 16.7% vs 7.3%; subD, 17.4% vs 5.8%. Both health-related QoL (PDQ-39; 18.1 ± 12.8 vs 11.6 ± 10; p < 0.0001) and global QoL (EUROHIS-QOL8; 3.7 ± 0.5 vs 4 ± 0.5; p < 0.0001) were significantly worse in subD (n = 120) than nonD (n = 348) PD patients. Non-motor Symptoms Scale (NMSS) total score was higher in subD patients (45.9 ± 32 vs 29.1 ± 25.8;p < 0.0001). Non-motor symptoms burden (NMSS;OR = 1.019;95%CI 1.011-1.028; p < 0.0001), neuropsychiatric symptoms (NPI; OR = 1.091; 95%CI 1.045-1.139; p < 0.0001), impulse control behaviors (QUIP-RS; OR = 1.035; 95%CI 1.007-1063; p = 0.013), quality of sleep (PDSS; OR = 0.991; 95%CI 0.983-0.999; p = 0.042), and fatigue (VAFS-physical; OR = 1.185; 95%CI 1.086-1.293; p < 0.0001; VAFS-mental; OR = 1.164; 95%CI 1.058-1.280; p = 0.0001) were related to subD after adjustment to age, disease duration, daily equivalent levodopa dose, motor status (UPDRS-III), and living alone.

CONCLUSIONS

SubD is a frequent problem in patients with PD and is more prevalent in these patients than in controls. QoL is worse and non-motor symptoms burden is greater in subD PD patients.

AB0334 COST-EFECTIVENESS OF JAK INHIBITORS IN RHEUMATOID ARTHRITIS IN THE REAL WORL PRACTICE

Background:

The Janus Kinase (JAK) inhibitors Baricitinib (BAR) and Tofacitinib (TOF), both in monotherapy or in combination with methotrexate, are indicated for moderate to severe active rheumatoid arthritis (RA) with inadequate response to conventional synthetic disease modifying anti-rheumatic drugs (csDMARD). Data about cost-effectiveness in a real-world setting are still scarce.

Objectives:

To assess the cost-effectiveness (C-E) of BAR and TOF in patients with RA in usual clinical practice.

Methods:

Retrospective observational study of adult RA patients who started BAR and TOF between September 2017 and December 2019, in a university hospital. Data were collected from the electronic medical records and the Dominion® External Patient Dispensing program. Demographic, clinical and laboratory parameters [erytrocyte sedimentation rate (ESR), C reactive protein (CRP), Rheumatoid factor (RF), anti-citrullinated peptide antibodies (ACPA)], concomitant csDMARD, previous biological (b) DMARD, DAS28-ESR activity score items, and treatment duration were registered. DAS28-ESR remission or low disease activity (LDA) were used as the effectiveness measure to estimate C-E. The official Spanish prices were considered to calculate the costs of the treatments. Statistical analysis was performed with SPSS v.15 program. Descriptive statistics are shown in proportions, medians and interquartile ranges (IQR). The Wilcoxon signed ranges test was applied for the changes from baseline of DAS28-ESR and CRP.

Results:

39 patients were included, 87.2% women, median age 62.9 (49.9-74.4) years. 9/39 patients (23.1%) werenaiveto bDMARD, 6 (15.4%) had received 1, 18 (46.1%) 2, and 6 (15.4 %) ≥3 previous bDMARD. Demographic, clinical and effectiveness characteristics are shown by drug in the Table:

Table 2.

Median for the time of survival of remission or LDA in RA patients treated with tofacitinib.

Baricitinib (n=30)Tofacitinib (n=9)p valueSex (women, n, %)26 (86,7)8 (88,9)0,676Age [med (IQR)]63,3 (49,7-74,8)59,7 (49,8-68,6)0,857Rheumatoid Factor + (n, %)23 (76,7)9 (100)0,132ACPA + (n, %)21 (70,0)7 (77,8)0,501Erosive disease (n, %)16 (53,3)6 (66,7)0,377Concomitant csDMARD (n, %)26 (86,7)8 (88,9)0,676bDMARD-naive(n, %)7 (23,3)2 (22,2)0,419Treatment duration (months) [med (IQR)]8,4 (6,5-20,3)13,2 (3,9-20,7)0,909Baseline CRP (mg/dl) [med (IQR)]2,2 (0,3-1,0)1,4 (0,3-1,0)0,806Final CRP (mg/dl) [med (IQR)]0,9 (0,1-0,3)1,0 (0,1-0,4)-Baseline DAS28-ESR [med (IQR)]5,5 (3,6-4,3)6,1 (3,8-5,3)0,315Final DAS28-ESR [med (IQR)]3,9 (2,2-2,8)5,5 (2,6-3,6)-DAS28-ESR Remission (n, %)10 (33,3)3 (33,3)0,663DAS28-ESR LDA (n, %)8 (26,7)1 (11,1)0,316

Regarding BAR, 17 patients (56.6%) continue on treatment and 3 (10%) changed to TOF. The change in DAS28VSG was statistically significant (p = 0.000), as well as difference in CRP (p = 0.008). The total cost per analysed period was € 357,806.40, with 18/30 patients (60%) achieving remission or LDA. The C-E was € 19,878.13. As for TOF, 6 patients (66.6%) remain on drug, with no switch to BAR. Neither the difference from baseline in DAS28VSG nor the CRP changes reached statistical significance (p = 0.08 and p = 0.735, respectively). The total cost per analysed period was € 90,201.72, with 4/9 patients (44.4%) achieving remission or LDA. The C-E was € 22,573.0

Conclusion:

In our daily practice, JAK inhibitors are mainly used in combination with csDMARD and commonly after failure to ≥ 1 bDMARD. In this real setting, BAR proves to be cost-effective, while TOF renders less effectiveness. However, results should be addressed with caution because of the smaller sample size of TOF population. Additional studies with greater follow-up and sample size are needed to confirm these findings.

Disclosure of Interests:

Alberto Calvo Garcia: None declared, Noelia García Castañeda: None declared, Cristina Valero: None declared, Irene Llorente Speakers bureau: Lilly, Janssen, Novartis, Sanofi, Gebro, Blanca Varas: None declared, Alberto García-Vadillo: None declared, Isidoro González-Álvaro Grant/research support from: Roche Laboratories, Consultant of: Lilly, Sanofi, Paid instructor for: Lilly, Speakers bureau: Abbvie, MSD, Roche, Lilly, Alberto Morell: None declared, Esther Ramirez: None declared, Rosario Garcia de Vicuna Grant/research support from: BMS, Lilly, MSD, Novartis, Roche, Consultant of: Abbvie, Biogen, BMS, Celltrion, Gebro, Lilly, Mylan, Pfizer, Sandoz, Sanofi, Paid instructor for: Lilly, Speakers bureau: BMS, Lilly, Pfizer, Sandoz, Sanofi

AB1339-HPR SAFETY AND ADHERENCE OF THE JAK INHIBITORS IN CLINICAL PRACTICE IN RHEUMATOID ARTHRITIS

Background:

The Janus Kinase (JAKi) inhibitors Baricitinib (BAR) and Tofacitinib (TOF) are indicated for moderate to severe active rheumatoid arthritis (RA). Data about safety, effectiveness in refractory patients and adherence in real clinical practice in our population are scarce.

Objectives:

An evaluation of safety, adherence and reasons to consider suspension of JAKi in routine clinical practice.

Methods:

Retrospective observational study of patients with RA treated with BAR and TOF according to usual clinical practice between September 2017 - December 2019. Data were collected from the electronic medical record and from the Dominion® Outpatient Drug Dispensing program.

Demographic, clinical, laboratory and treatment-related variables were collected, including reasons for discontinuing JAKi (inefficiency and toxicity). Adherence was calculated using the Compliance Questionnaire on Rheumatology (CQR-5), and the average possession ratio (RMP), which is defined as the number of days with treatment dispensed between the total days of the period analyzed, considering the adherent patient when RMP had a ≥ 0.8.

Laboratory abnormalities were defined according to normal limit values (NLV) and specifications of data sheet. A descriptive analysis was performed using proportions, medians and interquartile ranges (IQR) using the SPSS v.15 program.

Results:

Thirty patients were included in treatment with BAR and nine with TOF. The median age was 62.9 (RIQ 49.9-74.4), 34 (87.2%) were women, 28 (71.2%) anti-CCP and 32 (82.1%) were rheumatoid factor positive, with erosive disease in 34 (87,2%) patients. In the previous treatment, 9 (23.1%) were naive to biological, 6 (15.4%) had received 1 biological, 18 (46.1%) 2 biologicals, and 6 (15.4%) ≥ 3 biologicals. The median treatment time was 8.4 months (RIQ 6.5-20.3) in BAR and 13.2 (RIQ 3.9-20.7) in TOF.

The reasons for consider suspension shown in Table 1.

Table 1.

Treatment Discontinuation

BARICITINIBInitial DAS28[median (IQR)]Final DAS28[median (IQR)]Continue treatmentn (%): 17/30 (55.6)4.20 (2.95-5.72)2.60 (1.70-2.77)Reasons for suspension-Refractory n (%): 7/13 (55.8%)4.38 (4.16-5.43)4,16 (3.56-5.23)-Side effects n (%): 4/13 (30.7)4.16 (3.45-4.84)3.15 (2.69-4.41) ◦Thrombocytosis (1) ◦Herpes Zoster (1) ◦Anemia (1) ◦Tubaritis (1)-Patient decisión n (%): 2/13 (15.4)TOFACITINIBContinue treatmentn (%): 6/9 (66.6)4.82 (3.28-6.20)2.61 (2.45-3.70)Reasons for suspension-Refractory n (%): 2/3 (66.6)5.27 (5.23-5.31)5.48 (5.04-5.92)-Side effects n (%): 1/3 (33.33)

Based on the CQR5 questionnaire, all patients treated with BAR and TOF were adherent “HIGH” class, and a median of RMP = 1.01 (IQR = 0.93-1.06) was obtained for BAR and RMP = 1, 00 (IQR = 0.91-1.01) for TOF, all adherents (≥ 0.8).

Table 2.

Safety results of the treatment shows the safety results.

Side EffectBaricitinib(n, %)Tofacitinib(n, %)Hb <11 g/dl7 (23,3)0Hb < 8 g/dl0 (0)/Hb Recovery >11 g/dl2/7 (28,6)/Neutrophils < 1500/mm30 (0)/Lymphocytes < 1000/mm33 (10,0)2 (22,2)Platelets > 600 × 103/mm31 (3,3)0AST o ALT > 1 NLV4 (13.3)0 (0)Hypercholesterolemia (> 1 NLV)13 (43.3)5 (55.5)Infections13 (43.3)0 (0)Herpes zoster6 (20,0)0 (0)

Conclusion:

In our population, mostly refractory to biological, more than half of the patients maintain treatment with JAKi, with optimal adherence. The main reason for the suspension of both drugs was inefficiency. The most frequent adverse effects were hypercholesterolemia in both groups and infections in BAR, with a high frequency of herpes zoster. No cardiovascular or thromboembolic events were observed.

Disclosure of Interests:

Cristina Valero: None declared, Alberto Calvo Garcia: None declared, Noelia García Castañeda: None declared, Ana Ortiz: None declared, Irene Llorente Speakers bureau: Gebro, Janssen, Sanofi, Lilly., Blanca Varas: None declared, Santos Castañeda: None declared, Rosario Garcia de Vicuna Grant/research support from: BMS, Lilly, MSD, Novartis, Roche, Consultant of: Abbvie, Biogen, BMS, Celltrion, Gebro, Lilly, Mylan, Pfizer, Sandoz, Sanofi, Paid instructor for: Lilly, Speakers bureau: BMS, Lilly, Pfizer, Sandoz, Sanofi, Esther Ramirez: None declared

FRI0132 EFFICACY AND SAFETY OF SWITCHING JAKINIBS IN RHEUMATOID ARTHRITIS

Background:

Different Jakinibs (JAKi) have shown efficacy in rheumatoid arthritis (RA) but in an important proportion of patients, insufficient response leads to therapy withdrawal. The different JAKi show variable selectivity for the four Jak isoforms (Jak1,2,3 y Tyk2) but there are no clinical trials analyzing the response to a JAKi after the suspension of another JAKi and therefore, observational data may be useful in this regard.

Objectives:

To describe efficacy and safety of the second JAKi in patients with suspension of the first due to failure or side effects.

Methods:

Spanish observational multicentric study. Data were retrospectively obtained from medical records of 28 patients with RA sequentially treated with baricitinib o tofacitinib in any order.

Results:

We identified 28 patients with RA treated with baricitinib and tofacitinib. Patient´s characteristics are summarized in Table 1. Half of the patients received tofacitinib first, and the other half baricitinib as the first JAKi. Mean survival for the first JAKi was 7,6 ± 6,1 months. The reason for withdrawal was inefficacy in 17 cases (61%) and adverse effects in 11 (39%). Mean follow-up after starting on the second JAKi was 9,6 ± 5,6 [3-19] months. Disease activity data along follow-up are depicted in Table 2. Survival on the second JAKi was 82% at 3, 76% at 6, and 62% at 12 months when 13 of the 21 patients maintained the therapy. In all 8 patients who discontinued the second JAKi, the reason was inefficacy. The treatment suspension rate was similar among patients discontinuing the first JAKi for inefficacy (n=5, 29,4%) or for adverse effects (n=3; 27,3%).

Table 1.

Baseline Charateristics.

N 28Clinical characteristicsFemale24 (86%)Age*61.2 ± 13.2ACPA (+)19 (67,9%)Erosions13 (46,4%)Extra-articular manifestations8 (28,6%)TJC*10,8 ± 5,4SJC *7,4 ± 4,6DAS28-CPR*5,4 ± 0,91 High disease activity71,5% Moderate disease activity23,8% Low disease activity4,7%Previous treatmentbDMARD24 (86%)N° of previous bDMARDs *3,9±2,2 iTNF75% No-iTNF67,9%

(*) Mean ± SD

Tabla 2.

Treatment results during the follow-up period.

Baseline (n 28)3 m (n 28)6 m (n 25)12 m (n 21)TJC10,8±5,43,8±3,34,23±2,51,9±1,5SJC7,2±4,61,8±1,71,7±20,7±1CPR mg/dL1±0,60,54±0,480,64±0,90,33±0,24DAS28CPR5,4±0,913,29±0,973,15±1,22,15±0,6Prednisone mg7,2±4,26,8±3,55,3±2,53,1±2,1

Conclusion:

Our data show that therapy with a second JAKi is a safe and efficacious option after discontinuation of the first JAKi due to either inefficacy or side effects. The response rate to the second JAKi is similar in patients with inefficacy or side effects which suggests that failure to the first does not reduce the chance of response to the second.

Acknowledgments:

M. Retuerto was recipient of a training grant from Sociedad Española de Reumatología (SER).

Disclosure of Interests:

None declared

Abnormal bone turnover in individuals with low serum alkaline phosphatase

The clinical spectrum of hypophosphatasia (HPP) is broad and variable within families. Along severe infantile forms, adult forms with mild manifestations may be incidentally discovered by the presence of low alkaline phosphatase (ALP) activity in serum. However, it is still unclear whether individuals with persistently low levels of ALP, in the absence of overt manifestations of HPP, have subclinical abnormalities of bone remodeling or bone mass. The aim of this study was to obtain a better understanding of the skeletal phenotype of adults with low ALP by analyzing bone mineral density (BMD), bone microarchitecture (trabecular bone score, TBS), and bone turnover markers (P1NP and ß-crosslaps). We studied 42 individuals with persistently low serum ALP. They showed lower levels of P1NP (31.4 ± 13.7 versus 48.9 ± 24.4 ng/ml; p = 0.0002) and ß-crosslaps (0.21 ± 0.17 versus 0.34 ± 0.22 ng/ml, p = 0.0015) than individuals in the control group. There were no significant differences in BMD, bone mineral content, or TBS. These data suggest that individuals with hypophosphatasemia have an overall reduction of bone turnover, even in the absence of overt manifestations of HPP or low BMD. We evaluated bone mineral density (BMD), bone microarchitecture, and bone turnover markers in patients with low serum levels of alkaline phosphatase. Our results show that these patients have low bone remodeling even in the absence of BMD abnormalities, thus supporting the recommendation of avoiding antiresorptives such as bisphosphonates in these subjects.

African histoplasmosis: new clinical and microbiological insights

African histoplasmosis is defined as the fungal infection caused by Histoplasma capsulatum var. duboisii (Hcd). Studies focused on distinguishing Hcd and H. capsulatum var. capsulatum (Hcc), which coexist in Africa, are scarce or outdated, and African strains are continuously underrepresented. In this work, 13 cases of African patients with histoplasmosis diagnosed in the Spanish Mycology Reference Laboratory have been reviewed showing that 77% had disseminated disease and AIDS as underlying disease although Hcd infection has been classically considered a rare presentation in AIDS patients. Strains isolated from these patients and other clinical and reference strains were studied by assessing classical identification methods and performing a three-loci multi-locus sequence analysis (MLSA). Classical identification methods based on biochemical tests and measurement of yeast size proved to be useless in distinguishing both varieties. The MLSA defined an African cluster, with a strong statistical support, that included all strains with African origin. Finally, mating type was also determined by using molecular methods revealing an unequal mating type distribution in African strains. In conclusion, historical statements and classical identification methods were useless to distinguish between varieties, whereas molecular analyses revealed that all strains with African origin grouped together suggesting that traditional classification should be revised. Further investigation is required in order to unravel traditional concepts about Hcd infection and support results obtained in this work.

Elective neck dissection during salvage surgery after radiotherapy in patients with head and neck squamous cell carcinoma

SUMMARY

Elective neck dissection in patients with recurrent head and neck squamous cell carcinoma (HNSCC) without evidence of neck disease (crN0) is poorly defined. A retrospective review was carried out on 165 crN0 patients treated with salvage surgery and elective neck dissection. Multivariate Cox analysis and recursive partitioning analysis were used to evaluate prognostic factors. The frequency of occult neck node metastases in the neck dissection (rpN+) was 16.4%. The risk of occult metastases for glottic rpT1-T2 recurrences was 5.9%, for glottic rpT3-T4 recurrences 13.2%, for non-glottic rpT1-T2 recurrences 16.1% and for locally advanced (rpT3-T4) non-glottic recurrences 31.1%. Patients with occult neck node metastases (rpN+) had a 5-year adjusted survival rate of 38.1%, while patients without nodal disease (rpN0) had a 5-year adjusted survival rate of 71.1% (p = 0.0001). Elective neck dissection can be omitted in crN0 patients with rT1-T2 glottic recurrence. We consider it advisable to perform elective neck dissection in all other situations.

Degradation of extracellular matrix regulates osteoblast migration: A microfluidic-based study

Bone regeneration is strongly dependent on the capacity of cells to move in a 3D microenvironment, where a large cascade of signals is activated. To improve the understanding of this complex process and to advance in the knowledge of the role of each specific signal, it is fundamental to analyze the impact of each factor independently. Microfluidic-based cell culture is an appropriate technology to achieve this objective, because it allows recreating realistic 3D local microenvironments by taking into account the extracellular matrix, cells and chemical gradients in an independent or combined scenario. The main aim of this work is to analyze the impact of extracellular matrix properties and growth factor gradients on 3D osteoblast movement, as well as the role of cell matrix degradation. For that, we used collagen-based hydrogels, with and without crosslinkers, under different chemical gradients, and eventually inhibiting metalloproteinases to tweak matrix degradation. We found that osteoblast's 3D migratory patterns were affected by the hydrogel properties and the PDGF-BB gradient, although the strongest regulatory factor was determined by the ability of cells to remodel the matrix.

High clinical inflammatory activity prior to the development of secondary progression: a prospective 5-year follow-up study

Objective: To study if there are different patterns of clinical activity - measured by the annual exacerbation rate (AER) - among relapsing-remitting multiple sclerosis (RRMS), "early" secondary multiple sclerosis (SPMS) and "late" SPMS. Methods: A prospective 5-year follow-up study in 80 MS patients has been carried out, calculating the AER and the mean expanded disability status scale (EDSS) change rate (MCR). Results: A significant difference on the AER, among RRMS, early SPMS and late SPMS, has been found. Conclusions: The SPMS has a high clinical inflammatory activity before and during its transformation from a RRMS. Multiple Sclerosis (2002) 8, 59-63

[Is the introduction of clinical management programs for patients with chronic obstructive pulmonary disease useful? Comparison of the effectiveness of two interventions on the clinical progress and care received]

Objetivo

Evaluar la efectividad de dos programas de gestión en pacientes con enfermedad pulmonar obstructiva crónica (EPOC).

Diseño

Estudio de diseño cuasi-experimental para evaluar la efectividad de dos intervenciones (I1, I2) para la asistencia de pacientes con EPOC, tras un seguimiento medio de 31,2 meses.

Emplazamiento

Centros de atención primaria de dos áreas sanitarias de Barcelona y sus hospitales de referencia.

Participantes

Pacientes EPOC seleccionados por muestreo aleatorio simple en los que constara algún código correspondiente a EPOC.

Intervenciones

I1: Programa de gestión integral que optimizaba y coordinaba los recursos. Se hizo formación y control de calidad de la espirometría. I2: Intervenciones aisladas, como el call-center. Compartían circuitos asistenciales y la historia clínica informatizada.

Mediciones principales

variables de función pulmonar, gravedad, uso de inhaladores, estilos de vida, calidad de vida y exacerbaciones.

Resultados

De los 393 pacientes evaluados al inicio, 120 y 104 (I1 e I2, respectivamente) realizaron la evaluación final. Con la I1 hubo una reducción de los pacientes fumadores (p = 0,034). En ambos grupos, la función pulmonar y la calidad de vida se mantuvieron y la disnea mostró un leve empeoramiento. El correcto uso de inhaladores aumentó, aunque solo alcanzó el 48 y el 61% con la I1 e I2, respectivamente. El porcentaje de pacientes exacerbados disminuyó con la I1 (respecto I2 [p < 0,001]) y el de ingresos hospitalarios por exacerbación disminuyó con la I2 (respecto I1 [p < 0,003]).

Conclusiones

Ambas intervenciones consiguieron mejoras relevantes y el no empeoramiento global de una enfermedad crónica y progresiva como es la EPOC.

Diverging results of areal and volumetric bone mineral density in Down syndrome

Population with Down syndrome (DS) has lower areal BMD, in association with their smaller skeletal size. However, volumetric BMD and other indices of bone microarchitecture, such as trabecular bone score (TBS) and calcaneal ultrasound (QUS), were normal.

INTRODUCTION

Patients with DS have a number of risk factors that could predispose them to osteoporosis. Several studies reported that people with DS also have lower areal bone mineral density, but differences in the skeletal size could bias the analysis.

METHODS

Seventy-five patients with DS and 76 controls without intellectual disability were recruited. Controls were matched for age and sex. Bone mineral density (BMD) was measure by Dual-energy X-ray Absorptiometry (DXA), and volumetric bone mineral density (vBMD) was calculated by published formulas. Body composition was also measured by DXA. Microarchitecture was measured by TBS and QUS. Serum 25-hidroxyvitamin D (25OHD), parathyroid hormone (PTH), aminoterminal propeptide of type collagen (P1NP), and C-terminal telopeptide of type I collagen (CTX) were also determined. Physical activity was assessed by the International Physical Activity Questionnaires (IPAQ-short form). To evaluate nutritional intake, we recorded three consecutive days of food.

RESULTS

DS individuals had lower height (151 ± 11 vs. 169 ± 9 cm). BMD was higher in the controls (lumbar spine (LS) 0.903 ± 0.124 g/cm² in patients and 0.997 ± 0.115 g/cm² in the controls; femoral neck (FN) 0.761 ± .126 g/cm² and 0.838 ± 0.115 g/cm², respectively). vBMD was similar in the DS group (LS 0.244 ± 0.124 g/cm³; FN 0.325 ± .0.073 g/cm³) and the controls (LS 0.255 ± 0.033 g/cm³; FN 0.309 ± 0.043 g/cm³). Microarchitecture measured by QUS was slightly better in DS, and TBS measures were similar in both groups. 25OHD, PTH, and CTX were similar in both groups. P1NP was higher in the DS group. Time spent on exercise was similar in both groups, but intensity was higher in the control group. Population with DS has correct nutrition.

CONCLUSIONS

Areal BMD is reduced in DS, but it seems to be related to the smaller body and skeletal size. In fact, the estimated volumetric BMD is similar in patients with DS and in control individuals. Furthermore, people with DS have normal bone microarchitecture.

Underdetection and underreporting of pertussis in children attended in primary health care centers: Do surveillance systems require improvement?

BACKGROUND

Pertussis is an underestimated disease. Several European countries have developed models to account for underreporting of pertussis. The aim of this study was to estimate pertussis underdetection and underreporting in pediatric patients attending primary health care centers (PHCCs).

METHODS

We reviewed clinical records of PHCCs in Barcelona in 2012. Factors associated with underdetection and underreporting were analyzed by logistic regression. Adjusted odds ratios (aORs) and 95% confidence intervals (95% CIs) were calculated.

RESULTS

We included 3,505 children aged < 7 years (mean age, 34  ±  20.7 months; range, 0-82 months) presenting with cough; 9.3% (326 out of 3,505) of patients also had ≥ 1 symptoms related to pertussis accompanied by cough for a duration ≥ 2 weeks. Of the 326 children receiving clinical criteria, only 31 (9.5%) were laboratory-confirmed and 6 (1.8%) were detected but not reported. There were 295 (90.5%) undetected suspected pertussis cases. Age ≥ 18 months (aOR, 8.51; 95% CI, 1.82-39.86), cyanosis (aOR, 6.71; 95% CI, 1.43-31.39), request for chest radiograph (aOR, 0.26; 95% CI, 0.07-0.99), and request for other laboratory tests (aOR, 5.39; 95% CI, 2.19-13.27) were associated with underdetection. Paroxysmal cough (aOR, 5.77; 95% CI, 1.05-31.76) and request for other laboratory tests (aOR, 2.91; 95% CI, 1.11-7.62) were associated with underreporting.

CONCLUSIONS

Both underdetection and underreporting complicate the understanding of pertussis epidemiology. Correct assessment of pertussis symptoms and notification of cases must be improved to control pertussis.

Nonlinear finite element simulations of injuries with free boundaries: application to surgical wounds

Wound healing is a process driven by biochemical and mechanical variables in which a new tissue is synthesised to recover original tissue functionality. Wound morphology plays a crucial role in this process, as the skin behaviour is not uniform along different directions. In this work, we simulate the contraction of surgical wounds, which can be characterised as elongated and deep wounds. Because of the regularity of this morphology, we approximate the evolution of the wound through its cross section, adopting a plane strain hypothesis. This simplification reduces the complexity of the computational problem; while allows for a thorough analysis of the role of wound depth in the healing process, an aspect of medical and computational relevance that has not yet been addressed. To reproduce wound contraction, we consider the role of fibroblasts, myofibroblasts, collagen and a generic growth factor. The contraction phenomenon is driven by cell-generated forces. We postulate that these forces are adjusted to the mechanical environment of the tissue where cells are embedded through a mechanosensing and mechanotransduction mechanism. To solve the nonlinear problem, we use the finite element method (FEM) and an updated Lagrangian approach to represent the change in the geometry. To elucidate the role of wound depth and width on the contraction pattern and evolution of the involved species, we analyse different wound geometries with the same wound area. We find that deeper wounds contract less and reach a maximum contraction rate earlier than superficial wounds.

Bone mass and vitamin D levels in women with a diagnosis of fibromyalgia

No differences in either bone mineral density or serum 25OHD levels have been found between 205 women with fibromyalgia (both pre- and postmenopausal) and their controls. However, a lack of the expected 25OHD summer rise was observed in patients.

INTRODUCTION

Contradictory data have been published regarding a possible association between fibromyalgia and osteoporosis or hypovitaminosis D. Most studies, however, have been performed in small size samples and have excluded postmenopausal women. We decided to study this association in a larger sample of fibromyalgia patients including both pre- and postmenopausal women.

METHODS

Two hundred five patients were recruited from a clinic specializing in fibromyalgia and 205 healthy controls were enrolled from the census of a Primary Care Center. Controls were matched with patients by age and the time of the year they were included in the study. Bone mineral density (BMD) was measured by DXA. Serum 25OHD, iPTH, P1NP, and CTX were also determined.

RESULTS

BMD was similar in both groups (lumbar spine, 0.971 ± 0.146 g/cm(2) in patients and 0.970 ± 0.132 g/cm(2) in controls; femoral neck, 0.780 ± 0.122 g/cm(2) and 0.785 ± 0.117 g/cm(2), respectively). 25OHD levels were also similar: 23.0 ± 9.5 ng/ml and 24.1 ± 9.6 ng/ml. However, while controls showed the usual summer rise in 25OHD, fibromyalgia patients did not. PTH did not show seasonal changes, but on average was higher in patients (51 pg/ml vs. 48 pg/ml; p = 0.034). P1NP or CTX were similar in both groups.

CONCLUSIONS

No differences in BMD were found between patients and controls. As for 25OHD, a lack of its expected summer rise was observed. It is doubtful whether this has any homeostatic consequence. We consider that the association reported in other studies is merely circumstantial, and not due to the intrinsic characteristics of these disorders.

Missense polymorphisms of the WNT16 gene are associated with bone mass, hip geometry and fractures

Two missense polymorphisms of WNT16 were associated with hip bone mineral density (BMD), the buckling ratio of the femoral neck, calcaneal ultrasound and hip fractures in individuals under 80 years of age. These results confirm the association of the WNT16 gene with bone mass and osteoporotic fractures.

INTRODUCTION

Osteoporosis has a strong genetic component. Wnt ligands stimulate the differentiation of osteoblast precursors and play a major role in skeletal homeostasis. Therefore, the aim of this study was to explore the association of allelic variants of the WNT16 gene with BMD, other structural parameters of bone and osteoporotic hip fractures.

METHODS

Six single nucleotide polymorphisms were analysed in 1,083 Caucasian individuals over 49 years of age.

RESULTS

Two missense polymorphisms (rs2908004 and rs2707466) were associated with femoral neck BMD, with average differences across genotypes of 35 mg/cm(2) (p = 0.00037 and 0.0015, respectively). Likewise, the polymorphisms were associated with calcaneal quantitative ultrasound parameters (p = 0.00004 and 0.0014, respectively) and the buckling ratio, an index of cortical instability of the femoral neck (p = 0.0007 and 0.0029, respectively). Although there were no significant differences in the genotype frequency distributions between 294 patients with hip fractures and 670 controls, among the subgroup under 80 years of age, TT genotypes were underrepresented in patients with fractures (odds ratio 0.50; CI 0.27-0.94).

CONCLUSION

Common missense polymorphisms of the WNT16 gene are associated with BMD at the hip, calcaneal ultrasound and the buckling ratio of the femoral neck, as well as with hip fractures in individuals under 80 years of age. Overall, these results confirm the association of the WNT16 locus with BMD identified in genome-wide association studies and support its role in determining the risk of osteoporotic fractures.

Factors associated with changes in quality of life of COPD patients: a prospective study in primary care

BACKGROUND

A primary objective in the treatment of patients with chronic obstructive pulmonary disease (COPD) is to improve their health status.

OBJECTIVE

To identify the factors associated with changes in health-related quality of life (HRQoL) in patients with COPD after one year of follow-up in primary care.

METHOD

Multicenter, prospective study with one year of follow-up. The end-point was the change in total score on the Saint George's Respiratory Questionnaire (SGRQ). Patients with a clinically relevant (>4 points) decrease or increase in SGRQ total score were compared. Factors associated with the changes in HRQoL observed after one year were determined by logistic regression analysis.

RESULTS

A total of 791 patients (mean age, 70.2 years) were analyzed. Mean FEV1 (% predicted) was 52.4%. Average total SGQR score was 37.1 (SD = 19.1) at baseline and 35.6 (SD = 18.9) at follow-up. Significantly improved HRQoL was observed in 36.7% of patients, and was associated with starting polymedication, pulmonology visits, and balanced diet; ending respiratory rehabilitation, quitting smoking; and not being a frequent exacerbator. Quality of life worsened significantly in 29.2% of patients, and was associated with worsening respiratory symptoms and increased hospital admissions.

CONCLUSIONS

Although overall changes in HRQoL observed after one year were minimal, more than one third of patients improved significantly, and one third had significantly worse HRQoL. Clinical factors were independently associated with these changes, emphasizing the relevance to improved HRQoL of starting a healthy lifestyle and respiratory treatments and the negative impact on HRQoL of COPD symptoms onset and admissions.

Clinical spectrum of peripheral facial paralysis in HIV-infected patients according to HIV status

Although peripheral facial palsy is the most common cranial neuropathy in HIV-infected patients, no series have been reported recently in the literature. In this study we reviewed the clinical records of HIV-infected patients with a diagnosis of peripheral facial palsy between 2000 and 2011 attending the Hospital Marqués de Valdecilla (Infectious Diseases Unit), a 900-bed university hospital in northern Spain. We identified eight patients (4 men, 4 women): median CD4 count and viral load were 232 cells per μL and 130,000 RNA copies per mL, respectively. Most of them presented co-morbidities, including hepatitis C virus in 75%, hepatitis B virus in 15% and tuberculosis in 15%. Aetiologies of palsy were varied: idiopathic Bell's palsy predominated at early stages of the disease, whereas secondary causes, such as lymphoma and infections were frequently the cause of paralysis in advanced HIV/AIDS. At early stages of HIV infection, facial palsy is similar, both in aetiology and prognosis, to cases in the general population. However, in advanced stages the palsy is frequently secondary to underlying complications. Clinicians should be aware of these differences to tailor the diagnostic work-up.

[Treating COPD in chronic patients in a primary-care setting]

The aging of the populations in Western countries entails an increase in chronic diseases, which becomes evident with the triad of age, comorbidities and polymedication. chronic obstructive pulmonary disease represents one of the most important causes of morbidity and mortality, with a prevalence in Spain of 10.2% in the population aged 40 to 80. In recent years, it has come to be defined not only as an obstructive pulmonary disease, but also as a systemic disease. Some aspects stand out in its management: smoking, the main risk factor, even though avoidable, is an important health problem; very important levels of underdiagnosis and little diagnostic accuracy, with inadequate use of spirometry; chronic patient profile; exacerbations that affect survival and cause repeated hospitalizations; mobilization of numerous health-care resources; need to propose integral care (health-care education, rehabilitation, promotion of self-care and patient involvement in decision-making).

Evaluation of a combined strategy directed towards health-care professionals and patients with chronic obstructive pulmonary disease (COPD): information and health education feedback for improving clinical monitoring and quality-of-life

Background

Chronic obstructive pulmonary disease (COPD) is a health problem that is becoming increasingly attended-to in Primary Care (PC). However, there is a scarcity of health-care programs and studies exploring the implementation of Clinical Practice Guidelines (CPG). The principal objective of the present study is to evaluate the effectiveness of a combined strategy directed towards health-care professionals and patients to improve the grade of clinical control and the quality-of-life (QoL) of the patients via a feedback on their state-of-health. A training plan for the health-care professionals is based on CPG and health education.

Method/Design

Multi-centred, before-after, quasi experimental, prospective study involving an intervention group and a control group of individuals followed-up for 12 months. The patients receive attention from urban and semi-urban Primary Care Centres (PCC) within the administrative area of the Costa de Ponent (near Barcelona). All the pacients corresponding to the PCC of one sub-area were assigned to the intervention group and patients from the rest of sub-areas to the group control. The intervention includes providing data to the health-care professionals (clinician/nurse) derived from a clinical history and an interview. A course of training focused on aspects of CPG, motivational interview and health education (tobacco, inhalers, diet, physical exercise, physiotherapy). The sample random includes a total of 801 patients (≥ 40 years of age), recorded as having COPD, receiving attention in the PCC or at home, who have had at least one clinical visit, and who provided written informed consent to participation in the study. Data collected include socio-demographic characteristics, drug treatment, exacerbations and hospital admissions, evaluation of inhaler use, tobacco consumption and life-style and health-care resources consumed. The main endpoints are dyspnoea, according to the modified scale of the Medical Research Council (MRC) and the QoL, evaluated with the St George's Respiratory Questionnaire (SGRQ). The variables are obtained at the start and the end of the intervention. Information from follow-up visits focuses on the changes in life-style activities of the patient.

Discussion

This study is conducted with the objective of generating evidence that shows that implementation of awareness programs directed towards health-care professionals as well as patients in the context of PC can produce an increase in the QoL and a decrease in the disease exacerbation, compared to standard clinical practice.

Trial Registration

Clinical Trials.gov Identifier: NCT00922545;

Assessment of a primary and tertiary care integrated management model for chronic obstructive pulmonary disease

BACKGROUND

The diagnosis and treatment of patients with chronic obstructive pulmonary disease (COPD) in Spain continues to present challenges, and problems are exacerbated when there is a lack of coordinated follow-up between levels of care. This paper sets out the protocol for assessing the impact of an integrated management model for the care of patients with COPD. The new model will be evaluated in terms of 1) improvement in the rational utilization of health-care services and 2) benefits reflected in improved health status and quality of life for patients.

METHODS/DESIGN

A quasi-experimental study of the effectiveness of a COPD management model called COPD PROCESS. The patients in the study cohorts will be residents of neighborhoods served by two referral hospitals in Barcelona, Spain. One area comprises the intervention group (n = 32,248 patients) and the other the control group (n = 32,114 patients). The study will include pre- and post-intervention assessment 18 months after the program goes into effect. Analyses will be on two datasets: clinical and administrative data available for all patients, and clinical assessment information for a cohort of 440 patients sampled randomly from the intervention and control areas. The main endpoints will be the hospitalization rates in the two health-care areas and quality-of-life measures in the two cohorts.

DISCUSSION

The COPD PROCESS model foresees the integrated multidisciplinary management of interventions at different levels of the health-care system through coordinated routine clinical practice. It will put into practice diagnostic and treatment procedures that are based on current evidence, multidisciplinary consensus, and efficient use of available resources. Care pathways in this model are defined in terms of patient characteristics, level of disease severity and the presence or absence of exacerbation. The protocol covers the full range of care from primary prevention to treatment of complex cases.

Association of aromatase and estrogen receptor gene polymorphisms with hip fractures

Two polymorphisms of the aromatase and estrogen receptor genes appeared to interact to influence the risk of hip fractures in women.

INTRODUCTION

Allelic variants of the aromatase gene have been associated with bone mineral density and vertebral fractures. Our objective was to analyze the relationship between two polymorphisms of the aromatase and estrogen receptor genes and hip fractures.

METHODS

We studied 498 women with hip fractures and 356 controls. A C/G polymorphism of the aromatase gene and a T/C polymorphism of the estrogen receptor alpha gene were analyzed using Taqman assays. Aromatase gene expression was determined in 43 femoral neck samples by real-time RT-PCR.

RESULTS

There were no significant differences in the overall distribution of genotypes between the fracture and control groups. However, among women with a TT genotype of the estrogen receptor, the CC aromatase genotype was more frequent in women with fractures than in controls (39 vs. 23%, p = 0.009). Thus, women homozygous for T alleles of estrogen receptor and C alleles of aromatase were at increased risk of fracture (odds ratio 2.0; 95% confidence interval 1.2-3.4). The aromatase polymorphism was associated with RNA levels in bone tissue, which were three times lower in samples with a CC genotype (p = 0.009).

CONCLUSIONS

These common polymorphisms of the aromatase and estrogen receptor genes appear to interact, influencing the risk of hip fractures in women.

Effect of relapses over early progression of disability in multiple sclerosis patients treated with beta-interferon

Observational study designed to explore the effect of demographical variables and number of relapses over the disability progression in the two first years of beta-interferon treatment for multiple sclerosis. One hundred and sixty two patients treated with beta-interferon for at least two years were included, 70.9% females, mean age 33.4 years, mean disease duration 75.1 months, mean EDSS 2.4, previous year relapse rate 1.3. Main end-point was defined as a sustained EDSS increase (1.5 if previous EDSS 0-2.0; 1.0 if previous EDSS 2.5-4.0; 0.5 if previous EDSS 4.5 or higher). 62.3% of patients presented one or more relapses and 32.7% patients reached sustained disability increase. The univariate and multivariate Cox regression analysis only showed statistical significance for the relapses in the two first years after the treatment (HR 1 relapse: 3.4, p = 0.05; HR ≥ 2 relapses: 4.3, p < 0.001). The Kaplan-Meier survival analysis showed a higher probability of EDSS progression for patients with one relapse (log rank 10.9, p = 0.02) and with ≥ 2 relapses (log rank 17.7, p < 0.001), with no differences between them ( p = 0.38). In conclusion, patients with one or more relapses in the first two years of interferon treatment developed an earlier sustained progression of the disability.

Bone mass in young adults with Down syndrome

BACKGROUND

Down syndrome (DS) is a frequent cause of intellectual disability. With the increasing life expectancy of these patients, concerns have been raised about the risk of osteoporosis. In fact, several investigators have reported a reduced bone mass in DS. However, the results may be confounded by comorbid diseases, and differences in lifestyle habits and body size. Therefore, we planned to determine anthropometric and lifestyle factors influencing bone mineral density (BMD) in young adults with DS.

METHODS

Thirty-nine patients with DS (mean age 26 years) and 78 controls were studied. Areal BMD was measured by dual x-ray densitometry (DXA); volumetric BMD at the lumbar spine and femoral neck was estimated with published formulae.

RESULTS

DS patients had lower areal BMD than controls at all regions (spine, hip and total body). Height and projected bone area were also lower. There were no differences between both groups regarding estimated volumetric BMD at the femoral neck. However, spine volumetric BMD was also lower in DS than controls. In multivariate analysis, DS, male sex, little physical activity and low sunlight exposure were associated with lower spine volumetric BMD; on the other hand, fat mass and sunlight exposure were associated with femoral neck volumetric BMD.

CONCLUSION

This study shows that patients with DS had a reduced areal BMD, but it is in part a consequence of the reduced body size, particularly at the femoral neck. Physical activity and sunlight exposure are associated to volumetric BMD and should be stimulated in order to maintain an adequate bone mass in these patients.

Association of the 163A/G and 1181G/C osteoprotegerin polymorphism with bone mineral density

The aim of the study was to investigate the distribution of 163 A/G osteoprotegerin gene promoter and 1181 G/C osteoprotegerin exon 1 polymorphisms in a group of women with different hormonal status and to analyze their relationship with BMD. Osteoprotegerin polymorphisms and BMD were analyzed in 332 women (69 premenopausal and 263 postmenopausal). BMD was quantified at the lumbar spine (L 2-4), femoral neck, and total hip. Genotyping for the presence of different polymorphisms was performed using the Custom Taqman ((R)) SNP Genotyping assays. There were not significant differences in BMD according to 163 A/G genotype. However, significant differences in lumbar spine BMD were found according to 1181 G/C alleles. Thus, women with CC genotype had significant higher BMD at the lumbar spine than those with GC or GG genotype. No differences were found in femoral neck and total hip BMD. In age-adjusted models, the 1181 G/C OPG polymorphism explained 2.2% of BMD variance at the spine, 0.3% at the femoral neck, and 0.9% at the total hip in the whole group. In the subgroup of premenopausal women, the polymorphism was strongly related to spine BMD, and explained 11.5% of the variance, whereas body weight explained 7.9%. The 1181 G/C polymorphism was associated with lumbar spine BMD in Spanish women. Premenopausal women with the CC genotype had a higher BMD.

[Adult-onset primary focal foot dystonia]

INTRODUCTION

Adult-onset primary focal foot dystonia is a rare event. Up to now, only 7 cases have been reported in the literature. Since the idiopathic-type food dystonia is uncommon in adults, secondary types must be ruled out.

CLINICAL REPORT

We present the case of a 51 year woman with a 3 year history of focal food dystonia. She had abnormal posture of the foot with plantar flexion and inversion, which worsened with action. Complementary studies aimed at ruling out secondary causes were all negative. The dystonia remained limited to her food and she did not develop any other neurological symptoms. She benefited from botulinum toxin treatment.

CONCLUSIONS

Primary focal foot dystonia is uncommon in adults. The most common pattern is plantar and five toes flexion. Associated pain is common. Its pathogenesis is only partially understood, the neurophysiologic studies and functional resonance showing a loss of inhibitory control at spine and brainstem levels, abnormal cortical plasticity and altered sensorimotor integration. The response of this disorder to drugs is poor, however, the patients may benefit from botulinum toxin infiltrations of the muscles involved.

MTHFR C677T polymorphism and osteoporotic fractures

The C677T (rs1801133) polymorphism of MTHFR (methylenetetrahydrofolate reductase) has been associated with the risk of cardiovascular events, and also with osteoporosis in some studies. However, the results are controversial. Our objective was to determine the relationship of the polymorphism with osteoporotic fractures by means of a case-control study. C677T was analyzed in 823 subjects (365 controls, 136 with vertebral fractures and 322 with hip fracture) by using a Taqman assay. The distribution of MTHFR genotypes was similar in patients and controls. In comparison with TC/CC genotypes, the age-adjusted OR for hip fractures of the TT genotype was 1.0 (95% confidence interval 0.6-1.7) in women and 0.7 (0.3-1.8) in men. The OR for vertebral fractures was 0.8 (0.4-1.7) in women and 1.7 (0.4-6.7) in men. A meta-analysis combining these data with previous reports confirmed the lack of association between MTHFR and fractures, with an OR of 1.1 (0.7-1.9, p=0.65) for vertebral fractures and 1.2 (0.7-2.0; p=0.45) for peripheral fractures, but there was significant heterogeneity among the results of individual studies, particularly about peripheral fractures. In conclusion, the C677T polymorphism of the MTHFR gene does not appear to be associated with the overall risk of osteoporotic fractures. However, given the heterogeneity of the results of published studies, further investigations are needed to evaluate its influence in specific population subgroups.

Axonal loss is progressive and partly dissociated from lesion load in early multiple sclerosis

OBJECTIVE

To assess the relationship between the spectroscopically measured axonal damage in the normal-appearing white matter of the brainstem, the total brain T2-hyperintense lesion volume (T2LV), and disability in patients with early relapsing-remitting multiple sclerosis (RRMS).

METHODS

Forty-three RRMS patients and 10 sex- and age-matched healthy controls were prospectively studied for 2 years. T2-weighted magnetic resonance (MR) images and proton MR spectroscopy were acquired at the time of recruitment and at year 2. Brainstem was considered, where large tracts join together, as a suitable region to detect early axonal damage. The T2LV was calculated with a semiautomatic program; N-acetylaspartate (NAA), creatine (Cr), and choline (Cho) resonances areas were integrated with the jMRUI program, and the ratios were calculated for the sum of the volume elements represented at brainstem.

RESULTS

The basal NAA/Cho ratio was significantly decreased in patients compared with controls. After 2-year follow-up, there was a decrease in the NAA/Cho (-9%; p = 0.002) and NAA/Cr (-13%; p = 0.001) ratios, and an increase in the T2LV (19%; p = 0.043) in multiple sclerosis patients, whereas control subjects had no significant metabolic changes. Significant NAA/Cr ratio decreases were observed in both patients, with and without relapses, whereas T2LV only increased in patients with relapses. The final Expanded Disability Status Scale (EDSS) score correlated with T2LV at baseline, but no significant correlations were found between metabolic values, T2LV change, or EDSS score over the study period.

CONCLUSIONS

Our data reveal an early and progressive axonal damage in relapsing-remitting multiple sclerosis. Axonal loss and T2 lesion volume seem to be at least partly dissociated processes in early stages of the disease.

[Proportion of individuals with indication criteria for bone densitometry and frequency of factors of risk of low osseous mass in primary care consultations]

OBJECTIVE

To find the number of individuals with indication for Bone Densitometry in Primary Care, according to the criteria of the WHO, the Agency for Evaluating Medical Technology of Catalonia (AETM) and the International Committee on Clinical Guides to Osteoporosis (CIGCO), and the frequency of factors of risk of low osseous mass.

DESIGN

Multi-centre, prospective, transversal study.

SETTING

Primary care consultations.

PARTICIPANTS

Patients over 18 (307 women and 139 men) with mean age of 54.3+/-16.8, who attended for consultation with an appointment.

MAIN MEASUREMENTS

Presence or absence of factors relating to each of the indication criteria for bone densitometry.

RESULTS

A 36.3% of individuals had indication of densitometry under the AETM criteria, 76.7% with the WHO criteria, and 50.5% with the CIGCO criteria (applicable only to women). Percentages increased with age and were higher for women. Concordance between the various criteria was under 37%.

CONCLUSIONS

The percentage of individuals with indication for bone densitometry was highly variable under different criteria. It was greater in women and increased with age. Concordance between different criteria was low.

Klotho gene polymorphism and male bone mass

The Klotho gene codes for a protein that is thought to influence the homeostasis of several tissues, including bone, as well as the aging process. Although the mechanism of action has not been fully elucidated, some studies in women have associated Klotho allelic variants to bone mineral density (BMD). The objective of this study was to determine the relationship of a common T/G polymorphism, resulting in a phenylalanine (F) to valine (V) substitution, with male bone mass. BMD was measured by dual-energy X-ray absorptiometry in 362 Spanish men aged 19-83 years. Klotho alleles were determined by a Taqman assay. Allele frequencies were 85% and 15% for the F and V alleles, respectively. In comparison with the most common FF genotype, young and middle-aged men (age less than 53 years) with FV/VV genotypes had higher age- and body mass index-adjusted BMD at the lumbar spine (1.059 +/- 0.017 vs. 1.016 +/- 0.011 g/cm(2), P = 0.036), the hip (1.077 +/- 0.017 vs. 1.033 +/- 0.011 g/cm(2), P = 0.028), and the calcaneus (0.599 +/- 0.125 vs. 0.547 +/- 0.108 g/cm(2), P = 0.012). Klotho alleles explained about 2-4% of BMD variance. However, Klotho genotype was not associated to BMD in older men. There were no Klotho-related differences in height, body weight, calcium intake, tobacco or alcohol consumption, or serum testosterone levels. In conclusion, these results suggest that allelic variants of Klotho constitute one of the genetic factors influencing BMD in male adults.

MTHFR polymorphism and bone mineral density: meta-analysis of published studies

The C677T (rs1801133) polymorphism of methylenetetrahydrofolate reductase (MTHFR) has been associated with bone status in some studies, but the results have been mixed. In order to have a better understanding of this issue, we performed a meta-analysis of studies about the association of the C677T polymorphism and bone mineral density (BMD). Eight studies analyzed the relationship with spine BMD. When their results were combined, individuals with TT genotype showed a small but significantly reduced BMD compared to those with TC and CC genotypes. The weighted mean difference (WMD) was 18.0 mg/cm2 (P = 0.001, 95% confidence interval [CI] 7.1-28.9), without statistical evidence for between-study heterogeneity (P = 0.28, I2 = 17%). Six studies analyzed femoral neck BMD. A test for heterogeneity was significant (P = 0.03, I2 = 56%). Individuals with TT alleles tended to have somewhat lower BMD, but the difference was not statistically significant. In random effects model, the WMD between the TT and TC/CC genotypes was 6.4 mg/cm2 (95% CI -7.8 to 21.2, P = 0.36). Total hip BMD was measured in four studies. They showed a significantly lower BMD in subjects with TT alleles: WMD 19.7 (95% CI 5.3-34.1) mg/cm2, P = 0.007, in comparison with TC/CC subjects. When we considered only studies on women, the WMD in BMD between TT and TC/CC genotypes was significant at the spine (22.1 mg/cm2, 95% CI 8.6-35.6; P = 0.001) and the femoral neck (15.5 mg/cm2, 95% CI 4.3-26.7; P = 0.007). There was no evidence for heterogeneity. The small number of studies did not allow a meaningful sex-stratified analysis of total hip BMD or a separate analysis of male data. In conclusion, the C677T polymorphism of the MTHFR gene is associated with small differences in BMD, at least in women.

[Unilateral facial and cerebral hyperplasia associated with neurofibromatosis type 1. Report of four patients]

INTRODUCTION

Plexiform neurofibroma in any location is one of the commonest complications associated with neurofibromatosis type 1 (NF1). Plexiform neurofibroma of the upper eyelid and orbit is usually associated with ipsilateral hemifacial hyperplasia. We present four patients with NF1 and plexiform neurofibroma of the eyelid and orbit associated with hemifacial hyperplasia, who also showed hyperplasia of the unilateral cerebral hemisphere.

CASE REPORTS

There are four patients, three females and one male, who consulted because of NF1 with plexiform neurofibroma of upper eyelid and hemifacial hyperplasia. Upper eyelid involvement was observed since birth and progressed during the first years of life. The patients showed normal neurological and mental development without motor or cerebellar disorders. Magnetic resonance studies demonstrated the asymmetric hyperplasia of the ipsilateral hemisphere in all four cases and of the cerebellar hemisphere in one case. The degree of hemispheric hyperplasia was related to the size and extension of the plexiform neurofibroma, as well as to the severity of the hemifacial hyperplasia. In our case which had the plexiform neurofibroma extended to the neck and the upper thorax, the hyperplasia not only affected the cerebral hemisphere but also the ipsilateral cerebellar hemisphere. All parts of the hemisphere showed increased size. The cortex of the entire hemisphere showed normal differentiation of the subcortical white matter.

CONCLUSION

NF1 appears to be related with facial and cerebral ipsilateral hemihyperplasia. The relation between the size and extension of the orbital, eyelid and facial plexiform neurofibroma and the degree of asymmetry of the hemispheric hyperplasia suggest that different influences of a still unknown agent, possibly a gene, obviously related to NF1, causes both the intracranial and extracranial abnormalities.