Angiogenic imbalance in maternal and cord blood is associated with neonatal birth weight and head circumference in pregnancies with major fetal congenital heart defect

OBJECTIVES

To ascertain whether abnormalities in neonatal head circumference and/or body weight are associated with levels of angiogenic/antiangiogenic factors in the maternal and cord blood of pregnancies with a congenital heart defect (CHD) and to assess whether the specific type of CHD influences this association.

METHODS

This was a multicenter case-control study of women carrying a fetus with major CHD. Recruitment was carried out between June 2010 and July 2018 at four tertiary care hospitals in Spain. Maternal venous blood was drawn at study inclusion and at delivery. Cord blood samples were obtained at birth when possible. Placental growth factor (PlGF), soluble fms-like tyrosine kinase-1 (sFlt-1) and soluble endoglin (sEng) were measured in maternal and cord blood. Biomarker concentrations in the maternal blood were expressed as multiples of the median (MoM).

RESULTS

PlGF, sFlt-1 and sEng levels were measured in the maternal blood in 237 cases with CHD and 260 healthy controls, and in the cord blood in 150 cases and 56 controls. Compared with controls, median PlGF MoM in maternal blood was significantly lower in the CHD group (0.959 vs 1.022; P < 0.0001), while median sFlt-1/PlGF ratio MoM was significantly higher (1.032 vs 0.974; P = 0.0085) and no difference was observed in sEng MoM (0.981 vs 1.011; P = 0.4673). Levels of sFlt-1 and sEng were significantly higher in cord blood obtained from fetuses with CHD compared to controls (mean ± standard error of the mean, 447 ± 51 vs 264 ± 20 pg/mL; P = 0.0470 and 8.30 ± 0.92 vs 5.69 ± 0.34 ng/mL; P = 0.0430, respectively). Concentrations of sFlt-1 and the sFlt-1/PlGF ratio in the maternal blood at study inclusion were associated negatively with birth weight and head circumference in the CHD group. The type of CHD anomaly (valvular, conotruncal or left ventricular outflow tract obstruction) did not appear to alter these findings.

CONCLUSIONS

Pregnancies with fetal CHD have an antiangiogenic profile in maternal and cord blood. This imbalance is adversely associated with neonatal head circumference and birth weight. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.

ODP109 PARATHYROID HORMONE AND 25 OH VITAMINA D IN PREGNANCY: DATA FROM AN ARGENTINEAN COHORT SUPPORTING SUPPLEMENTATION

 

Vitamin D (Vit D) deficiency has become a global health care issue, as it affects a great number of women during pregnancy and lactation. Vit D levels are critical during pregnancy, being the mother the only source of them for the developing fetus; an enzymatic system for conversion of 25OH VitD into 1-25(OH) 2 VitD is present in the placenta, thus reinforcing the importance of VitD during gestation. VitD deficiency has been associated with obstetric complications and adverse outcomes in offspring, affecting skeletal, immunological and respiratory systems. It is known that prenatal supplements available do not contain enough VitD to fulfil requirements. It is generally accepted that elevated PTH is an indicator of VitD deficiency, and Hysaj O et al (2021) showed that 25OH VitD is a statistically significant determinant of PTH levels in early and late pregnancy.

Aim

To evaluateVitD status and its relationship to parathyroid hormone (PTH) in a cohort of pregnant women representative of multiple Argentinian regions.

Subjects and Methods

Data from samples of 423 pregnant women in 1st and 2nd trimester were collected between 2016 and 2021. VitD was measured in different platforms: DiaSorin Liaison CLIA (n=184), Roche COBAS ECLIA (n=166), Abbott ARCHITECT CMIA (n=33), Biomérieux VIDAS ELFA (n=18) and Siemens CENTAUR CLIA (n=16). PTH (ng/L) was measured in 162 samples by SIEMENS IMMULITE CLIA and Roche COBAS ECLIA. As VitD is light-exposure dependent, we considered warm and high light-exposure season period from December to March and cold and low light season from April to September. VITD (ng/L) levels were classified as Deficient (<20), Insufficient (between 21 and 29) and Sufficient (>30) (Endocrine Society, 2014).

Results

From 423 data collected, 102 were excluded because of lacking information on VitD supplementation. From the remaining non supplemented 321 samples, 48% resulted insufficient, 30% deficient and 22% sufficient for VitD (groups comparison: p< 0. 05, Kruskal Wallis-Dunn test). The seasonal period and pregnancy trimester distributions didn't show significant differences. Similar results of VitD insufficiency were found in the major used platforms, regardless the seasonal period considered. PTH results expressed as median and interquartile range were (ng/L): 32. 0 (13.7-169. 0) in Deficient pregnancies (N=92), 23.7(13.3-88. 0) in Insufficient (n=50) and 18.7 (9.8-55.7) in Sufficient (n=20).

Conclusions

This study shows VitD inadequate levels in 78% in non-supplemented pregnancies, regardless season or measurement platform. Relative elevated levels of PTH were associated to pregnancies with VitD deficiency, evidenciating a regulatory role according to published data. To improve VitD status during pregnancy it would be advisable to pose new strategies for prenatal supplements developed by a multidisciplinary professional team.

Presentation: No date and time listed

AB1339 MUSCLE ULTRASOUND FOR THE DIAGNOSIS OF SARCOPENIA IN RHEUMATOID ARTHRITIS (RA)

Background

Sarcopenia is a muscular disease characterized by a loss of muscle mass and function. The condition is associated with chronic diseases and ageing and predicts disability, hospitalization and death (1). Due to chronicity and disability produced by RA, it is convenient to see the relationship with sarcopenia.

Objectives

To assess the diagnostic utility of ultrasound (US) for sarcopenia.

Methods

Cases: Outpatients, 65 years old or more, with RA (ACR/EULAR 2010 criteria) from the rheumatology clinics of 4 Spanish University Hospitals were randomly selected consecutively from rheumatology consultation since May 2021 to September 2021. Controls: Control subjects without rheumatoid disease were selected from family members or friends of the cases, paired by age, gender and social status from May to September 2021.

Variable and measures:

The main evaluated outcome was sarcopenia as defined in 2019 by the European Working Group on Sarcopenia in Older People (EWGSOP). Crossectional Ultrasounds (US) of the third proximal forearm were evaluated for the perpendicular distance (milimetres) between superficial surface of subcutaneous celular tissue and the deep surface close to the ulnae with two different measures (66% and 75%).

Crossectional US images were also obtained of lower limbs, at an equidistant point between anterosuperior iliac spine and the upper border of the patella for measuring the distance between superficial surface of subcutaneous celular tissue and the deep interface of the femur with vastus medialis muscle with two different measures (50% and 75%).

Handheld dynamometer was used to measure the strength in upper limbs.

Body composition was evaluated using dual-energy X-ray densitometry.

Statistics: A descriptive analysis, chi square y T-student tests were done to compare the main characteristics and results between patients and controls. Correlations between forearm US and strength and between thigh US and total DEXA were calculated by Pearson’s test.

Results

76 patients and 76 controls were included in the study, 120 were women (78,9%), with media ± SD of age 74,7 ±6,98 of media and 32 (21,1%) were men, with age 70,1 ±3,78 of media. In comparation with controls, RA patients presented more frequency of sarcopenia (30 [19,53%] vs 6 [3,94%]; p=0,005) according to EWGSOP criteria.

From the point of view of ultrasound, RA patients presented less muscle mass in cubital forearm and thigh. Control group presented larger size of muscle (Table 1).

Table 1.

Results measirements case-control in milimeters

Control (m±ds)RA (m±ds)p-valorRight forearm 66% ulnar42,92±838,72±9,330,003Left forearm 66% ulnar41,17±8,9737,93±9,270,03Left forearm 75% cubital38,74±7,735,18±8,50,008Right Thigh 50% FR+VI30,9±7,4628,09±6,310,011Right Thigh 50%VI14,5±4,2613,08±4,270,042Right Thigh 50% FR15,26±3,613,5±3,280,002Right Thigh 50% area FR588±181,29481,49±140,560,001Lefth Thigh 50% FR+VI27,67±8,922,37±8,26<0,001

Ultrasound measurements in forearm which showed a positive correlation with strength were: right forearm: 66% ulnar (r=0,364, p=0,001), 75% ulnar (r=0,365, p=0,001); left forearm: 66% ulnar (r=0,348, p=0,002), 75% ulnar (r=0,337, p=0,003). In the other hand, ultrasound measurements in thigh which showed a positive correlation with DXA were: right thigh 50% femoral rectus (FR)-vastus intermedius (VI) (r=0,255, p=0,003), 50% VI (r=0,256,p=0,003), 50% FR (r=0,265, p=0,002), 50% area FR (r=0,280, p=0,003), 75% FR-VI (r=0,357,p<0,001), 75% VI (r=0,382,p<0,001), 75% FR (r=0,240, R2=0,006), 75% area FR (r=0,218,p=0,023); Left thigh: 50% FR-VI (r=0,251, p=0,004), 50% VI (r=0,293,p=0,001), 50% FR (r=0,214, p=0,015), 75% FR-VI (r=0,347,p<0,001), 75% VI (r=0,342, p<0,001), 75% FR (r=0,295, p=0,001).

Conclusion

Muscle Ultrasound is a useful diagnostic tool to detect sarcopenia. It can be cost-efficient and faster when compared with DEXA and the results correlate consistently with the strength in forearm. Patients with rheumatoid arthritis are in high risk of suffering sarcopenia and US could be used to control the evolution of this condition.

Disclosure of Interests

None declared

POS1556-HPR RECOMMENDATIONS FOR NURSES ON THE MANAGEMENT OF PATIENTS WITH SYSTEMIC LUPUS ERYTHEMATOUS: A DELPHI CONSENSUS

Background

Nurses play a key role in the management of Systemic Lupus Erythematosus (SLE) due to their close contact with the patient. Well-structured resources and specialized training are necessary to ensure comprehensive and quality care. However, no complete clinical practice guidelines for nurses have been developed for the management of SLE in Spain or Europe [1].

Objectives

In this context, the OpenReuma scientific society decided to promote the RECOMIENDAles project, the aim of which is to create consensus-based recommendations for the management of SLE patients by nurses in Spain.

Methods

Following a bibliographic review, the Delphi method [2] was followed to reach the consensus and a structured survey was sent to nurses with expertise in SLE. Two successive rounds were conducted. Consensus was established when at least 70% of the panelists agreed or disagreed on a topic.

The final questionnaire contained 90 items divided into 3 sections (Figure 1).

Results

In Spain, few nurses could be considered experts in SLE, hence the number of panelists was small: 25 nurses from different specialties (Rheumatology: 80%, Autoimmune Disease Units: 4%, Internal Medicine: 4%, and Day Hospital Services: 12%) with sufficient experience to ensure validated recommendations that could translate into practice. All the participants worked in public hospitals and had more than 2 years of experience treating SLE patients.

A high consensus was reached on the role and responsibilities that nurses should have in relation to SLE patient management. The main results are summarized in Table 1.

Table 1.

Summary of the main recommendations reached in the RECOMIENDAles Project.

RECOMMENDATIONS% of agreement (7 – 9 score)General recommendations•Multidisciplinary teams with at least one nurse trained in SLE100%•Participate throughout the SLE patient care process and have their own agenda of visits and content92%•Psychological and social worker support96%•Access to continuous training (SLE management, individual and group counselling and communication techniques)100%•Access to research projects96%Specific recommendationsDiagnosis:•Inform the patient about the diagnosis (manage expectations and resolve doubts and fears)100%•Provide contact channels with the service and reliable sources of information100%•Collaborate in the physical examination92%•Collaborate performing diagnostic tests76%Education:•Have a structured plan for patient education, engaging family and friends100%•Inform about the pathology (disease course, symptoms indicating aggravation, comorbidities)96%•Inform about healthy lifestyle habits (diet, hydration, exercise, rest patterns, photoprotection measures), avoiding toxic habits such as alcohol or smoking100%Treatment:•Play an active role in treatment training, including self-administration and adherence monitoring100%•Take part in the decision to introduce injectable therapy at home76%•Prepare a youth-adult therapeutic transition plan100%Follow-up:•Supervise patient condition to prevent comorbidities (diabetes, obesity, osteoporosis, cardiovascular problems)96%•Promote family planning measures100%•Monitor patient needs during the youth-adult transition96%

Conclusion

Despite the high consensus achieved, to bring these recommendations to fruition it is necessary to: 1) Reinforce the role and presence of the specialized nurse in multidisciplinary teams treating SLE patients; 2) Establish a specific training plan for nurses: accredited, subsidized and supported by the Scientific Societies; and 3) Create detailed clinical practice guidelines for the SLE nurse specialist.

References

[1]Urizar E, Antepara C, Urtaran-Laresgoiti M, Nuño-Solinís R. Servicios de Reumatología en España: Estado de situación. 2019.

[2]Dalkey NC. The Delphi Method: An Experimental Study of Group Opinion. Santa Monica Rand Corp [Internet]. RAND Corporation; 1969 [cited 2021 Nov 19]; Available from: https://www.rand.org/pubs/research_memoranda/RM5888.html

Acknowledgements

We would like to thank all the expert nurses who participated in the RECOMIENDAles Delphi Project, without whom this project would not have been possible: Ana Isabel Rodríguez Vargas (Canarias University Hospital, Santa Cruz de Tenerife); Carmen Domínguez Quesada (Virgen Macarena University Hospital, Seville); Coral Mouriño Rodríguez (do Meixoeiro Hospital, Pontevedra); Cristina Campins Reus (Manacor Hospital, Balearic Islands); Esther Vílchez Ocaña (Marítimo Torremolinos Hospital, Málaga); Idoya Piudo de Blas (Navarra Hospital Complex, Navarra); Isabel Pozo Jiménez (University Hospital of Jerez de la Frontera, Cádiz); Jenny de la Torre Aboki (General and University Hospital, Alicante); José María Martín Martín (Nuestra Señora de Candelaria University Hospital, Santa Cruz de Tenerife); Juan Crisostomo Vacas Pérez (Reina Sofía University Hospital, Murcia); Laura Cano García (Malaga Regional University Hospital, Malaga); Manuel Moreno Galeano (Virgen Macarena University Hospital, Seville); Maria Rodero López (San Carlos Clinical Hospital, Madrid); María Amparo Molina Tercero (University Hospital of Gran Canaria Dr. Negrin, Las Palmas de Gran Canaria); María del Carmen Herrero Manso (12 de Octubre University Hospital, Madrid), Maria Dolores Aragón Álvarez (San Cecilio University Hospital, Granada); María Isabel Castro López (University Hospital Complexo of Santiago, A Coruña); María Luisa Uriondo Martínez (A Coruña University Hospital, A Coruña); Marta Rodríguez Álvarez (Burgos University Hospital, Burgos); Noor Al-Mashhandani (Civil Hospital of Malaga, Malaga); Nuria Sapena Fortea (Barcelona Clinic Hospital, Barcelona); Patricia García Casado (Ramón y Cajal University Hospital, Madrid); Rosa Serrano Loro (Germans Tries i Pujol Hospital, Barcelona); Silvia García Díaz (Sant Joan Despí Moisès Broggi Hospital, Barcelona) and Susana Fernández Sánchez (Santa Creu and Sant Pau Hospital, Barcelona).

We would like to thank GSK for its financial support to this project. We would also like to thank Adelphi Targis S.L. for the logistical support provided to develop the project.

Disclosure of Interests

Laura Cano Garcia Consultant of: GSK, fees for her advice as a member of the Scientific Committee of the RECOMIENDAles Project., Carmen Dominguez Consultant of: GSK, fees for her advice as a member of the Scientific Committee of the RECOMIENDAles Project., Ana Isabel Rodriguez Vargas Consultant of: GSK, fees for her advice as a member of the Scientific Committee of the RECOMIENDAles Project., ELISA TRUJILLO MARTIN Consultant of: GSK, fees for her advice as a member of the Scientific Committee of the RECOMIENDAles Project., José Maria Martín Martín Consultant of: GSK, fees for his advice as a member of the Scientific Committee of the RECOMIENDAles Project.

AB0255 SARCOPENIA IN PATIENTS WITH RHEUMATOID ARTHRITIS OVER 65 YEARS OF AGE: PREVALENCE AND PREDISPOSING FACTORS

Background

Sarcopenia is a muscle disease which is characterized by loss of muscle mass and function. This condition is associated with chronic disease and ageing which predicts inability, hospitalization and death.

Objectives

Describe sarcopenia prevalence and risk factors in patients with reumathoid arthritis (RA) over 65 years of age.

Methods

Design:

A case-control study.

Subjects

Cases: Recruitment was performed by random sampling between patients over 65 years of age with RA (ACR/EULAR 2010 criteria) attended at 4 Spanish University Hospitals.

Controls: Recruitment of subjects without rheumatoid disease was performed asking for case patients who attended to medical center with a similar-age (age of range +/- 5 years) and same-gender person from same social or family environment.

Variables: The main variable was sarcopenia which was defined according to European Working Group on Sarcopenia in Older People (EWGSOP) 2019. Sarcopenia risk factors assessed were: economic status, malnutrition, measured with Mini Nutritional Assessment (MNA), dual-energy x-ray absorptiometry (DEXA) in spine and hip to osteoporose screening, toxic habits, comorbidities and Charlson index, physical activity measured with Global physical activity questionnaire (GPAQ) and Short Physical Performance Battery (SPPB).

Other variables were: haemoglobin, calcium, D and B12 vitamins, total proteins, albumin, C reactive protein, body mass index (BMI), polimedication, quality of life measured with EQ-5D and RA related factors, activity disease measured with DAS28, SDAI and CDAI; physical function measured with HAQ (Health assessment questionnaire) and global functional status according ACR criteria.

Statistical analysis:

Descriptive and multivariative analysis was performed to identify factors associated to sarcopenia in RA.

Results

76 patients and 76 controls were included in the study, 120 were women (78,9%), with media ± SD of age 74,7 ±6,98 of media and 32 (21,1%) were men, with age 70,1 ±3,78 of media. In comparation with controls, RA patients presented more frequency of sarcopenia (30 [19,53%] vs 6 [3,94%]; p=0,005). RA patients who presented sarcopenia, were upper average age (p=0,001), worse results in Short Physical Performance Battery (SPPB) (p=0,037), higher DAS28 (3,55 ± 1,09 vs 2,78 ± 1,05; p=0,017), higher score HAQ (1,18 ± 0,79 vs 1,69 ± 0,68; p=0,024), worse score in EQ5D (0,27 ± 0,28 vs. 0,54 ± 0,25; p=0,001) and Visual analogic scale VAS EQ5D (45,7 ± 17,4 vs. 56,9 ± 17,6; p=0,035).

By the way, RA patients presented lower levels of total proteins (p=0,018), worse results in MNA (p=0,001) and they performed less physical activity by GPAQ (p=0,011). Multivariative models (Table 1) identified as independent predictors of sarcopenia in RA: age (p=0,014), proteins levels (p=0,044) and disease activity measured by DAS28 (p=0,030). This model could explain 37% of sarcopenia in RA (R2=0,37).

Table 1.

Multivariativeanalysis (VD: Sarcopenia)

OR(IC)pAge, years1,213 (1,041-1,414)0,014Proteins (g/dL)0,185 (0,036-0,958)0,044DAS282,146(1,076-4,881)0,030

R2=0,37

Conclusion

Sarcopenia is more prevalence in over 65 years-old RA people. Older age and higher activity disease measured by DAS28 more risk of sarcopenia. Proteins levels have a protected association with sarcopenia.

Disclosure of Interests

None declared

AB1545-HPR MALNUTRITION IN PATIENTS WITH RHEUMATOID ARTHRITIS OVER 65 YEARS OF AGE

Background

Malnutrition is one of the most important geriatric syndrome and fragility factor in older people. In adittion to being a disease sign, its presence is related with increasing of morbility, longer hospitalizations, institucionalization and mortality due to concomitant diseases.

Objectives

Describe prevalence of malnutrition risk and associated factor in patients with rheumatoid arthritis (RA) over 65 years of age.

Methods

Design:

A case-controls study.

Participants:

Cases: Recruitment was performed by random sampling between patients over 65 years of age with RA (ACR/EULAR 2010 criteria) attended at 4 Spanish University Hospitals. Controls: Recruitment of subjects without rheumatoid disease was performed asking for case patients who attended to medical center with a similar-age (age of range +/- 5 years) and same-gender person from same social or family environment.

Variables y measures:

The main variable was malnutrition risk, measured by screening of Mini Nutritional Assessment.

Other variables were: presence of sarcopenia, defined according to European Working Group on Sarcopenia in Older People (EWGSOP) 2019, economic status, dual-energy x-ray absorptiometry (DEXA) in spine and hip to osteoporose screening, toxic habits, comorbidities and Charlson index, physical activity measured with Global physical activity questionnaire (GPAQ) and Short Physical Performance Battery (SPPB), haemoglobin, calcium, D and B12 vitamins, total proteins, albumin, C reactive protein, body mass index (BMI), polimedication, quality of life measured with EQ-5D and RA related factors, activity disease measured with DAS28, SDAI and CDAI; physical function measured with HAQ (Health assessment questionnaire) and global functional status according ACR criteria.

Statistical analysis: Descriptive and multivariative analysis was performed to identify factors associated to sarcopenia in RA.

Results

152 subjects were included in the study, 76 RA and 76 controls.More patients than controls with malnutrition risk were found, although there were no significative difference (24 [31,6%] vs 17 [22,4%]; p=0,136). More women with RA were included (78,9%), with media ± SD of age 74,7 ± 3,78., sarcopenia was presented in 9/24 (37,5%) and Charlson index was 3 points in 11/24 patients (45,8%) and 4 points in 8/24 patients (33,3%). According to the treatment, almost a 40%, no DMARDs were taken and neither 25% biological DMARD. 58,3 % of patients received corticosteroids and mayority of them (95,8%) were polimedicated. RA patients who presented desnutrition risk, in comparison with the rest of patients, had a media of upper age (p=0,007), more frequency of sarcopenia (p=0,006), right tricipital skinfold thickness (p=0,043). Also, higher values were found in activity index like physical function and quality of life: DAS28 (p=0,003), HAQ (p=0,044), Vitamin D (p=0,035), IPAQ (p=0,003), SPPB (p=0,018), EQ5D (p=0,01), VAS EQ5D (p=0,044), SDAI (p= 0,006), CDAI (p=0,008). In multivariative análisis, factors associated by independent way to malnutrition risk were age (OR [CI 95%], 1,148 [1,020-1,291]; p=0,022) and inflammatory disease by DAS28 (OR [CI 95%], 2,043 [1,198-3,483]; p=0,009) (R2=0,252).

Conclusion

Even though frequency of malnutrition was similar in cases and controls, in RA was associated with inflammatory activity and older age. It´s important monitoring malnutrition risk in this kind of patients to perform correct interventions to prevent and improve nutrition.

Disclosure of Interests

None declared

OP0213-HPR RECOMMENDATIONS FOR NURSES IN THE MANAGEMENT OF RA PATIENTS ON TREATMENT WITH JAKINIBS

Background

The number of new treatments available in rheumatology continues to increase. Kinase inhibitors, or jakinibs, pose an added challenge due to their variety and because they are oral. The most important role of the rheumatology nurse is patient education, especially on how to take the medication. The better the nurse understands the drugs, the better their practical recommendations and decisions will be and the better they will be able to respond to the patient. Guidelines or recommendations for inflammatory diseases do not usually include key practical details for nurses. It is our understanding that these points that will subsequently determine adherence and safety should be specially addressed in a specific document for nurses.

Objectives

To establish practical, evidence-based nursing recommendations for the management of people with RA undergoing treatment with jakinibs.

Methods

To reach an evidence-based consensus we used systematic review and Delphi survey. A multidisciplinary panel of experts was formed with 6 rheumatology nurses, 2 rheumatologists, 1 psychologist, 1 dietician-nutritionist and 1 patient on treatment with jakinibs. This panel met on 2 occasions and was kept informed at all times of the progress of the project through the Miro platform. At the preparatory meeting the scope and users, structure and PICOt questions were established (these included efficacy and adverse effects, infections, cardiovascular risk, surgery, vaccination, pregnancy and breastfeeding, interactions and switches between jakinibs).

The steering group made recommendations based on the issues raised at the first meeting. Only those that achieved 65% in favour were included as items in a Delphi survey. The Delphi survey was sent to all members of the society nurses and rheumatologists (n=60). Voting ranged from 0 to 10 (strongly disagree to strongly agree). Items with more than 75% agreement in the first round did not proceed to a second round.

Results

The Table 1 shows the recommendations with their level of evidence and level of agreement after the Delphi (n=40; 67%). One item with only 50% agreement was rejected and did not proceed to a second round.

Table 1.RecommendationLevel of evidenceDegree of agreementBefore starting treatment with a jakinib, it should be confirmed that the patient has no contraindications.5100%The patient’s efficacy and outcome expectations for the drug should be explored and those that need to be adjusted.585%It should be indicated that a double dose should not be taken if one is missed.4100%As with other DMARDs, the patient should be instructed that close management will follow.599%The use of contraception and discontinuation of the drug is recommended in case of gestational desire or unplanned pregnancy.396%It is recommended to explain the warning signs of infection: fever, blisters, burning pain in the ribs, itching when urinating, productive cough, diarrhoea, pus-filled wounds, phlegmon.1a100%It is recommended to instruct the patient on preventive measures for infectious diseases (dental and hand hygiene, HPV, social distance, etc.).1a89%Vaccination against common germs in immunocompromised persons and shingles with the current vaccine is recommended.1a93%CV risk factors should be monitored, and the patient trained for signs of thrombosis, HF or ischaemic heart disease.1a89%Close monitoring of elderly patients (CV risk, infections) is recommended.2100%Emphasis on adherence is recommended for jakinibs to be effective.3100%Before surgery, discontinuation of jakinib should be scheduled depending on the type of surgery and comorbidities.389%

Conclusion

These recommendations will allow a practical approach to the management of jakinibs by nurses and enjoy an adequate consensus among potential users.

Disclosure of Interests

José Maria Martín Martín Speakers bureau: Lilly, Consultant of: Lilly, Grant/research support from: Galapagos, Silvia García-Díaz Grant/research support from: Galapagos, Amparo Molina Grant/research support from: Galapagos, Carmen Dominguez Grant/research support from: Galapagos, Loreto Carmona: None declared, Laura Cano Garcia Grant/research support from: Galapagos

POS0475 INTEGRATIVE CLINICAL, MOLECULAR AND COMPUTATIONAL ANALYSES ALLOW THE IDENTIFICATION OF DISTINCTIVE PHENOTYPES OF RHEUMATOID ARTHRITIS PATIENTS RELATED TO THE CLINICAL INVOLVEMENT AND THE RESPONSE TO TNF INHIBITORS

Background:

TNF inhibitors (TNFi) represent an extraordinary advance in the management of Rheumatoid Arthritis (RA). Despite their benefits, there is a percentage of patients (20–40%) that do not achieve clinical improvement. Therefore, it is necessary to search for new and easily accessible biomarkers predictive of therapeutic response that might guide precision medicine.

Objectives:

1. To explore changes in the molecular profile of RA patients following TNFi therapy in serum samples. 2. To search for new and reliable biomarkers predictive of TNFi response, based on clinical and molecular profiles of RA patients, by using machine learning algorithms.

Methods:

In a prospective multicenter study, 79 RA patients undergoing TNFi and 29 healthy donors (HD) were enrolled. Twenty-two RA patients were further included as a validation cohort. Serum samples were obtained before and after 6 months of treatment, and therapeutic efficacy was evaluated. Patients’ response was determined following EULAR response criteria. Serum inflammatory profile was analyzed by a multiplex immunoassay, along with oxidative and NETotic profiles, evaluated by commercial kits. A circulating miRNA array was also performed by next-generation sequencing. Clustering analysis was carried out to identify groups of patients with distinctive molecular signatures. Then, clinical and molecular changes induced by TNFi were delineated after 6 months of therapy. Finally, integrative clinical and molecular signatures as predictors of response were assessed at baseline by supervised machine learning methods, using regularized logistic regressions.

Results:

Inflammatory, oxidative stress and NETosis-derived biomolecules were found altered in RA patients versus HD, closely interconnected and associated with several deregulated miRNAs. This altered molecular profile at baseline allowed the unsupervised division of three clusters of RA patients with distinctive clinical phenotypes, further linked to TNFi effectiveness. Cluster 1 included RA patients with low levels of pro-inflammatory cytokines, associated with a medium-low disease activity score and good clinical response. Clusters 2-3 comprised patients with high levels of pro-inflammatory cytokines, associated with a high disease activity and a non-response rate of 30%.

After 6 months of therapy the molecular profile found altered in RA patients was reversed in responder patients, who achieved a molecular phenotype similar to HDs. However, non-responder patients’ molecular profile remained significantly deregulated, including alterations in inflammatory mediators (IL-6, L-8, TNFα, VEGF, IL-1RA, IL-5, IL-15, GMCSF, GCSF, FGFb), oxidative stress markers (LPO) and NETosis-derived products (Elastase), along with specific miRNAs (miR-199a-5p). These molecular changes further correlated with changes in disease activity score. Machine-learning algorithms identified clinical (Creatinine, IgM, Vitamin D, Swollen Joints, C4, Disease Duration and Tryglicerides) and molecular (Nucleosomes, IL-10, miR-106a-5p, IL-13, IL-12p70, IL-15 and LPO) signatures as potential predictors of response to TNFi treatment with high accuracy. Furthermore, the integration of both features in a combined model increased the predictive value of these signatures (AUC: 0.91). These results were further confirmed in an independent validation cohort.

Conclusion:

1. RA patients display distinctive altered molecular profiles directly linked to their clinical status and associated with TNFi effectiveness. 2. Clinical response was associated with a specific modulation of the inflammatory profile, the reestablishment of the altered oxidative status, the reduction of NETosis and the reversion of related altered miRNAs. 3. The integrative analysis of the clinical and molecular profiles using machine learning allows the identification of novel signatures as potential predictors of therapeutic response to TNFi therapy.

Disclosure of Interests:

None declared

Scaling Laws in the Dynamics of Collapse of Single Bubbles and 2D Foams

Avalanches of rupturing bubbles play an important role in the dynamics of collapse of macroscopic liquid foams. We hypothesized that the occurrence of cascades of rupturing bubbles in foams depends, at least in part, on the power released during the rupture of a bubble. In this paper, we present results on the dynamics of single bubble bursting obtained by analyzing the pressure wave (sound) emitted by the bubble when collapsing. We found that the released energy varies linearly with bubble size, the frequency of the emitted sound follows a power law with exponent 3/2 (compatible with the Helmholtz resonator model) and the duration of a rupturing event seems to be independent of bubble size. To correlate the dynamics of individual bubbles with the dynamics of foams, we studied the occurrence of avalanches on bubble rafts and found that the phenomenon appears to be a self-organized criticality (SOC) process. The distribution functions for the size of the avalanches are a power law with exponents between 2 and 3, depending on the surfactant concentration. The distribution of times between ruptures also follows a power law with exponents close to 1, independently of the surfactant concentration.

Reduction of the Carbapenemase Inactivation Method (CIM) assay time by real-time PCR

Carbapenemase Inactivation Method (CIM) is a test to detect presence of the carbapenemase in Gram-negative bacteria. Determination of the carbapenemase production by inactivation of meropenem requires that a zone of control E. coli inhibition be measured approximately 6-24 h after plating. We have modified the CIM test by developing a rapid method which instead measures the growth of E. coli indicator strain ATCC 25922 using real-time PCR, referred to as a nucleic acid testing CIM (natCIM). Our natCIM, therefore reduces the detecting time from 6 to 24 h to approximately 4 h.

AB1355-HPR THE IMPACT OF A STRUCTURED TRAINING PROGRAMME FOR THE DETECTION OF SYNOVITIS WITH MUSCULOSKELETAL ULTRASOUND (MSUS) IN RHEUMATOLOGY NURSING

Background:

Objectives:

To analyse the effect of a teaching intervention for the technical performance of a reduced index of ultrasound synovitis by nurses without previous experience in musculoskeletal ultrasound (MSUS).

Methods:

Design: Quasi-experimental study of the before-after type. Protocol: The nurses received a theoretical-practical, face-to-face and intensive training of 8 hours, by an expert rheumatologist in musculoskeletal ultrasound (MSUS), to perform the Perricone index, which assesses the presence of grey-scale synovitis (GS) and quantifies the presence of a power-doppler (PD) signal semiquantitatively (0-3), in 6 joints (Wrists, 2nd Metacarpophalangeal (MCP) joints and knees). The theoretical knowledge acquired was assessed by an exam test type at the end of the training, and the technical skills were assessed by an ultrasound examination in patients with rheumatoid arthritis, immediately after the teaching session and at 18 months later. Variables: Illumination of the consultation, protection of privacy and unequivocal identification of the patient, technique (explorer ergonomics, bilateral comparison, use of both hands, measurement, marking and saving data), GS (probe position, centred image, cortical-cartilage-tendon display, depth, focus, frequency, gain), PD (probe pressure, PRF, position-width-depth of the box, focus, frequency, gain), synovial recesses (dorsal and palmar examination of the wrist, 2nd Metacarpophalangeal (MCP) joints and supra and parapatellar medial and lateral examination of the knees) and semi-quantitative gradation of synovitis in GS and PD. Statistical analysis: descriptive analysis, and in relation to the statistical significance tests for paired variables (pre and post teaching intervention) the McNemar test was used for dichotomous qualitative variables and McNemar-Bowker test for those of more than two categories.

Results:

5 nurses, 80% women, aged between 36 and 54 years participated. They adequately answered 100% of the 4-student test questions, and the remaining one matched 80% of them. The average time of baseline exploration was 45,2 ±3,8 minutes and the final time was 32,6 ± 3,5, improving the 5 students in an average of 12,6± 4,4 minutes. The technical aspects not performed correctly in the baseline ultrasound examination were the bilateral comparative, centred image, grey scale gain, measuring, correct anatomical image of the synovial recess of the wrist and position-width-depth of the Doppler box. An improvement was observed at 18 months in the unequivocal identification of the patient, adequate illumination of the consultation, bilateral comparison, correct anatomical acquisition of synovial recesses and the quantification of GS synovitis, but no statistically significant differences were observed, before and after the teaching intervention, in possible relation with the difficulty to use the ultrasound in their respective Rheumatology Units in clinical practice, but mainly because the aspects correctly performed in the baseline exploration were numerous.

Conclusion:

A formal training of rheumatology nurses in musculoskeletal ultrasound (MSUS) could be very useful, and cost-efficient, in the health care of patients with rheumatoid arthritis.

Disclosure of Interests:

None declared

SAT0043 SERUM BIOMOLECULES AS POTENTIAL BIOMARKERS OF CLINICAL EFFICACY AND PREDICTORS OF RESPONSE TO BIOLOGIC DISEASE MODIFYING ANTI-RHEUMATIC DRUGS IN RHEUMATOID ARTHRITIS PATIENTS

Objectives:

To evaluate the changes promoted in levels of circulating inflammatory mediators in RA patients in response to TNF-α inhibitors (TNFi) and anti-CD20 therapies, in order to identify biomarkers of clinical efficacy and potential predictors of therapeutic response to these drugs.

Methods:

In a prospective RA cohort multicenter study, we collected serum from RA patients with moderate or high disease activity prior and after 6 months of treatment with TNFi or rituximab (RTX), and analyzed levels of 27 proteins that constitute a multi-biomarker test of the inflammatory profile of these samples, using a multiplex immunoassay. Patients’ response was determined according to the EULAR response criteria (good/moderate/no). We compared basal levels of inflammatory molecules between the differential response patient groups and analyzed their discriminative ability. Logistic prediction models were created to assess the added value of potential inflammatory predictors.

Results:

Among 111 total RA patients, 50 of 85 (59%) patients in the TNFi group and 18 of 26 patients in the RTX group (69%) responded to the biologic treatment. High DAS28 or SDAI scores, or titers of auto-antibodies (RF or ACPA) at baseline were not predictive of response to any treatment. Instead, smoking habit and hyperlipidemia at baseline were predictors of a worse response to any of these bDMARDs.

Of the molecules analyzed by the multiplex assay, 14 inflammatory mediators showed a significant downregulation on patients’ responders to TNFi therapy. Moreover, the decline on 7 biomolecules was related to reduced DAS28. After RTX treatment, 15 inflammatory mediators were reduced in patients with good clinical response; downregulation in 4 of those biomolecules correlated with reduced DAS28.

In the search for predictors of response to each bDMARD, by using the MetaboAnalyst software, we could classify patients with distinctive therapeutic response based on the baseline levels of the inflammatory molecules analyzed. Receiver operating characteristic (ROC) analyses for those multiple biomarkers allowed us to further identify specific signatures of inflammatory biomolecules that may serve as predictors of response to each bDMARD therapy with high sensitivity and specificity. Thus, a signature of five molecules was identified as potential predictor of TNFi response [Vascular endothelial growth factor (VEGF), Eotaxin, RANTES, IL7 and IL-17]. Indeed, a signature including three highly expressed cytokines/chemokines in RA serum were identified as predictors of RTX response [interferon-inducible protein 10 (IP10), Eotaxin and monocyte chemotactic protein 1 (MCP-1)].

Conclusion:

The extensive analysis of serum inflammatory profile allowed to identify specific and distinctive signatures of biomolecules that, in coordination with known clinical and serological profiles, might predict the response of RA patients to TNFi or RTX treatments.

Acknowledgments :

Funded by Junta de Andalucía (PI-0285-2017), ISCIII, (PI18/00837 and RIER RD16/0012/0015) co-funded with FEDER

Disclosure of Interests:

María Luque-Tévar: None declared, Carlos Perez-Sanchez: None declared, Font Ugalde Pilar: None declared, Montserrat Romero-Gómez: None declared, Alejandra M. Patiño-Trives: None declared, Desiree Ruiz: None declared, Iván Arias de la Rosa: None declared, Maria del Carmen Abalos-Aguilera: None declared, Rafaela Ortega Castro: None declared, Alejandro Escudero Contreras: None declared, Carlos Rodríguez-Escalera Speakers bureau: Lilly, GSK, Novartis and Sanofi, José Javier Pérez Venegas: None declared, María Dolores Ruiz Montesinos: None declared, Carmen Dominguez: None declared, Carmen Romero Barco: None declared, Antonio Fernandez-Nebro: None declared, Natalia Mena-Vázquez: None declared, Jose Luis Marenco Speakers bureau: ABbvie, Pfzer, lilly, Julia Uceda: None declared, Mª Dolores Toledo-Coello: None declared, Nuria Barbarroja Puerto Grant/research support from: ROCHE and Pfizer., Speakers bureau: ROCHE and Celgene., Maria A Aguirre: None declared, Chary Lopez-Pedrera Grant/research support from: ROCHE and Pfizer., Eduardo Collantes-Estévez Grant/research support from: ROCHE and Pfizer., Speakers bureau: ROCHE, Lilly, Bristol and Celgene.

Premature placental aging in term small-for-gestational-age and growth-restricted fetuses

OBJECTIVE

To perform a comprehensive assessment of the placental aging process in small term fetuses classified as being small-for-gestational age (SGA) or having fetal growth restriction (FGR) through analysis of senescence and apoptosis markers.

METHODS

This was a prospective nested case-control study of singleton pregnancies delivered at term, including 21 control pregnancies with normally grown fetuses and 36 with a small fetus classified as SGA (birth weight between the 3^rd and 9^th percentiles and normal fetoplacental Doppler; n = 18) or FGR (birth weight < 3^rd percentile and/or abnormal cerebroplacental ratio and/or uterine artery Doppler; n = 18). Telomerase activity, telomere length (quantified by comparing the amount of amplification product for the telomere sequence (T) to that of a single copy of the gene 36B4 (S)) and RNA expression of senescence (Sirtuins 1, 3 and 6) and apoptosis (p53, p21, BAX and Caspases 3 and 9) markers (analyzed using the 2^-ΔΔCt method) were determined in placental samples collected at birth and compared between the three groups.

RESULTS

Compared to pregnancies with a normally grown fetus, both SGA and FGR pregnancies presented signs of accelerated placental aging, including lower telomerase activity (mean ± SD, 12.8 ± 6.6% in controls vs 7.98 ± 4.2% in SGA vs 7.79 ± 4.6% in FGR; P = 0.008), shorter telomeres (mean ± SD T/S ratio, 1.20 ± 0.6 in controls vs 1.08 ± 0.9 in SGA vs 0.66 ± 0.5 in FGR; P = 0.047) and reduced Sirtuin-1 RNA expression (mean ± SD 2^-ΔΔCt , 1.55 ± 0.8 in controls vs 0.91 ± 0.8 in SGA vs 0.63 ± 0.5 in FGR; P = 0.001) together with increased p53 RNA expression (median (interquartile range) 2^-ΔΔCt , 1.07 (0.3-3.3) in controls vs 5.39 (0.6-15) in SGA vs 3.75 (0.9-7.8) in FGR; P = 0.040). FGR cases presented signs of apoptosis, with increased Caspase-3 RNA levels (median (interquartile range) 2^-ΔΔCt , 0.94 (0.7-1.7) in controls vs 3.98 (0.9-31) in FGR; P = 0.031) and Caspase-9 RNA levels (median (interquartile range) 2^-ΔΔCt , 1.21 (0.6-4.0) in controls vs 3.87 (1.5-9.0) in FGR; P = 0.037) compared with controls. In addition, Sirtuin-1 RNA expression, telomerase activity, telomere length and Caspase-3 activity showed significant linear trends across groups as severity of the condition increased.

CONCLUSIONS

Accelerated placental aging was observed in both clinical forms of late-onset fetal smallness (SGA and FGR), supporting a common pathophysiology and challenging the concept of SGA fetuses being constitutionally small. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

The cis-Regulatory Atlas of the Mouse Immune System

A complete chart of cis-regulatory elements and their dynamic activity is necessary to understand the transcriptional basis of differentiation and function of an organ system. We generated matched epigenome and transcriptome measurements in 86 primary cell types that span the mouse immune system and its differentiation cascades. This breadth of data enable variance components analysis that suggests that genes fall into two distinct classes, controlled by either enhancer- or promoter-driven logic, and multiple regression that connects genes to the enhancers that regulate them. Relating transcription factor (TF) expression to the genome-wide accessibility of their binding motifs classifies them as predominantly openers or closers of local chromatin accessibility, pinpointing specific cis-regulatory elements where binding of given TFs is likely functionally relevant, validated by chromatin immunoprecipitation sequencing (ChIP-seq). Overall, this cis-regulatory atlas provides a trove of information on transcriptional regulation through immune differentiation and a foundational scaffold to define key regulatory events throughout the immunological genome.

Changes in uterine artery Doppler velocimetry and circulating angiogenic factors in the first half of pregnancies delivering a small-for-gestational-age neonate

OBJECTIVE

To assess the relationship between longitudinal changes in placental Doppler indices and maternal circulating angiogenic factors in the first half of pregnancy and delivery of a small-for-gestational-age (SGA) neonate, and ascertain whether longitudinal evaluation of these variables improves the prediction achieved by second-trimester cross-sectional evaluation.

METHODS

From a prospective cohort of unselected singleton pregnancies undergoing first-trimester screening for aneuploidy, 138 were included in this study. Of these, 46 were complicated by SGA (delivering after 34 weeks' gestation with a birth weight < 10^th centile) and 92 were appropriate-for-gestational-age (AGA) pregnancies, which were included as controls (ratio 1:2). First-to-second trimester longitudinal changes in uterine artery (UtA) Doppler indices and maternal circulating levels of placental growth factor (PlGF) and soluble fms-like tyrosine kinase-1 (sFlt-1) were analyzed.

RESULTS

Compared with the AGA group, SGA pregnancies had significantly higher UtA impedance in the first (Z-score: 0.46 vs -0.57; P < 0.001) and second (Z-score: 1.71 vs -0.75; P < 0.001) trimesters. Likewise, the sFlt-1/PlGF ratio was significantly higher in SGA than in AGA pregnancies in the first (98.0 vs 67.9; P = 0.01) and early second (22.4 vs 8.8; P < 0.001) trimesters. The predictive performance of the longitudinal changes in UtA Doppler indices for SGA was significantly lower than that of second-trimester cross-sectional values (area under receiver-operating characteristics curve (AUC), 60.8% vs 84.3%; P = 0.0035). The detection rate of SGA, at a 10% false-positive rate (FPR), was 17.7% by longitudinal changes in UtA Doppler and 56.2% by second-trimester cross-sectional UtA Doppler values. Similarly, the predictive performance of the longitudinal changes in PlGF was significantly lower than that of early second-trimester cross-sectional values (AUC, 71.4% vs 76.5%; P = 0.008). The detection rate of SGA at a 10% FPR was 40.6% when screening by longitudinal changes in PlGF and 52.1% when screening by early second-trimester cross-sectional values.

CONCLUSIONS

First- and second-trimester UtA Doppler velocimetry and maternal circulating angiogenic markers have clinical utility as a cross-sectional assessment for the identification of pregnancies at high risk of delivering a SGA neonate, however, they do not improve prediction when their longitudinal changes are used. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Differential performance of first-trimester screening in predicting small-for-gestational-age neonate or fetal growth restriction

OBJECTIVE

To assess the ability of integrated first-trimester screening, combining maternal characteristics and biophysical and biochemical markers, to predict delivery of a small-for-gestational-age (SGA) neonate, and compare this with its ability to predict fetal growth restriction (FGR).

METHODS

This was a prospective cohort study of singleton pregnancies undergoing routine first-trimester screening. SGA was defined as birth weight (BW) < 10^th percentile and FGR was defined as an ultrasound estimated fetal weight < 10^th percentile plus Doppler abnormalities, or BW < 3^rd percentile. Logistic regression-based predictive models were developed for predicting SGA and FGR. Models incorporated the a-priori risk from maternal characteristics, and mean arterial pressure, uterine artery Doppler, placental growth factor and soluble fms-like tyrosine kinase-1.

RESULTS

In total, 9150 births were included. Of these, 979 (10.7%) qualified for a postnatal diagnosis of SGA and 462 (5.0%) for a prenatal diagnosis of FGR. For predicting SGA, the model achieved a detection rate of 35% for a false-positive rate (FPR) of 5% and 42% for a 10% FPR. The model's performance was significantly higher for predicting FGR (P < 0.001), with detection rates of 59% and 67%, for a FPR of 5% and 10%, respectively.

CONCLUSION

The predictive performance of first-trimester screening for cases with growth impairment by a combination of maternal characteristics and biophysical and biochemical markers is improved significantly when a prenatal and strict definition of FGR is used rather than a postnatal definition based on BW. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

First-trimester screening with specific algorithms for early- and late-onset fetal growth restriction

OBJECTIVE

To develop optimal first-trimester algorithms for the prediction of early and late fetal growth restriction (FGR).

METHODS

This was a prospective cohort study of singleton pregnancies undergoing first-trimester screening. FGR was defined as an ultrasound estimated fetal weight < 10(th) percentile plus Doppler abnormalities or a birth weight < 3(rd) percentile. Logistic regression-based predictive models were developed for predicting early and late FGR (cut-off: delivery at 34 weeks). The model included the a-priori risk (maternal characteristics), mean arterial pressure (MAP), uterine artery pulsatility index (UtA-PI), placental growth factor (PlGF) and soluble fms-like tyrosine kinase-1 (sFlt-1).

RESULTS

Of the 9150 pregnancies included, 462 (5%) fetuses were growth restricted: 59 (0.6%) early and 403 (4.4%) late. Significant contributions to the prediction of early FGR were provided by black ethnicity, chronic hypertension, previous FGR, MAP, UtA-PI, PlGF and sFlt-1. The model achieved an overall detection rate (DR) of 86.4% for a 10% false-positive rate (area under the receiver-operating characteristics curve (AUC): 0.93 (95% CI, 0.87-0.98)). The DR was 94.7% for FGR with pre-eclampsia (PE) (64% of cases) and 71.4% for FGR without PE (36% of cases). For late FGR, significant contributions were provided by chronic hypertension, autoimmune disease, previous FGR, smoking status, nulliparity, MAP, UtA-PI, PlGF and sFlt-1. The model achieved a DR of 65.8% for a 10% false-positive rate (AUC: 0.76 (95% CI, 0.73-0.80)). The DR was 70.2% for FGR with PE (12% of cases) and 63.5% for FGR without PE (88% of cases).

CONCLUSIONS

The optimal screening algorithm was different for early vs late FGR, supporting the concept that screening for FGR is better performed separately for the two clinical forms. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Epidemiology of Emergent Madariaga Encephalitis in a Region with Endemic Venezuelan Equine Encephalitis: Initial Host Studies and Human Cross-Sectional Study in Darien, Panama

Background

Neurotropic arboviral infections are an important cause of encephalitis. A zoonotic, vector-borne alphavirus, Madariaga virus (MADV; formerly known as South American eastern equine encephalitis virus), caused its first documented human outbreak in 2010 in Darien, Panama, where the genetically similar Venezuelan equine encephalitis virus (VEEV) is endemic. We report the results of a seroprevalence survey of animals and humans, illustrating contrasting features of MADV and VEEV ecology and epidemiology.

Methods

Small mammals were trapped in 42 sites in Darien, Panama, using Sherman traps, Tomahawk traps, and mist nets for bats. Blood was tested for the presence of neutralizing antibodies to MADV and VEEV. In addition, bird sera collected in 2007 in Chagres, Panama, were tested for MADV and VEEV neutralizing antibodies. Viremia was ascertained by RT-PCR. Human exposure to these two viruses was determined by IgG ELISA, followed by plaque reduction neutralization tests. To identify relevant risk factors for MADV or VEEV exposure, logistic regression analysis was performed, and the most parsimonious model was selected based on the Akaike information criterion.

Results

The animal survey yielded 32 bats (16 species), 556 rodents (12 species), and 20 opossums (4 species). The short-tailed cane mouse (Zygodontomys brevicauda) found abundantly in pasture and farms, had the highest MADV seroprevalence (8.3%). For VEEV, the shrub and forest-dwelling long-whiskered rice rat (Transandinomys bolivaris) had the highest seroprevalence (19.0%). Viremia was detected in one animal (Z. brevicauda). Of the 159 bird sera (50 species) tested, none were positive for either virus. In humans (n = 770), neutralizing antibodies to MADV and VEEV were present in 4.8% and 31.5%, respectively. MADV seropositivity was positively associated with cattle ranching, farming, and fishing. Having VEEV antibodies and shrubs near the house diminished risk. Age, forest work, farming and fishing were risk factors for VEEV, while having MADV antibodies, glazed windows, waste pick-up and piped water were protective.

Conclusion

Our findings suggest that the short-tailed cane mouse and the long-whiskered rice rat serve as hosts for MADV and VEEV, respectively. The preferred habitat of these rodent species coincides with areas associated with human infection risk. Our findings also indicate that MADV emerged recently in humans, and that the transmission cycles of these two sympatric alphaviruses differ spatially and in host utilization.

Arthropod-borne viruses are important causes of encephalitis. In 2010, the first documented human outbreak of the mosquito-borne, zoonotic Madariaga virus (MADV) occurred in the Darien region of Panama. Neither its epidemiology nor its transmission cycle is understood. In this study, the authors searched for possible animal hosts of this virus, and sought to describe its epidemiology. They contrast the findings with those for Venezuelan equine encephalitis virus (VEEV), an endemic, genetically similar virus. Zygodontomys brevicauda, the short-tailed cane mouse, had the highest seroprevalence for MADV. This rodent species is most often found in pasture and farm land. Indeed, the risk factors for human MADV exposure were cattle ranching and farming. The animal with highest seroprevalence for VEEV, the long-whiskered rice rat (Transandinomys bolivaris), commonly occurs in forest, and the epidemiological risk factors included working in the forest. Farming and fishing were risk factors for exposure to both viruses, and having antibodies to one virus diminished the risk of being positive for the other. Increasing prevalence with age was seen for VEEV, confirming that VEEV is endemic in the region. This association was absent for MADV, suggesting that this virus emerged recently to infect humans.

Spectrally-resolved measurement of concentrated light distributions for Fresnel lens concentrators

A test method that measures spectrally resolved irradiance distribution for a concentrator photovoltaic (CPV) optical system is presented. In conjunction with electrical I-V curves, it is a means to visualize and characterize the effects of chromatic aberration and nonuniform flux profiles under controllable testing conditions. The indoor characterization test bench, METHOD (Measurement of Electrical, Thermal and Optical Devices), decouples the temperatures of the primary optical element (POE) and the cell allowing their respective effects on optical and electrical performance to be analysed. In varying the temperature of the POE, the effects on electrical efficiency, focal distance, spectral sensitivity, acceptance angle and multi-junction current matching profiles can be quantified. This work presents the calibration procedures to accurately image the spectral irradiance distribution of a CPV system and a study of system behavior over lens temperature.

Notch is a signal integrating hub that controls differentiation of effector CD8+ T cells (LYM7P.614)

Activated CD8+ T-cells must choose between different effector cell fates. Two major fates are the short lived terminal effector cell (TEC) fate and the memory precursor cell (MPC) fate. Differentiation of immediately protective TECs is proportional to the severity of the infection, suggesting the existence of signals that relay information about the infection to promote the generation of this effector cell type. We here show that the choice between the TEC and MPC fates is governed by inductive signaling via Notch. This cell surface receptor promotes differentiation of TEC and is correspondingly required for clearance of influenza-virus infection. Notch activates a major portion of the TEC-specific gene expression program and suppresses the MPC-program, thus creating maximal separation between the two cell fates. Influenza infection induces ligands for Notch on lung derived migratory dendritic cells in mediastinal lymph nodes. Notch receptors are induced on naïve CD8+ T-cells by inflammatory mediators and IL-2 via mTOR and T-bet dependent pathways. These pathways are subsequently amplified downstream of Notch, thus creating a positive feedback loop to bolster full adoption of the TEC fate. Our results show that Notch functions as a central hub where signals from different sources of information converge and refuel to match effector T-cell differentiation to the demands of the infection.

The Morbidity of Reoperative Surgery for Recurrent Benign Nodular Goitre: Impact of Previous Unilateral Thyroid Lobectomy versus Subtotal Thyroidectomy

Background. Subtotal thyroidectomy (STT) was previously considered the gold standard in the surgical management of multinodular goitre despite its propensity for recurrence. Our aim was to assess whether prior STT or unilateral lobectomy was associated with increased reoperative morbidity. Methods. A retrospective analysis was conducted extracting data from our endocrine surgical database for the period from January 1991 to June 2006. Two patient groups were defined: Group 1 consisted of patients with previous unilateral thyroid lobectomy; Group 2 had undergone previous STT. Specific outcomes investigated were transient and permanent recurrent laryngeal nerve (RLN) injury and hypoparathyroidism. Results. 494 reoperative cases were performed which consisted of 259 patients with previous unilateral lobectomy (Group 1) and 235 patients with previous subtotal thyroidectomy (Group 2). A statistically significant increase relating to previous STT was demonstrated in both permanent RLN injury (0.77% versus 3.4%, RR 4.38, P = 0.038) and permanent hypoparathyroidism (1.5% versus 5.1%, RR 3.14, P = 0.041). Transient nerve injury and hypocalcaemia incidence was comparable. Conclusions. Reoperative surgery following subtotal thyroidectomy is associated with a significantly increased risk of permanent recurrent laryngeal nerve injury and hypoparathyroidism when compared with previous unilateral thyroidectomy. Subtotal thyroidectomy should therefore no longer be recommended in the management of multinodular goitre.

Identification of seven novel SMPD1 mutations causing Niemann-Pick disease types A and B

Niemann-Pick disease (NPD) types A and B are autosomal, recessively inherited, lysosomal storage disorders caused by deficient activity of acid sphingomyelinase (E.C. 3.1.4.12) because of mutations in the sphingomyelin phosphodiesterase-1 (SMPD1) gene. Here, we present the molecular analysis and clinical characteristics of 15 NPD type A and B patients. Sequencing the SMDP1 gene revealed eight previously described mutations and seven novel mutations including four missense [c.682T>C (p.Cys228Arg), c.1159T>C (p.Cys387Arg), c.1474G>A (p.Gly492Ser), and c.1795C>T (p.Leu599Phe)], one frameshift [c.169delG (p.Ala57Leufs*20)] and two splicing (c.316+1G>T and c.1341delG). The most frequent mutations were p.Arg610del (21%) and p.Gly247Ser (12%). Two patients homozygous for p.Arg610del and initially classified as phenotype B showed different clinical manifestations. Patients homozygous for p.Leu599Phe had phenotype B, and those homozygous for c.1341delG or c.316+1G>T presented phenotype A. The present results provide new insight into genotype/phenotype correlations in NPD and emphasize the difficulty of classifying patients into types A and B, supporting the idea of a continuum between these two classic phenotypes.

Angiogenic and antiangiogenic factors before and after resolution of maternal mirror syndrome

Mirror syndrome is a rare condition that involves fetal hydrops, placentomegaly and severe maternal edema. The pathogenesis of this syndrome mimics endothelial dysfunction observed in pre-eclampsia. We report a case of maternal mirror syndrome caused by bilateral fetal hydrothorax that resolved after intrauterine pleuroamniotic shunt placement. At the time of the clinical manifestation there was an antiangiogenic state similar to that seen in pre-eclampsia, which resolved after fetal treatment. Our findings suggest that mirror syndrome is a manifestation of a broad spectrum of pathological conditions that induces an antiangiogenic state.

ZEB2 plays a role in promoting T-bet expression and terminal differentiation of CD8+ T cells (121.10)

We are interested in deciphering the transcriptional programs that underlie the differentiation of the effector CD8 T cell response. Prior work has shown T-bet operates in a gradient fashion, with higher T-bet expression being critical for the development of terminal effector (TE) CD8 T cells. Expression profiling revealed that T-bet regulates ZEB2, a transcriptional repressor that is expressed 10 fold higher in TE cells compared to memory precursor (MP) effector CD8 T cells. To further investigate what role ZEB2 might play in promoting terminal differentiation of CD8 T cells we conditionally knocked out ZEB2 in activated CD8 T cells using Granzyme B Cre ZEB2 flox/flox mice (ZEB2 KO). Upon infection with LCMV, the CD8 T cell expansion in the ZEB2 KO was about half that of wild type mice. The ZEB2 KO CD8 T cells showed an accelerated maturation of the effector CD8 T cell compartment to a memory phenotype with increased IL-2 production and the acquisition of CD62L. Further analysis revealed that these phenotypes might be largely due to the reduction of the TE subset. In the absence of ZEB2, TE CD8 T cells adopt some MP characteristics such as CD27, CXCR3, and Eomes but reduced T-bet and Blimp-1. Our observations suggest that ZEB2 is critical for the maintenance of the transcriptional program that drives terminal differentiation including T-bet. Hence, we propose that ZEB2 and T-bet operate in a positive-feedback mechanism to drive CD8 T cells towards terminal differentiation.

Altered expression of the gap junction protein connexin43 is associated with papillary thyroid carcinomas when compared with other noncancer pathologies of the thyroid

BACKGROUND

Gap junctions are membrane structures composed of connexins (Cx) that allow diffusion of small molecules between cells. They are involved in tissue homeostasis, and various organ dysfunctions have been associated with gap junction defects. To verify their possible involvement in thyroid pathologies, the expression of connexin43 (Cx43), the major Cx in the human thyroid, was evaluated in a variety of diseases including cancer.

METHODS

There were 122 samples from various thyroid pathologies that were collected to analyze the presence of Cx43 by immunofluorescence. Through confocal microscopy, different patterns of Cx43 localization were identified as normal (membrane) or abnormal (cytoplasmic or lack of detection). The analysis of Cx43 expression was further performed by quantitative reverse transcriptase-polymerase chain reaction and immunohistochemistry in a subset of 25 papillary carcinomas and compared with nontumoral thyroid tissues.

RESULTS

The presence of Cx43 was commonly altered in thyroid cancer, as abnormal Cx43 staining was detected in 94.1% of cancer, 47.4% of adenomas, 45.7% of multinodular goiter, 16.7% of Graves' disease, and 25% of thyroiditis. In papillary carcinoma samples, the deregulation of Cx43 expression was mostly the consequence of a decrease of Cx43 mRNA (68% of cases) when compared with normal tissue. When Cx43 mRNA was not downregulated (32% of cases), both loss of membrane staining and aberrant cytoplasmic distribution of the protein were observed.

CONCLUSIONS

These results show that aberrations of Cx43 expression are associated with thyroid papillary carcinoma.

A G protein-coupled receptor is essential for Schwann cells to initiate myelination

The myelin sheath allows axons to conduct action potentials rapidly in the vertebrate nervous system. Axonal signals activate expression of specific transcription factors, including Oct6 and Krox20, that initiate myelination in Schwann cells. Elevation of cyclic adenosine monophosphate (cAMP) can mimic axonal contact in vitro, but the mechanisms that regulate cAMP levels in vivo are unknown. Using mutational analysis in zebrafish, we found that the G protein-coupled receptor Gpr126 is required autonomously in Schwann cells for myelination. In gpr126 mutants, Schwann cells failed to express oct6 and krox20 and were arrested at the promyelinating stage. Elevation of cAMP in gpr126 mutants, but not krox20 mutants, could restore myelination. We propose that Gpr126 drives the differentiation of promyelinating Schwann cells by elevating cAMP levels, thereby triggering Oct6 expression and myelination.

KBP is essential for axonal structure, outgrowth and maintenance in zebrafish, providing insight into the cellular basis of Goldberg-Shprintzen syndrome

Mutations in Kif1-binding protein/KIAA1279 (KBP) cause the devastating neurological disorder Goldberg-Shprintzen syndrome (GSS) in humans. The cellular function of KBP and the basis of the symptoms of GSS, however, remain unclear. Here, we report the identification and characterization of a zebrafish kbp mutant. We show that kbp is required for axonal outgrowth and maintenance. In vivo time-lapse analysis of neuronal development shows that the speed of early axonal outgrowth is reduced in both the peripheral and central nervous systems in kbp mutants. Ultrastructural studies reveal that kbp mutants have disruption to axonal microtubules during outgrowth. These results together suggest that kbp is an important regulator of the microtubule dynamics that drive the forward propulsion of axons. At later stages, we observe that many affected axons degenerate. Ultrastructural analyses at these stages demonstrate mislocalization of axonal mitochondria and a reduction in axonal number in the peripheral, central and enteric nervous systems. We propose that kbp is an important regulator of axonal development and that axonal cytoskeletal defects underlie the nervous system defects in GSS.

3-D modulable PDMS-based microlens system

The design, simulation, fabrication and characterization of 3-D modulable micro-optical system based on poly-dimethilsiloxane (PDMS) are presented in this paper. This system consists on two uncoupled PDMS lenses with different diameter (2 and 10 microm). Under stretching conditions, the dimensions of the small lens are not modified, whereas the geometry of the bigger lens is shifted from spherical to elliptical. A combination of different technologies is used to fabricate this microsystem: silicon, polymer and soft-lithography microfabrication techniques. This combination allows obtaining structures with a simple and mass production technology. Experimental results confirm the predicted numerical simulations, showing that, when the structure is under stretching conditions, the first focus is virtually invariable whereas the second focus becomes a Sturm zone.

Anti-Mullerian hormone indicates early ovarian decline in fragile X mental retardation (FMR1) premutation carriers: a preliminary study

BACKGROUND

Women who carry the fragile X mental retardation (FMR1) premutation are at risk for fragile X-associated primary ovarian insufficiency. Past studies have shown that carriers who are still cycling have increased levels FSH compared with non-carriers. As anti-Mullerian hormone (AMH) has been shown as an excellent marker of ovarian decline, we examined AMH levels among premutation carriers to characterize their ovarian function.

METHODS

We determined the level of FSH and AMH in serum samples collected during early follicular phase from women who carried longer FMR1 repeat alleles (defined as >or=70 repeats, n = 40) and those with shorter repeat alleles (<70 repeats, n = 75), identified by DNA analysis. Comparisons were made stratified by age and carrier status.

RESULTS

For all age groups, AMH levels were significantly lower among longer repeat allele carriers compared to shorter repeat allele carriers (P = 0.002, 0.006 and 0.020 for women ages 18-30, 31-40 and 41-50 years, respectively). In contrast, increased FSH indicative of early ovarian decline was only evident for longer repeat allele carriers aged 31-40 years (P = 0.089, 0.001 and 0.261 for women ages 18-30, 31-40 and 41-50 years, respectively).

CONCLUSIONS

These preliminary data suggest that AMH levels indicate early ovarian decline among women with longer FMR1 repeat alleles; moreover, AMH appears to be a better marker than FSH in identifying this early decline.

Examination of reproductive aging milestones among women who carry the FMR1 premutation

BACKGROUND

The fragile X premutation is characterized by a large CGG repeat track (55-199 repeats) in the 5' UTR of the FMR1 gene. This X-linked mutation leads to an increased risk for premature ovarian failure; interestingly, the association of repeat size with risk is non-linear. We hypothesize that the premutation-associated ovarian insufficiency is due to a diminished oocyte pool and examined reproductive aging milestones by repeat size group to determine if the same non-linear association is observed.

METHODS

We analyzed cross-sectional reproductive history questionnaire data from 948 women with a wide range of repeat sizes.

RESULTS

We have confirmed the non-linear relationship among premutation carriers for ovarian insufficiency. The mid-range repeat size group (80-100 repeats), not the highest group, had an increased risk for: altered cycle traits (shortened cycle length, irregular cycles and skipped cycles), subfertility and dizygotic twinning. Smoking, a modifiable risk, decreased the reproductive lifespan of women with the premutation by about 1 year, similar to its effect on non-carriers. As expected, premutation carriers were found to be at an increased risk for osteoporosis.

CONCLUSIONS

Possible molecular mechanisms to explain the non-linear repeat size risk for ovarian insufficiency are discussed.

Examination of reproductive aging milestones among women who carry the FMR1 premutation

BACKGROUND

The fragile X premutation is characterized by a large CGG repeat track (55-199 repeats) in the 5' UTR of the FMR1 gene. This X-linked mutation leads to an increased risk for premature ovarian failure; interestingly, the association of repeat size with risk is non-linear. We hypothesize that the premutation-associated ovarian insufficiency is due to a diminished oocyte pool and examined reproductive aging milestones by repeat size group to determine if the same non-linear association is observed.

METHODS

We analyzed cross-sectional reproductive history questionnaire data from 948 women with a wide range of repeat sizes.

RESULTS

We have confirmed the non-linear relationship among premutation carriers for ovarian insufficiency. The mid-range repeat size group (80-100 repeats), not the highest group, had an increased risk for: altered cycle traits (shortened cycle length, irregular cycles and skipped cycles), subfertility and dizygotic twinning. Smoking, a modifiable risk, decreased the reproductive lifespan of women with the premutation by about 1 year, similar to its effect on non-carriers. As expected, premutation carriers were found to be at an increased risk for osteoporosis.

CONCLUSIONS

Possible molecular mechanisms to explain the non-linear repeat size risk for ovarian insufficiency are discussed.

A genetic screen identifies genes essential for development of myelinated axons in zebrafish

The myelin sheath insulates axons in the vertebrate nervous system, allowing rapid propagation of action potentials via saltatory conduction. Specialized glial cells, termed Schwann cells in the PNS and oligodendrocytes in the CNS, wrap axons to form myelin, a compacted, multilayered sheath comprising specific proteins and lipids. Disruption of myelinated axons causes human diseases, including multiple sclerosis and Charcot-Marie-Tooth peripheral neuropathies. Despite the progress in identifying human disease genes and other mutations disrupting glial development and myelination, many important unanswered questions remain about the mechanisms that coordinate the development of myelinated axons. To address these questions, we began a genetic dissection of myelination in zebrafish. Here we report a genetic screen that identified 13 mutations, which define 10 genes, disrupting the development of myelinated axons. We present the initial characterization of seven of these mutations, defining six different genes, along with additional characterization of mutations that we have described previously. The different mutations affect the PNS, the CNS, or both, and phenotypic analyses indicate that the genes affect a wide range of steps in glial development, from fate specification through terminal differentiation. The analysis of these mutations will advance our understanding of myelination, and the mutants will serve as models of human diseases of myelin.

Data-driven docking: HADDOCK's adventures in CAPRI

We have shown previously that given high-resolution structures of the unbound molecules, structure determination of protein complexes is possible by including biochemical and/or biophysical data as highly ambiguous distance restraints in a docking approach. We applied this method, implemented in the HADDOCK (High Ambiguity Driven DOCKing) package (Dominguez et al., J Am Chem Soc 2003;125:1731-1737), to the targets in the fourth and fifth rounds of CAPRI. Here we describe our results and analyze them in detail. Special attention is given to the role of flexibility in our docking method and the way in which this improves the docking results. We describe extensions to our approach that were developed as a direct result of our participation in CAPRI. In addition to experimental information, we also included interface residue predictions from PPISP (Protein-Protein Interaction Site Predictor; Zhou and Shan, Proteins 2001;44:336-343), a neural network method. Using HADDOCK we were able to generate acceptable structures for 6 of the 8 targets, and to submit at least 1 acceptable structure for 5 of them. Of these 5 submissions, 3 were of medium quality (Targets 10, 11, and 15) and 2 of high quality (Targets 13 and 14). In all cases, predictions were obtained containing at least 40% of the correct epitope at the interface for both ligand and receptor simultaneously.

Light coupling into an optical microcantilever by an embedded diffraction grating

By measuring the excitation efficiency of an optical waveguide on a diffraction grating one can accurately register the changes in the incidence angle of the exciting light beam. This phenomenon was applied to detect ultrasmall deflections of silicon dioxide cantilevers of submicrometer thickness that were fabricated with corrugation on top to act as diffraction grating couplers. The power of light coupled into the cantilevers was monitored with a conventional photodetector and modulated using mechanical vibration of the cantilever, thus changing the spatial orientation of the coupler with respect to the incident light beam. The technique can be considered as an alternative to the methods known for detection of cantilever deflection.

Halothane and propofol differentially affect electroencephalographic responses to noxious stimulation

BACKGROUND

Anaesthetics blunt neuronal responses to noxious stimulation, including effects on electroencephalographic (EEG) responses. It is unclear how anaesthetics differ in their ability to modulate noxious stimulation-evoked EEG activation. We investigated the actions of propofol and halothane on EEG responses to noxious stimuli, including repetitive electrical C-fibre stimulation, which normally evokes neuronal wind-up.

METHODS

Rats were anaesthetized with halothane (n=8) or propofol (n=8), at 0.8x or 1.2x the amount required to produce immobility in response to tail clamping [minimum alveolar concentration (MAC) for halothane and median effective dose (ED(50)) for propofol]. We recorded EEG responses to repetitive electrical stimulus trains (delivered to the tail at 0.1, 1 and 3 Hz) as well as supramaximal noxious tail stimulation (clamp; 50 Hz electrical stimulus, each for 30 s).

RESULTS

Under halothane anaesthesia, noxious stimuli evoked an EEG activation response manifested by increased spectral edge frequency (SEF) and median edge frequency (MEF). At 0.8 MAC halothane, the tail clamp increased the MEF from approximately 6 to approximately 8.5 Hz, and the SEF from approximately 25.5 to approximately 27 Hz. At both 0.8 and 1.2 MAC halothane, similar patterns of EEG activation were observed with the 1 Hz, 3 Hz and tetanic stimulus trains, but not with 0.1 Hz stimulation, which does not evoke wind-up. Under propofol anaesthesia, noxious stimuli were generally ineffective in causing EEG activation. At 0.8 ED(50) propofol, only the tail clamp and 1 Hz stimuli increased MEF ( approximately 8 to approximately 10-10.5 Hz). At the higher propofol infusion rate (1.2 ED(50)) the repetitive electrical stimuli did not evoke an EEG response, but the tetanic stimulus and the tail clamp paradoxically decreased SEF (from approximately 23 to approximately 21.5 Hz).

CONCLUSIONS

Propofol has a more significant blunting effect on EEG responses to noxious stimulation compared with halothane.