Wunderlich syndrome as a rare complication of polyarteritis nodosa: a case report

Spontaneous subcapsular and perirenal hemorrhage, known as Wunderlich syndrome (WS), is a rare clinical manifestation of polyarteritis nodosa (PAN). We report a case of a 48-year-old male with a history of recurrent episodes of leg muscle tenderness and dysesthesia, bilateral flank pain, painful nodular skin lesions in the lower limbs, weight loss, and difficult-to-control arterial hypertension. The abdominopelvic computed tomography angiography showed a large left perirenal hematoma, leading to the patient's admission to the intensive care unit. After the exclusion of infectious or neoplastic foci, the patient was diagnosed with PAN and started intravenous methylprednisolone pulses with a good response. Since WS is a rare initial clinical manifestation of PAN, an early diagnosis and aggressive treatment will significantly improve clinical outcomes.

POS0560 ASSESSMENT OF THE SWOLLEN TO TENDER JOINT COUNT RATIO AS A PREDICTOR OF RESPONSE IN RHEUMATOID ARTHRITIS PATIENTS: A COHORT STUDY

Background

Several response predictors have already been studied in rheumatoid arthritis, especially since the introduction of biological therapies. The swollen to tender joint count ratio (STR) has been proposed as a predictor of response in patients receiving anti-TNF therapy, but its usefulness in other therapies is not yet well established.

Objectives

To assess whether STR can be a predictor of response in patients with rheumatoid arthritis under b/tsDMARD.

Methods

Longitudinal and retrospective study that included patients diagnosed with rheumatoid arthritis followed in the Rheumatology Department of a tertiary hospital, under therapy with b/tsDMARD.

Demographic, laboratory, and clinical data were collected, including tender and swollen joint counts (as included in DAS 28), Visual Analog Scale (VAS), DAS28 4V, SDAI, CDAI, ACR and EULAR responses, and HAQ. All patients were evaluated at 0, 6 and 12 months after starting the first b/tsDMARD therapy performed after 2015. The variation in each parameter compared to baseline was calculated at 6 and 12 months and represented as a delta. A cutoff of 1 was defined for comparison between STR groups.

The correlations between the continuous variables were assessed by Pearson’s test and comparison between groups of ratios using t test (continuous variables) and chi-square test (categorical variables). Multiple linear regression and multivariate logistic regression were performed to determine response predictors.

Results

A total of 287 patients were included, 238 (82.9%) females, aged 55.7±10.8 years and diagnosed with rheumatoid arthritis for 11.2±8.1 years. Two hundred and sixty-nine (93.7%) were on csDMARD; with regard to b/tsDMARD therapy, 66 started etanercept (23.0%), 62 tocilizumab (21.6%), 58 rituximab (20.2%), 44 adalimumab (15.3%), 17 golimumab (5.9%), 14 abatacept (4.9%), 7 certolizumab (2.4%), 5 upadacitinib and baricitinib (1.7%), 4 infliximab (1.4%), 3 tofacitinib (1.0%), and 2 anakinra (0.7%).

At the start of therapy with b/tsDMARD, the mean DAS28 4V was 4.7±1.5, CDAI 20.4±12.2, SDAI 22.8±16.4, erythrocyte sedimentation rate 31.8±24.4, C-reactive protein (CRP) 1.5±1.7, patient VAS 62.6±1.5, physician VAS 41.4±29.7, pain VAS 62.5±24.8, and HAQ 1.5±0.6; median tender joint count was 4 (interquartile range - IQR - 6), swollen joint count was 3 (IQR 6), and STR joint count was 0.9 (IQR 0.5). When the STR < 1 and STR ≥1 groups were compared, it was found that there were no differences in these variables when starting b/tsDMARD, nor in the therapies they performed.

At 6 months, the STR ≥1 group showed a higher proportion of patients in CDAI remission (CDAI ≤2.8 – 15.3% vs 6.9%, p=0.033) and in DAS28 4V remission or low disease activity according to DAS28 4V (DAS28 4V ≤3.2 – 36.5% vs 22.4%, p=0.008).

At 12 months, the STR ≥1 group exhibited less disease activity (mean DAS28 4V 3.2±1.2 vs 3.6±1.3, p=0.028) and a higher proportion of patients in DAS28 4V remission (25.2% vs 19.7%, p=0.047).

No significant differences were found between the groups in the other variables studied.

In the correlation studies, a weak correlation was identified between STR and CRP at 12 months (r=0,28, p<0,001).

In multiple linear regression studies, when adjusted for sex, age, prednisolone, csDMARD, inflammatory parameters, b/tsDMARD, STR was not shown to be a predictor of DAS28 4V disease activity at 1 year; in multivariate logistic regression studies, when adjusted for the same variables previously described, STR was not shown to be a predictor of remission or remission or low disease activity according to DAS28 4V at 1 year.

Conclusion

The STR is a practical, easy-to-use index that can be used as an adjunct in clinical practice in the evaluation of patients with rheumatoid arthritis, as it is associated with a better response to b/tsDMARD therapy, regardless of patient status and therapy, although it should not be used alone, as it does not appear to be a predictor of response, according to the indices that are currently used.

References

[1]Kristensen LE et al. Arthritis Care Res (Hoboken). 2014 Feb;66(2):173-9.

Disclosure of Interests

None declared.

POS0502 WHAT IS THE ROLE OF VITAMIN D STATUS IN DISEASE ACTIVITY IN RHEUMATOID ARTHRITIS PATIENTS TREATED WITH bDMARDs? – DATA FROM A RHEUMATOLOGY CENTER

Background:

Vitamin D is a fat-soluble vitamin, mainly involved in the regulation of calcium metabolism, and it has gained increasing interest in recent years because of its potential role in immunomodulatory activity. Recent data suggest that it is negatively associated with disease activity in rheumatoid arthritis (RA), however this is not yet fully understood.

Objectives:

This study’s aim was to investigate if there is any correlation between vitamin D serum levels at baseline, before taking the first biological disease-modifying antirheumatic drug (bDMARD), and at 6 months after, with disease activity in a cohort of RA patients.

Methods:

This is a cross-sectional study, including all the rheumatoid arthritis patients taking the first bDMARD with evaluation of the vitamin D status at baseline and 6 months after biologic therapy at our Rheumatology Department and registered in the national database (Reuma.pt).

Demographic, clinical and laboratorial characteristics and disease activity measures were collected from the baseline visit and the visit after 6 months of treatment with the first biologic. For the statistical analysis, two groups were defined, based on the serum levels of 25(OH) vitamin D, considering the most common cut-off of 30 ng/mL. For comparison analyses between groups, chi-square test was used for categorical variables and Mann-Whitney U and T-tests were applied for continuous variables.

Results:

Seventy-seven patients were included, 58 (75.3%) were females; the mean age was 54.24 ±11.0 years and seropositivity was founded in 65 (84.4%) for anti-citrullinated protein antibodies and in 58 (75.3%) for rheumatoid factor. The first bDMARD most commonly prescribed were etanercept (28.6%) and rituximab (26%). Regarding the vitamin D status at baseline, the mean serum level for 25(OH)vitamin D was 28.35 ± 18.21 ng/mL, with the majority of patients having vitamin D insufficiency (25(OH)vitamin D < 30 ng/mL) (63.6%). After 6 months of treatment with the first bDMARD, disease activity measures showed that remission or low activity were achieved in 29.9% of the patients, using DAS28 criteria; in 42.9% and 46.8%, according CDAI and SDAI criteria, respectively. Vitamin D serum levels at 6 months were 26.81 ±11.72, with the majority of patients still with vitamin D insufficiency (62.3%).

At baseline, patients with vitamin D insufficiency had greater patient VAS (79.00 ± 19,14 vs 71.71 ± 21.95), greater erythrocyte sedimentation rate (ESR) (40.67 ± 23.17 vs 32.46 ± 26.09) and greater Health Assessment Questionnaire (HAQ) score (1.75 ± 0.609 VS 1.61 ± 0.659) with neither of them having statistical significance. However, when comparing CRP levels at 6 months, it achieved statistical significance with the Mann-Whitney U-test (1.05 ± 1.79 VS 1.41 ± 5.22; p=0.026).

The same tendency was confirmed when analyzing vitamin D levels at 6 months. Patients with vitamin D insufficiency presented greater patient VAS (55.33 ± 28.82 vs 42.86 ± 28.28), greater ESR (26.19 ± 21.57 vs 21.00 ± 20.38) and greater HAQ score (1.35 ± 0.662 VS 1.34 ± 0.705), although without statistical significance. However, it did achieve statistical significance when comparing baseline DAS28 and HAQ (5.60 ± 0.91 VS 5.38 ± 1.31; p=0.013 and 1.76 ± 0.53 VS 1.59 ± 0.75; p=0.007, respectively).

Conclusion:

Our data failed to demonstrate a statistically significant association between vitamin D serum levels at baseline and at 6 months with disease activity in our RA sample. However, it revealed a positive trend of vitamin D insufficiency related to higher activity disease. Interestingly, it showed that vitamin D insufficiency after 6 months of bDMARD treatment is related to higher DAS28 and HAQ at baseline. Nonetheless, we insist it is of paramount importance to conduct larger studies to confirm these findings.

References:

[1]Bellan M, Sainaghi PP, Pirisi M. Role of Vitamin D in Rheumatoid Arthritis. Adv Exp Med Biol. 2017;996:155-168.

Disclosure of Interests:

None declared

AB0476 VITAMIN D SERUM CONCENTRATION VARIES ACCORDING TO DISEASE ACTIVITY IN SPONDYLOARTHRITIS

Background:

Several studies have shown dissimilar results for the relationship between serum 25-hydroxyvitamin D concentration (25-OH-D) and disease activity in spondyloarthritis (SpA).

Objectives:

This study aims to assess whether vitamin D levels vary according to disease activity in patients with SpA before and after starting treatment with biologic disease-modifying anti-rheumatic drugs (bDMARDs).

Methods:

An observational retrospective study was performed in SpA patients followed in the Rheumatology department of a tertiary university hospital. Demographic and clinical data were collected from the Rheumatic Diseases Portuguese Register (Reuma.pt). Patients were assessed for 25-OH-D levels before and after 6 months of treatment with the first bDMARD. Correlation between 25-OH-D levels and disease activity measured by Ankylosing Spondylitis Disease Activity Score (ASDAS) at baseline and after 6 months were assessed using student’s t-test for two samples and one-way ANOVA and with post hoc tests for multiple comparisons.

Results:

A total of 189 patients were included. Ninety-seven patients were females (51.3%). The mean age at diagnosis was 34.8±11.2 years and the median disease duration at the start of the first bDMARD was 4.9 years (min: 0.1; max: 46.0). All patients fulfilled the ASAS criteria for SpA. Nonsteroidal anti-inflammatory drugs were used by 102 patients (54.0%) and conventional synthetic DMARDs by 69 patients (36.5%). At 6 months, 188 patients were treated with tumor necrosis factor inhibitors and one with interleukin-17 inhibitor. According to ASDAS criteria, at baseline 36.8% of patients had high disease activity and 59.5% had very high disease activity. After 6 months of treatment with bDMARD 14.7% of patients have inactive disease, 21.6% low disease activity, 36.3% high activity and 12.6% very high disease activity. The mean value of 25-OH-D at baseline was significantly lower in the group of patients with very high disease activity compared to the patients with high disease activity (21.9±11.1 ng/ml vs 26.1±11.6 ng/ml, p= 0.02). At 6 months of treatment the mean value of 25-OH-D in inactive, low, high and very high disease activity was 31.0±17.1ng/ml, 28.5±11.2ng/ml, 25.8±10.8ng/ml and 19.3 ±9.5ng/ml, respectively. There was a statistically significant difference between the groups, as determined by one-way ANOVA (p = 0.001). A post hoc Dunnett T3 test revealed that patients with very high disease activity have significantly lower mean 25-OH-D levels (19.29 ± 9.5) than patients with inactive disease (31.0 ± 17.1, p = 0.025) and low activity (28.5 ± 11.2, p = 0.009). Among the groups with high and very high disease activity, the significance is only marginal (p = 0.068).

Conclusion:

Vitamin D serum concentration varies according to disease activity in SpA. In fact, SpA patients with lower levels of 25-OH-D are associated with higher rates of disease activity, even in patients treated with biologics agents. It is important to be aware of vitamin D level as it can play a role in the management and treatment of the disease, mainly in the most severe patients.

References:

[1]Zhao SZ, Thong D, Duffield S, Goodson N. Vitamin D Deficiency in Axial Spondyloarthritis is Associated With Higher Disease Activity. Arch Rheumatol. 2017 Mar 24;32(3):209-215. doi: 10.5606/ArchRheumatol.2017.6212. PMID: 30375524; PMCID: PMC6190948.

Disclosure of Interests:

None declared.

POS1067 BASELINE VITAMIN D LEVELS AND DISEASE ACTIVITY AND RESPONSE IN PORTUGUESE PATIENTS WITH PSORIATIC ARTHRITIS UNDER bMDARD: DOES IT MAKE A DIFFERENCE?

Background:

There is growing evidence that vitamin D [25(OH)D]) plays an important role in maintaining skeletal health and modulating the immune system. Epidemiological data indicate that vitamin D deficiency is common in immune-mediated rheumatic diseases, especially in rheumatoid arthritis, but there is little data regarding its association with disease activity and response to therapy in patients with psoriatic arthritis (PsA) under bDMARD therapy.

Objectives:

We aimed to assess whether 25(OH)D basal levels correlate with disease activity and clinical response to the first bDMARD, at 6 and 12 months of therapy, in a monocentric cohort of patients with PsA.

Methods:

This retrospective study was carried out on PsA patients from a Rheumatology department of a tertiary hospital, fulfilling CASPAR criteria and registered in our national database (Reuma.pt), who started the first bDMARD since 2008. Demographic, clinical and laboratory criteria were evaluated at 0, 6 and 12 months of biologic therapy. Disease activity was assessed using CDAI, SDAI, DAS28(4V), BASDAI, ASDAS, DAPSA and the response was measured using the EULAR, BASDAI50, ASDAS, ASAS, ACR and PsARC responses. Correlations were made between absolute serum levels of 25(OH)D and continuous variables, as well as associations between different vitamin D cutoffs and disease activity measures and response criteria. Multiple linear and logistic regression analyses were performed to determine whether vitamin D is a predictor of disease activity and therapeutic response.

Results:

We included 81 patients, 41 (50.6%) females; with a mean age of 48.0±11.7 years, a mean disease duration of 9.5±7.4 years and a mean body mass index of 28.4±5.2 kg/m2. Thirteen (16.0%) were smokers. The mean 25(OH)D basal level was 25.5±13.2 ng/ml, 21 (25.9%) had 25(OH)D basal levels ≥30 ng/mL and 31 (38.3%) ≤20 ng/mL. Sixty-two patients (76.5%) were under csDMARD therapy. Golimumab (29, 35,8%), etanercept (28, 34.6%) and adalimumab (10, 12.3%) were the most frequently prescribed bDMARDs. There were only very weak, albeit positive, correlations between 25(OH)D levels and measures of disease activity. The BASDAI50 response at 6 months was associated with higher basal 25(OH)D levels (29.5±14.5 vs 21.5±10.2 ng/mL, p = 0.013); the ASAS20 (33.9±15.9 vs 24.2±12.8 ng/mL; p = 0.023), ASAS40 (31.9±14.6 vs 25.0±13.8 ng/mL; p = 0.023) and ASAS70 (47.0±4.2 vs 26.6±14.2; p = 0.027) responses at 12 months were associated with higher basal levels of 25(OH)D; basal 25(OH)D levels were ≥ 30ng/mL in a significantly higher proportion of patients who achieved CDAI (38.9% vs 10.5%; p = 0.027) and SDAI (38.9% vs 7.7%; p = 0.008) remission and ASDAS disease inactive (29.4% vs 7.3%; p = 0.040) at 1 year. In the regression models, basal levels of 25(OH)D were found to be predictors of good EULAR responders (OR 1.315, 1.017-1.213 95% CI; p = 0.037) at 6 months. Basal levels of 25(OH)D were not significantly different in patients who discontinued bDMARD and no significant correlations or associations were identified regarding more specific PsA activity measures, such as DAPSA and PsARC, nor were they predictive of these responses.

Conclusion:

We can conclude that there is a global trend for an association between higher levels of vitamin D and lower measures of disease activity and better therapeutic responses to the first biologic. It was possible to find statistically significant associations with some disease activity measures and response criteria that, although primarily designed for other rheumatic diseases, are often used in PsA.

Disclosure of Interests:

None declared.

AB0137 THE ASSOCIATION BETWEEN AUTOANTIBODY LEVELS AND THE OUTCOMES OF ANTI-TUMOUR NECROSIS FACTOR ALPHA TREATMENT IN RHEUMATOID ARTHRITIS - A RETROSPECTIVE COHORT STUDY WITH TWO YEARS FOLLOW-UP

Background:

In rheumatoid arthritis (RA), autoantibodies namely anticitrullinated protein antibodies (Anti-CCP) have prognostic value, independently predicting radiologic progression. However, the evidence is still controversial about how the autoantibody levels change over time and their role in treatments outcomes and in monitoring disease activity in RA.

Objectives:

This study aimed to characterize the changes of autoantibodies levels (rheumatoid factor (RF) and Anti-CCP) over time and to explore the association between these autoantibodies and the outcomes of the first anti-tumour necrosis factor alfa (anti-TNF-α) therapy as first biologic agent in RA.

Methods:

An observational retrospective cohort study was conducted with two years of follow-up. Patients with diagnosis of RA according to American College of Rheumatology (ACR) criteria and registered on Rheumatic Diseases Portuguese Register (Reuma.pt) who started their first anti-TNFα agent (as first biologic) between 2003 and 2018 were included. Patients with positive RA (>30 UI/mL) and/or positive Anti-CCP (>10 U/mL) at their first visit were included. Demographic, clinical and laboratory data were obtained by consulting Reuma.pt. Disease Activity Score for 28 joints [DAS28(3v); DAS28(4v); DAS28(3v; C-Reactive Protein (CRP)), DAS28(4v; CRP), delta DAS28(4v)], Health Assessment Questionnaire (HAQ), delta HAQ, Anti-CCP and RF levels were assessed at baseline, 12 and 24 months. Continuous variables are presented with mean, standard deviation, median, quartile 1 and quartile 3. Categorical variables are presented with absolute and relative frequencies. To examine the differences between Anti-CCP and RF levels at baseline, 12 months and 24 months the Wilcoxon test for paired samples was performed. In order to correlate the Anti-CCP and RF levels with DAS28 variables, delta DAS28(4v), HAQ and delta HAQ at baseline, 12 months and 24 months, a correlation coefficient, Spearman’s coefficient, was used.

Results:

A total of 116 patients (mean age of 50.2±10.4 years old; 85.3% female) with RA were included with a median disease duration of 10.5 [5-18.5] years and a follow-up time of 8 [5-14] years. About 49% of patients were FR and Anti-CCP positivity, 38% only FR positivity and 13% only Anti-CCP positivity. At baseline, 64 (55.2%) patients had an erosive disease and 50 (43.1%) had extra-articular manifestations. Compared to the baseline (160[74.8-496]), FR levels decreased significantly at 12 months (121[49.1-321.8]) and 24 months (107.5[43.3-332]) with a p=0.017 and p=0.029, respectively. There were no differences in Anti-CCP levels over time. No correlation was found between FR/Anti-CCP levels and different DAS28 variables, DAS28(4v) delta, HAQ, and HAQ delta at 12 months and 24 months.

Conclusion:

We found that in patients with RA treated with a first anti-TNF-α agent as first biologic, FR levels decreased at 12 months and 24 months follow-up. However, our study failed to demonstrate a correlation between autoantibodies levels and disease activity (DAS28 variables and delta DAS28(4v)), HAQ and delta HAQ. In fact, previous research demonstrated that there is an association between autoantibodies levels and disease activity in RA, nonetheless not being static and increasing with signs of inflammation at baseline. So, further research with large samples is needed to explore this correlation considering the adjustment for confounding inflammatory variables, such as number of swollen or tender joints and morning stiffness.

Disclosure of Interests:

None declared

AB0835 IS BASELINE VITAMIN D STATUS RELATED WITH THE RESPONSE TO BDMARDS IN SPONDYLOARTHRITIS PATIENTS?

Background:

Vitamin D is thought to have an important role in immune regulation and is being subject of research in several autoimmune diseases. Some data suggest that vitamin D deficiency is common in Spondyloarthritis (SpA) and may be associated with disease activity and structural damage.

Objectives:

To evaluate if there is a relation between baseline vitamin D status and the response to biologic disease-modifying antirheumatic drugs (bDMARDs) in a SpA monocentric cohort.

Methods:

Retrospective study including all the SpA patients (ASAS classification criteria) followed at our Rheumatology Department, registered in the national database and treated with bDMARD between June 2008 and July 2020. Demographic, clinical and laboratorial data (including 25-hydroxyvitamin D [25-OHvitD]) at baseline and disease activity measures at 6 and 12 months of treatment with the first bDMARD were collected. Correlations between variables were evaluated by Spearman rank test, Mann-Whitney U test was used to the comparison analysis between groups and univariate logistic regression was used in the prediction analysis.

Results:

A total of 195 SpA patients were included: 103 (52.8%) females, 47 (24.1%) smokers and 91 (46.7%) HLA-B27 positive; 139 (71.3%) had Ankylosing Spondylitis, 18 (9.2%) had Inflammatory Bowel Disease Associated SpA and 38 (19.5%) had Undifferentiated SpA. At the time of the first bDMARD, the mean age was 43.5 years (±9.6) and the median disease duration was 12.4 years (0.7-52.7). The mean ASDAS-CPR (Ankylosing Spondylitis Disease Activity Score with C-reactive protein) was 3.9 (±0.8) and, in addition, 61 (31.3%) patients had 25-OHvitD levels below 30 ng/mL and 12 (6.2%) had 25-OHvitD levels below 20 ng/mL. Fifty-three patients (27.2%) were taking NSAIDs (nonsteroidal anti-inflammatory drugs), 77 (39.5%) were under csDMARDs (conventional synthetic disease-modifying antirheumatic drugs). Adalimumab (56%) and golimumab (33.3%) were the most frequently initiated bDMARDs in the first line.

There were no statistically significant correlations between baseline 25-OHvitD levels and ASDAS-CRP at 6 (r=0.031; p=0.714) and 12 months (r=0.035; p=0.672) of bDMARD.

In the subgroup analysis: there were no statistically significant differences in the response to bDMARD at 6 and 12 months evaluated by ASDAS response and ASAS 20, 40 and 70 responses according to the baseline 25-OHvitD levels (25-OHvitD <20ng/mL vs ≥20ng/mL; 25-OHvitD <30ng/mL vs ≥30ng/mL); and there were no statistically significant differences in the baseline 25-OHvitD levels at baseline according to the response to bDMARD at 6 and 12 months of bDMARD (ASDAS: no response vs clinically important improvement or major improvement; ASAS 20: no response vs response).

In the line of these previous results, baseline 25-OHvitD levels did not predict the ASDAS response at 6 (OR 0.97 [0.95-1.00], 95% CI) or 12 (OR 0.98 [0.95-1.01], 95% CI) months of bDMARD.

Conclusion:

Despite some data that suggest that lower levels of 25-OHvitD may be associated with higher disease activity in SpA, our results failed to demonstrate that the baseline 25-OHvitD levels can be related or predict treatment response after 6 and/or 12 months of therapy with the first bDMARD in real-life SpA patients.

Disclosure of Interests:

None declared

POS1106 FRAX AND THE EFFECT OF TERIPARATIDE ON BONE MINERAL DENSITY IN SECONDARY OSTEOPOROSIS

Background:

Teriparatide has been shown to increase spine and hip bone mineral density (BMD) and to reduce vertebral and non-vertebral fractures. (1) It is currently not clear whether the effect of teriparatide is dependent on the baseline risk of fracture or osteoporosis (OP) type, a finding that could have an impact on our therapeutic decision.

Objectives:

Investigate if there is a relationship between teriparatide effect in BMD and baseline 10-year fracture probability, assessed using FRAX®, in primary and secondary OP patients.

Methods:

This is a longitudinal, retrospective study including consecutive patients with the diagnosis of OP treated with teriparatide for 24 months, with a ten-year follow-up period, at our rheumatology department. Demographic, clinical, laboratorial, BMD and occurrence of fracture data were collected. The 10-year risk of osteoporotic fracture was estimated using the fracture risk assessment tool (FRAX) v 4.1 with the Portuguese population reference. Statistical analysis was performed using the software SPSS 23.0. Correlations between continuous variables were evaluated with spearman coefficient. p<0.05 was considered statistically significant.

Results:

Eighty patients (88.8% female, median age 65.00 (59; 75)) were included. Forty-nine patients (61.3%) has secondary OP, mainly of cortisonic etiology (61.2%, n=30). Before treatment, median lumbar spine BMD was 0.870 [0.767, 0.964] g/cm2, median T-score of -2.60 (-3.30, -1.90); median total femur BMD was 0.742 [0.667, 0.863] g/cm2, median T-score of -2.10 (-2.80, -1.30); median femoral neck BMD was 0.671 [0.611, 0.787] g/cm2, median T-score of -2.50 [-3.20, -1.85]. Regarding fracture risk, median FRAX-based 10-year major fracture risk (with BMD) at baseline was 16% [10.0; 23], and median hip fracture risk was 7.2% [3.4; 13.8].

The median variation of BMD, after finishing teriparatide treatment, in the spine was 0.107 [0.029; 0.228]; median BMD variation in total femur was 0.013 [-0.013; 0.068] and median BMD femoral neck was 0.046 [-0.002; 0.109]. We observed a numerically superior effect, albeit without any statistical significance, of teriparatide on bone mineral density gain in secondary OP (versus primary OP) at lumbar spine, total femur and femoral neck.

Most patients continued anti-osteoporotic treatment with a bisphosphonate (81.2%, n=65) and, during follow-up, 17 patients had an incident fracture (8 hip fractures and 6 vertebral fractures), median of 5 [1.75, 8.25] years after ending teriparatide.

We found a discrete correlation between FRAX-based hip fracture probability and the variation of bone mineral density in total femur (Spearman’s coefficient 0.248, p = 0.04). There was no correlation between FRAX-based major fracture probability and and the variation of bone mineral density in the spine or femur. When we separately analyze the relationship between the variation in total hip BMD and the FRAX-based fracture risk, depending on whether it is a secondary or primary OP, we find that the correlation is stronger and only remains in secondary OP (Spearman’s coefficient 0.348, p = 0.03).

Conclusion:

Our data suggest that teriparatide could be an important weapon in the treatment of secondary cause OP, particularly cortisonic, and in patients at high fracture risk, although further larger studies are needed to confirm these findings.

References:

[1]Kendler DL, Marin F, Zerbini CAF, Russo LA, Greenspan SL, Zikan V, Bagur A, Malouf-Sierra J, Lakatos P, Fahrleitner-Pammer A, Lespessailles E, Minisola S, Body JJ, Geusens P, Möricke R, López-Romero P. Effects of teriparatide and risedronate on new fractures in post-menopausal women with severe osteoporosis (VERO): a multicentre, double-blind, double-dummy, randomised controlled trial. Lancet. 2018 Jan 20;391(10117):230-240. doi: 10.1016/S0140-6736(17)32137-2.

Disclosure of Interests:

None declared.

AB0231 OUTCOMES IN RHEUMATOID ARTHRITIS PATIENTS UNDER TOCILIZUMAB AS FIRST bDMARD: A REAL-LIFE MONOCENTRIC COHORT STUDY

Background:

Rheumatoid arthritis (RA) is one of the most frequent systemic inflammatory rheumatic diseases, being constantly assessed regarding new disease activity monitoring tools and new therapeutic targets and therapies. Tocilizumab (TCZ) is one of the latest biological disease-modifying antirheumatic drugs (bDMARDs) approved for RA’s treatment, usually as a second line agent in daily clinical practice.

Objectives:

Evaluate the different disease and patient reported outcomes in patients undergoing treatment with tocilizumab as the first biologic therapy.

Methods:

All patients with a definite RA diagnosis who had undergone treatment with TCZ as the first biologic therapy at a tertiary hospital’s rheumatology department were included in this analysis. Diverse socio-demographic data, as well as disease and patient related outcomes were assessed at baseline, 6 and 12 months of treatment with TCZ, and posteriorly extracted from the Portuguese register of rheumatic diseases (Reuma.PT). Statistical analysis included non-parametric tests such as Wilcoxon test and univariate analysis using linear and logistic regression models.

Results:

Fifty-one patients were included, 88.2% females, with a median age at introduction of TCZ of 53.5 +/- 10.4 years; mainly seropositive for either rheumatoid factor (66%) or anti citrullinated peptide antibody (ACPA; 68%), with an erosive disease (75.6%) and concomitantly treated with a conventional synthetic disease modifying anti-rheumatic drug (csDMARD) (70.5%). During follow-up there was a statistically significant reduction at 6 and 12 months of TCZ treatment regarding DAS28 (4 variables) (4v) and DAS28(4V)-CRP scores (p < 0.001), SDAI (p < 0.001), CDAI (p < 0.001), 68/66 tender and swollen joint counts (TJC/SJC) (p < 0.001), ESR and CRP (p < 0.001), patient and physician VAS (p < 0.001) and HAQ score (p = 0.01 at 6 months and p < 0.001 at 12 months). Rheumatoid factor and ACPA serum levels weren’t statistically different at 6 and 12 months of treatment with TCZ compared to the initial assessment, as well as the ACR responders at the same 6 months versus those at 12 months. A majority of patients showed good EULAR response at 6 (52.6%) and 12 (56.3%) months, as well as moderate to high mean improvement in ACR core set measures at 6 (53.3±22.7) and 12 (54.3±25.2) months. Assessment of subsequent therapeutic maintenance showed that 75% of patients remained under tocilizumab with an average treatment duration of 48.8±37.7 months. Reasons for switch ranged from adverse effects (63.6%) to primary failure (18.2%) and secondary failure (18.2%). There was a significant reduction in DAS28(4V), DAS28(4V)-CRP, CDAI, SDAI, TJC and SJC, ESR, CRP, patient and physician VAS and HAQ scores between 6 and 12 months of therapy (p < 0,001). ACR and EULAR responses didn’t differ significantly between assessments at 6 and 12 months. In the absence of a representative number of RA patients on TCZ monotherapy, it wasn’t possible to draw conclusions about the need to use combined therapy with a csDMARD for better clinically significant response.

A higher degree of ACR response at 6 months was associated with higher serum rheumatoid factor levels (OR 1.13, p < 0.05) at baseline, while a lower degree of response was seen with higher TJC (p = 0.05) and HAQ score (p < 0.01). ACR response at 12 months was lower in patients with erosive disease at baseline (p < 0.05). Regarding EULAR response criteria at 6 months, there was a negative association with higher TJC (p < 0.05), while at 12 months the negative trend was associated with ESR levels (p < 0.05) and HAQ scores (p < 0.05) at baseline.

Conclusion:

There seems to be evidence of good therapeutic response to TCZ in bDMARD naïve RA patients assessed at 6 months from baseline, without evidence of significant improvement of response measures further down the line. Basal serum rheumatoid factor levels, TJC, HAQ scores and the presence of erosive disease may have some predictive value on the therapeutic response. Further studies comparing TCZ as the first bDMARD in naïve RA patients against TNF inhibitors are needed.

Disclosure of Interests:

None declared

AB0536 EFFICACY OF TNF INHIBITORS IN MONOTHERAPY VERSUS COMBINATION THERAPY WITH csDMARDs IN PORTUGUESE PATIENTS WITH PSORIATIC ARTHRITIS: A REAL-WORLD STUDY

Background:

Tumor necrosis factor inhibitors (TNFi) are a key therapeutic weapon in psoriatic arthritis (PsA), and can be used as monotherapy or in combination with other csDMARDs, which are usually used as first line therapy in these patients, although its efficacy is not as well documented as in other rheumatic diseases. The optimal use of iTNF in PsA, as monotherapy or in combination therapy with csDMARDs, is still under debate.

Objectives:

We aimed to compare the response to treatment with TNFi in monotherapy and combined with csDMARDs, as first biologic, in patients with PsA.

Methods:

Retrospective study that included PsA patients followed at our Rheumatology department under TNFi as first biologic, fulfilling CASPAR classification criteria and registered in Reuma.pt. Clinical and laboratory data were collected at the start of the first iTNF and in the last visit of 2019. Disease activity was assessed using CDAI, SDAI, DAS28(4V), BASDAI, ASDAS, and the response measured using the BASDAI50, ASDAS, ASAS, ACR and PsARC responses. Comparison between groups was performed using the chi-square test, Mann-Whitney U/t-test (categorical and continuous variables, respectively). Logistic regression analyses were performed to determine predictors of bDMARD failure, and survival analysis to measure persistence under the first bDMARD regarding csDMARD status at baseline.

Results:

We included 99 patients, 47 (47.5% females) with a mean age of 47.9 ± 11.7 years at the start of the first iTNF. Fifty-one patients (51.5%) had symmetric polyarthritis, 26 (26.3%) spondyloarthritis, 16 (16.2%) asymmetric oligoarthritis, 3 (3.0%) distal arthritis and 1 (1.0%) arthritis mutilans. Sixty-three percent were under corticosteroid therapy and 77.8% under csDMARD therapy at the start of the first iTNF (mostly methotrexate, in 55.6% of patients under csDMARD). Etanercept (41, 41.4%), golimumab (25, 25.3%), adalimumab (22, 22.2%), infliximab (9, 9.1%) and certolizumab (2, 2.0%) were the iTNF started in these patients.

Patients who started iTNF as monotherapy had more frequent involvement of axial skeleton compared with combined therapy (54.5% vs 19.5%, p=0.001), were less exposed to corticosteroids (26.3% vs 72.6%, p<0.001) and had higher mean BASMI (3.7±1.8 vs 3.0±0.8, p=0.021) and BASFI (6.7±1.3 vs 4.7±2.5, p=0.036). Patients who were on iTNF monotherapy at the last consultation (43.4%) had lower mean tender (1.0±1.5 vs 3.6±4.3, p=0.002) and swollen (0.2±0.7 vs 0.8±1.0, p=0.012) joint counts, median patient VAS (30±46 vs 50±44, p=0.023), mean CDAI (5.6±4.4 vs 8.7±4.9, p=0.019), SDAI (6.2±4.6 vs 9.1±5.1, p=0.032), and DAS28(4V) (2.2±0.8 vs 2.7±0.9, p=0.047). iTNF failure was not significantly different in both groups. In the regression models, we found that basal DAS28(4V) (OR 1.874, 1.147-3.062 95%CI; p=0,012) was a predictor of first iTNF failure; there were no differences regarding csDMARD status.

When evaluating only patients without spondyloarthritis, we found that, at the last visit, iTNF monotherapy patients still had less exposure to corticosteroids (26.9% vs 54.3%, p=0.002), fewer mean tender (0.7±1.0 vs 2.6±4.4, p=0.006) and swollen (0.2±0.7 vs 1.1±2.5, p=0.025) joint counts, with no other differences observed. In the regression models, we found no differences regarding csDMARD status in these patients, while adalimumab (OR 0.009, 0.001-0.139 95% CI; p=0.009) was a negative predictor of bDMARD failure. Survival analysis revealed no differences between mono- and combined therapy.

Conclusion:

We can conclude that the differences observed regarding csDMARD status in patients with PsA are mainly due to different patterns of arthritis, namely, predominance of axial involvement. In patients without spondyloarthritis, iTNF monotherapy did not differ significantly in terms of response to treatment and disease activity measures, nor does monotherapy predict bDMARD failure and treatment response. These results suggest that iTNF monotherapy is possible in PsA without compromising treatment response.

Disclosure of Interests:

None declared.

AB0327 DRUG-INDUCED LUPUS ERYTHEMATOSUS SECONDARY TO ANTI-TNF-Α AGENTS IN PATIENTS WITH SPONDYLOARTHRITIS AND PSORIATIC ARTHRITIS

Background:

Induction of autoantibodies is frequently observed in patients treated with TNF-α antagonist and the possible development of drug-induced lupus erythematosus (DILE) remains a matter of concern. The prevalence of DILE secondary to anti-TNF-α therapy is estimated around 0.5-1% and clinical features include arthritis/arthralgia, rash, serositis, fever, myalgias, cytopenias, among others. According to the literature, DILE secondary to anti-TNF-α agents differs in several ways from the clinical and laboratory findings typically associated with classic DILE.

Objectives:

To estimate the incidence of induction of antinuclear antibodies (ANA) and DILE in a monocentric cohort of patients with spondyloarthritis and psoriatic arthritis treated with anti-TNF-α agents. To describe the clinical and laboratorial features and outcomes of patients with DILE.

Methods:

We performed a retrospective analysis of patients with spondyloarthritis and psoriatic arthritis treated with anti-TNF-α agents, from our University Hospital, who have been registered on the Portuguese Rheumatic Diseases Register (Reuma.pt) between July 2001 and December 2020. Patients with positive ANA (titer > 1/100) before the anti-TNF-α therapy were excluded. Because specific criteria for the diagnosis of DILE have not been established, we considered the diagnosis in case of a temporal relationship between clinical manifestations and anti-TNF-α treatment and fulfillment of ACR/EULAR 2019 classification criteria for SLE. In patients with DILE, clinical features, laboratory findings, systemic therapies and outcome after discontinuation of medication were collected from reuma.pt and medical records. For the clinical and demographic predictors, continuous variables were analyzed using a two-sided t-test and categorical variables using a Fisher’s exact test. P-value <0.05 was considered statistically significant.

Results:

In the spondyloarthritis group, 290 patients were included (44.8% females, mean age at diagnosis of 33.3 ± 11.5 years and mean disease duration of 15.1 ± 10.4 years) and in the psoriatic arthritis group, 116 patients were included (50.0% females, mean age at diagnosis of 40.1 ± 11.0 years and mean disease duration of 13.1 ± 6.8 years). In our study, we observed high serology conversion rates (positive ANA in 67.9% and 58.6% of patients with Spondyloarthritis and Psoriatic Arthritis, respectively), with similar conversion rates between different anti-TNF drugs. Three patients with spondyloarthritis (1.0%) and 1 patient with psoriatic arthritis (0.9%) developed DILE. Etanercept was the causative agent in 2 cases, infliximab and adalimumab in 1 case, each. Peripheral arthritis (new onset or abrupt worsening) occurred in 2 patients, serositis in 1 patient, constitutional symptoms in 2 patients, subnephrotic proteinuria in 1 patient, lymphopenia in 2 patients and hypocomplementemia in 1 patient. Specific treatment was prescribed to the 4 patients (oral corticosteroids) and they achieved complete recovery. After anti–TNF-α treatment interruption, no patient had recurrent disease. We observed that patients with DILE had a significantly longer disease duration (> 8.4 years; p=0.04) and a significantly longer duration of therapy with anti-TNF (> 4.0 years; p=0.04) when compared to patients without DILE.

Conclusion:

Despite the frequent induction of autoantibodies, the development of DILE secondary to anti–TNF-α agents is rare. Our study demonstrates an incidence rate similar to other studies reported before. The clinical and laboratorial characteristics of our patients with DILE attributable to anti–TNF-α agents differ significantly from DILE due to more traditional agents, as is described in literature. Overall, patients in this study had mild disease that improved after therapy discontinuation, without recurrence of the disease. It seems that a longer disease duration and a longer period under anti-TNF-α therapy may increase the risk of DILE development.

Disclosure of Interests:

None declared

POS1113 ANTIRESORPTIVE THERAPY AFTER TERIPARATIDE DISCONTINUATION – WHEN IS THE BEST TIME TO STARTING IT?

Background:

Treatment with teriparatide (TPTD) is associated with reduction of fracture risk in patients with severe osteoporosis. This drug can only be used for up to 2 years. After that a treatment course with antiresorptives should be considered, in order to prevent the rebound of bone turnover observed after TPTD discontinuation. In this regard, interest in sequential osteoporosis therapy has grown in recent years but the ideal timing for starting another treatment after TPTD is not well established.

Objectives:

The aim of this study is to assess if the timing of onset of antiresorptive therapy after TPTD discontinuation has implications in total hip bone mineral density (BMD) and in fracture risk.

Methods:

We performed a retrospective cohort study that included patients with severe osteoporosis treated with TPTD 20mcg/day for 24 months and followed for at least 2 more years in the rheumatology department of a tertiary university hospital. For analysis, demographic and clinical data and results of dual-energy X-ray absorptiometry (DXA) after cessation of teriparatide were used. For comparison between groups Mann-Whitney U test was used.

Results:

Fifty-five patients with osteoporosis, with a median age of 68 (32-85) years, were included. Forty-nine patients were female (89.1%). Nineteen patients (34.5%) had primary osteoporosis and 36 (65.5%) glucocorticoid-induced osteoporosis. The median time for initiating antiresorptive treatment was 7 (0-35) months after cessation of TPTD. Forty-three patients (78.2%) started a bisphosphonate, 6 denosumab (10.9%) and 6 patients did not receive any other treatment. The most prescribed bisphosphonate was zoledronate (69.8%). All patients received calcium and vitamin D supplementation. After completion of TPTD regimen 8 patients experienced at least one fragility fracture (14.5%). At follow-up, 37 (67.3%) of patients underwent DXA on average 30.0±15.4 months after starting antiresorptive agents. The median total hip BMD in patients who started antiresorptive therapy in the first 12 months (inclusive) after cessation of TPTD regime was 0,738 (0.587-0.993) g/cm2 and the median total hip BMD of patients who started therapy after one year of discontinuation of TPTD was 0.683 (0.390-0.813) g/cm2. This difference is marginally significant (p=0.067). The median time in starting antiresorptive treatment is higher in patients with new fragility fractures after TPTD than in patients without new fractures however this difference was not statistically significant (10.0 [2-35] vs 6.0 [0-35] months; p=0.393, respectively).

Conclusion:

Although this study is unable to show that anti-resorptive treatment should be started in the first year after discontinuation of TPTD, it is promising since the difference between the medians in the total hip BMD values obtained until one year and after one year are marginally significant. These results can be linked to the small sample size and highlight the need for further studies in this area.

References:

[1]Napoli N, Langdahl BL, Ljunggren Ö, Lespessailles E, Kapetanos G, Kocjan T, Nikolic T, Eiken P, Petto H, Moll T, Lindh E, Marin F. Effects of Teriparatide in Patients with Osteoporosis in Clinical Practice: 42-Month Results During and After Discontinuation of Treatment from the European Extended Forsteo® Observational Study (ExFOS). Calcif Tissue Int. 2018 Oct;103(4):359-371. doi: 10.1007/s00223-018-0437-x. Epub 2018 Jun 16. PMID: 29909449; PMCID: PMC6153867.

Disclosure of Interests:

None declared.

POS0488 THE IMPACT OF ANTINUCLEAR ANTIBODIES INDUCED BY ANTI-TUMOUR NECROSIS FACTOR ALPHA AGENTS ON THE LONG-TERM TREATMENT OUTCOMES IN RHEUMATOID ARTHRITIS PATIENTS

Background:

The seroconversion of antinuclear antibodies (ANA) induced by anti-tumour necrosis factor alpha (anti-TNF-α) therapy remains a matter of concern in various inflammatory conditions namely rheumatoid arthritis. However, evidence is still scarce regarding the impact of these autoantibodies on the clinical response to treatment in these patients.

Objectives:

This study aimed to explore the impact of ANA induced by anti-TNF-α therapy on the outcomes of treatment in patients with rheumatoid arthritis over two years of follow-up.

Methods:

An observational retrospective cohort study was conducted with two years of follow-up. Patients diagnosed with rheumatoid arthritis, according to the American College of Rheumatology (ACR) criteria, and registered on the Rheumatic Diseases Portuguese Register (Reuma.pt) who started their first anti-TNFα agent as first biologic between 2003 and 2018 were included. Patients with positive ANA (titer ≥100) and/or positive anti-double stranded DNA (anti-dsDNA) antibodies and/or with a diagnosis of SLE at their first visit were excluded. Demographic, clinical and laboratory data were obtained by consulting Reuma.pt. Disease Activity Score for 28 joints (DAS28), DAS28 delta, Health Assessment Questionnaire (HAQ), HAQ delta were assessed at baseline, 6, 12, 18 and 24 months. Clinical response was evaluated by EULAR criteria and three response categories were defined: good, mild and no response. The rate of switch of biological treatment was assessed over 24 months. To examine the differences between groups with and without ANA seroconversion independent samples t test for normally distributed continuous data, Mann-Whitney U-tests for non-normally distributed continuous data and Chi-square tests for categorical data were used. Logistic regression models were used to assess the effects of ANA seroconversion on clinical response to treatment over 6, 12, 18 and 24 months.

Results:

A total of 185 patients (mean age of 49.3±10.9 years old; 85.4% female) with a median follow-up of 7 [4-14] years were included. We found an ANA seroconversion rate (titer ≥100) of 77.3% (n=143) with median time of 36 [15-72.3] months. There were no differences among groups regarding age, gender, disease duration, be seropositivity or not (for rheumatoid factor and/or anti-citrullinated protein antibodies) and have an erosive disease or not. DAS28 delta was significantly different (p=0.035) between group with positive ANA (2.01±1.29) and negative ANA (1.15±1.51) at 6 months. DAS28 was significantly different (p=0.014) between group with positive ANA (5.06±3.39) and negative ANA (3.99±1.43) at 12 months. No statistically significant differences were found in the DAS28, DAS28 delta, HAQ, HAQ delta at 18 and 24 months and in the EULAR response at any time. Switch rate was significantly different between patients with ANA seroconversion (median 1[0-1]) versus absence of seroconversion (median 0[0-1]), p=0.025. In the regression model ANA seroconversion did not predict switch rate and EULAR response over time.

Conclusion:

This study showed that the majority of patients with rheumatoid arthritis treated with an anti-TNF-α agent developed ANA and that their presence may be associated with worse clinical results (DAS28) at 6 and 12 months. In fact, previous research suggested that a decrease in anti-TNF-α drug concentration due to the production of autoantibodies may lead to worse outcomes of treatment. Moreover, our data demonstrated that patients with ANA seroconversion had a higher switch rate. Despite these results, there are no differences in the EULAR response between the two groups and ANA seroconversion did not predict this response over time. Therefore, ANA induced by anti-TNF-α agents should be monitored in patients with rheumatoid arthritis and its impact on treatment must be considered. Further research is needed to explore these results through large-scale prospective studies.

Disclosure of Interests:

None declared

POS0914 IS THERE AN ASSOCIATION BETWEEN AUTOANTIBODIES INDUCTION AND LOSS OF THERAPEUTIC EFFICACY IN PATIENTS WITH AXIAL SPONDYLOARTHRITIS AND PSORIATIC ARTHRITIS TREATED WITH ANTI-TNF-α AGENTS?

Background:

Induction of autoantibodies is frequently observed in patients treated with a TNF-α blocker. According to other authors, the incidence of induction of antinuclear antibodies (ANA) and anti-double stranded DNA antibodies (anti-dsDNA) varies between 23-57% and 9-33%, respectively. However, it is unknown whether the induction of these autoantibodies affects the pharmacokinetics and bioavailability of biotherapy and, consequently, reduces the efficacy and safety of the drug.

Objectives:

To analyze if there is an association between autoantibodies induction and therapeutic efficacy in a monocentric cohort of patients with axial spondyloarthritis (axSpA) and psoriatic arthritis (PsA) treated with anti-TNF-α agents.

Methods:

The authors performed a retrospective analysis of patients with axSpA and PsA treated in our University Hospital with a TNF-α blocker as first biologic agent, and analysed the autoantibodies induction rate after 12 (T12) and 24 (T24) months of therapy. Then, they investigated the influence of autoantibodies in therapeutic efficacy at T12 and T24. Clinical evaluation, laboratory findings including erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) and disease activity and functional scores (Bath Ankylosing Spondylitis Disease Activity Index – BASDAI, AS Disease Activity Score with CPR - ASDAS-CRP, Bath AS Functional Index - BASFI) were collected from reuma.pt and medical records. For PsA patients, Disease Activity Score-28-CRP (DAS28-CRP), Simple Disease Activity Index (SDAI), Clinical Disease Activity Index (CDAI) and Health Assessment Questionnaire (HAQ) scores were also collected. Patients with positive ANA (titer > 1/100) prior to anti-TNF-α therapy were excluded. Continuous variables were analyzed using a t-test and categorical variables using a Chi-square test. P-value <0.05 was considered statistically significant.

Results:

In the axSpA group, 235 patients were included, 44.5% were females, mean age at diagnosis of 42.3 ± 12.4 years and median disease duration of 11.5 (IQR 6.0-21.0) years. Positive ANA were observed in 16.9% at T12 and 26.3% at T24 and positive anti-dsDNA in 3.4% at T12 and 3.8% at T24, with similar conversion rates between different anti-TNF drugs and no significant gender difference. A significant difference in ASDAS-CPR was found in axSpA patients with and without ANA at T12 (p=0.047). ASDAS-CPR was 1.16 times higher in patients with ANA comparing to patients without them. However, no difference was found in the others disease activity and functional scores at T12. Furthermore, no significant difference, including ASDAS-CPR, was found at T24. Also, there was no significant difference found when comparing patients with and without anti-dsDNA.

In the PsA group, 94 patients were included, 46.8% were females, mean age at diagnosis of 46.7 ± 11.7 years and median disease duration of 11.5 (IQR 6.5-16.5) years. Positive ANA were found in 14.9% at T12 and 21.3% at T24 and positive anti-dsDNA in 2.1% at T12 and 3.2% at T24. When comparing the groups with and without ANA and with and without anti-dsDNA at T12 and T24, no significant difference in disease activity and functional scores was found.

Conclusion:

This study revealed high rates of serology conversion, similar to the rates described before. The authors found that ASDAS-CPR was higher in axSpA patients with ANA after 12 months of therapy. However, this difference was no longer evident after 24 months. No other significant difference was found between patients with and without ANA or with and without anti-dsDNA. The authors consider that the induction of autoantibodies may interfere with the response to anti-TNF-α therapy in a short and initial period of time. Long-term follow-up data are lacking to say whether that influence will disappear consistently over the long run, as they observed after 12 months of therapy. However, they can state that, a priori, seroconversion should not lead to treatment suspension because of concerns about loss of efficacy.

Disclosure of Interests:

None declared

AB0478 IN PREVIOUSLY BIOLOGIC-NAÏVE RHEUMATIC PATIENTS WITH DRUG INDUCED LUPUS SECONDARY TO A FIRST ANTI-TNF THERAPY, IS IT SAFE TO SWITCH TO A SECOND ANTI-TNF-α AGENT?

Background:

Drug-induced lupus erythematosus (DILE) secondary to anti-TNF-α agents results from an immunogenicity phenomena not yet fully understood and is a rare condition. Withdrawal of anti-TNF- α therapy usually leads to total resolution of symptoms, however sometimes immunosuppression is needed. It is not clear if this condition is drug specific or class related. Therefore, there are doubts about the safety of switching to a second TNF inhibitor: will a further anti-TNF-α agent increase the risk of DILE recurrence?

Objectives:

To analyze the outcomes in patients with DILE secondary to an anti-TNF-α agent that switch to a second anti-TNF-α agent.

Methods:

We performed a retrospective analysis of patients with spondyloarthritis, psoriatic arthritis and rheumatoid arthritis from our University Hospital, who developed DILE secondary to an anti-TNF-α agent as a first biologic and switch to a second anti-TNF-α agent. Because specific criteria for the diagnosis of DILE have not been established, DILE diagnosis was considered when a temporal relationship between clinical manifestations and anti-TNF alpha treatment was found and ACR/EULAR 2019 classification criteria for SLE were fulfilled. Clinical and laboratorial features and outcomes were collected from the Portuguese Rheumatic Diseases Register (Reuma.pt) and medical records.

Results:

Six of 617 patients developed DILE secondary to anti-TNF-α agents (2 secondary to etanercept, 2 to adalimumab and 2 to infliximab). These patients had total resolution of symptoms and autoantibodies (ANA and anti-DNAds), induced by the therapy, disappeared after withdrawal of the anti-TNF-α agent implied.

Afterwards, 4 of these 6 patients switched to a second anti-TNF-α agent: 1 to etanercept, 1 to certolizumab, 1 to adalimumab and another to golimumab. The time interval between the two therapies was 2,0 ± 0,8 months. Regarding the outcomes, in all four patients, no DILE recurrence or autoantibodies induction recurrence was observed. These patients have a good response to the new biotherapy, without side effects reported, and a significant clinical improvement was observed.

Conclusion:

Our study results are in agreement with the literature described before. It seems that exist a low rate of DILE recurrence with an alternative anti-TNF-α agent. Thus, this condition seems to be drug specific rather than class related. Therefore, it seems secure to use a second anti-TNF-α agent, even in a short period of time after DILE development. There is no evidence about the best or securest second TNF inhibitor, so any anti-TNF-α agent can be prescribed. A carefully monitoring of symptoms of relapse should be ensured. In conclusion, DILE secondary to a TNF inhibitor should not be an absolute contraindication to the use of a subsequent anti-TNF-α agent.

Disclosure of Interests:

None declared.

AB0112 TNF INHIBITOR MONOTHERAPY IN RHEUMATOID ARTHRITIS: IS THERE REALLY A DIFFERENCE IN COMPARISON WITH COMBINATION THERAPY WITH CSDMARDS IN REAL-LIFE?

Background:

In Rheumatoid Arthritis (RA), tumor necrosis factor inhibitors (TNFi) in combination with conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) has shown advantages concerning efficacy and immunogenicity in comparison with monotherapy. However, in clinical practice, up to 40% of patients under biological DMARDs (bDMARDs) are on monotherapy.

Objectives:

To compare the efficacy outcomes of TNFi in monotherapy and in combination therapy in a RA monocentric cohort.

Methods:

Retrospective, cross-sectional study including all the RA patients under TNFi followed at our Rheumatology Department and registered in the national database. Demographic, clinical and laboratorial data and disease activity measures were collected at the last visit of 2019 from each patient. Mann-Whitney U and chi-square tests were used to the comparison analysis between the two groups (continuous and categorical variables, respectively).

Results:

A total of 144 patients were included: 84% were females; at the last visit of 2019, the mean age was 56.3±10.9 years and the mean disease duration was 18.3±10.2 years; 73.6% were positive for rheumatoid factor (RF), 81.9% for anti-citrullinated protein autoantibodies (ACPA) and 45.1% had erosive disease. There were no statistically significant differences in these variables between the monotherapy and the combination therapy groups (table 1).

Table 1.

Demographic and disease-related variables in the monotherapy and the combination therapy group.

Monotherapy(n=31)Combination therapy (n=113)Age - mean±SD59.1±14.0 years55.5±9.8 yearsDisease duration - mean±SD20.5±11.2 years17.7±9.7 yearsRF positive - n (%)20 (60.4%)86 (76.8%)ACPA positive - n (%)25 (80.6%)93 (85.3%)Erosive disease - n (%)15 (48.4%)50 (44.6%)

Thirty-one patients (21.5%) were under monotherapy with TNFi and etanercept was the most frequent TNFi in both groups (54.8% vs 50.0%; monotherapy and combination therapy groups, respectively). At the start of the first bDMARD, the monotherapy group had a higher disease activity score 28 - 4 variables (DAS 28 4V; 6.083±0.930 vs 5.605±1.043, p=0.039) and a higher simple disease activity score (SDAI; 36.12±11.77 vs 28.76±9.98, p=0.035); also, in the monotherapy group more patients had already started the bDMARD in monotherapy (22.6% vs 2.7%, p<0.001), less patients were under (38.7% vs 73.2%, p=0.001) or had already been treated with (77.4% vs 93.8%, p=0.007) methotrexate, in comparison with the combination group therapy.

At the last visit of 2019, the monotherapy group had a higher mean years of duration of iTNF treatment (5.5±5.8 vs 3.4±4.5, p=0.048), a higher mean patient global assessment - visual analogue scale (PGA-VAS; 49±18 vs 39±25, p=0.023), a higher mean prednisolone equivalent dose in mg/day (7.6±6.3 vs 5.6±3.2, p=0.045) and a lower proportion of American College of Rheumatology 50 and 70 responses (ACR 50: 12.9% vs 17.0%, p=0.023; ACR 70: 3.2% vs 10.7%, p=0.045) in comparison with the combination therapy group.

Conclusion:

In line with the literature, our real-life results demonstrate some direct (higher PGA-VAS and lower ACR 50 and 70 responses) and indirect (higher current prednisolone equivalent dose) data that suggest that patients with TNFi monotherapy may have a worst disease activity control in comparison with combination therapy.

Disclosure of Interests:

None declared

POS0100 VITAMIN D LEVEL IN RHEUMATOID ARTHRITIS PATIENTS STARTING A BIOLOGIC DISEASE-MODIFYING DRUG AND ITS CORRELATION WITH DISEASE ACTIVITY AND RESPONSE TO TREATMENT

Background:

Vitamin D, a fat soluble vitamin that is mainly involved in the regulation of calcium/phosphate metabolism, has a increasingly understood role in immunomodulatory activity, both in innate and adaptive immune system. In rheumatoid arthritis (RA), vitamin D showed to suppress the proliferation of synoviocytes and to reduce the production of proinfammatory cytokines, in vitro. (1) Recently the hypothesis has been raised that vitamin D has a negative association with RA activity. (2)

Objectives:

This study aimed to evaluate the relationship between the 25-hydroxyvitamin D (25(OH) vitD) level, RA activity and response to a first biologic disease-modifying drug (bDMARD).

Methods:

This is a longitudinal, retrospective study including consecutive patients with the diagnosis of RA followed at our rheumatology department. Demographic, clinical, and laboratorial data were collected from our national database at baseline, 6 and 12 months after initiation of a first bDMARD. Statistical analysis was performed using SPSS 23.0. Correlations between variables were studied using Spearman correlation analysis and comparison between groups was performed using Wilcoxon and Kruskal-Wallis tests; p<0.05 was considered statistically significant.

Results:

Mean age of patients (n=236) was 51.5 ± 11.2 years old, 192 (81.4%) were females with a median disease duration of 10.1 [4.7, 16.7] years. Seropositivity for anti-citrullinated protein antibodies was present in 192 (81.4%) patients and for rheumatoid factor in 175 (74.2%). The majority exhibited a very high or high disease activity at baseline (median DAS28 5.75 [4.99 – 6.63]) and 90% (n=212) of them were concomitantly using corticosteroids and/or other disease-modifying anti-rheumatic drugs (117 with methotrexate (MTX), 62 with leflunomide and 32 with sulfasalazine). Regarding bDMARD, 56.8% (n=134) initiated an TNF alpha inhibitor.

After 6 and 12 months from a bDMARD initiation there was a significant reduction of ESR, CRP levels, TJCs, SJCs and DAS28 (all p-values < 0.001), as expected. Median baseline serum 25(OH) vitD concentrations was 25.5 [16.5, 30.0] ng/ml; notably, 34.2% of our sample was affected by hypovitaminosis D at baseline (25(OH) vitD< 20 ng/mL).

Among our study population 42.5% patients were responders to first bDMARD (23.8% good and 18.7% moderate responders) according to the EULAR response criteria. Disease remission (DAS28 < 2.6) was achieved by 17.6% of patients.

The percentage of good responders was significantly lower in the subgroup of patients with hypovitaminosis D compared to subjects with normal 25(OH) vitamin D levels at baseline (p=0.002), as it was for the percentage of disease remission (p=0.015).

The bivariate correlation analyses showed that 25(OH) vit D levels at baseline correlated with CRP levels and good response to RA treatment after 12 months (Spearman’s coefficient -0.201, p = 0.028; Spearman’s coefficient 0.255, p < 0.019, respectively). 25(OH) vit D levels at baseline, 6 and 12 months after bDMARD initiation did not correlate with age, BMI, ESV, number of tender or swollen joints, DAS28, HAQ or with SDAI or CDAI at 6 or 12 months of treatment.

Conclusion:

In patients with RA, basal 25(OH) vit D levels correlated with response to a bDMARD. These results suggest a role of basal vitamin D status in the prediction of disease evolution and support the hypothesis that vitamin D has an immunomodulatory potential.

References:

[1]Huhtakangas JA, Veijola J, Turunen S et al. 1,25(OH)2D3 and calcipotriol, its hypocalcemic analog, exert a long-lasting anti-infammatory and anti-proliferative effect in synoviocytes cultured from patients with rheumatoid arthritis and osteoarthritis. J Steroid Biochem Mol Biol 2017; 173: 13- 22.

[2]Lee YH, Bae SC. Vitamin D level in rheumatoid arthritis and its correlation with the disease activity: a meta-analysis. Clin Exp Rheumatol. 2016 Sep-Oct;34(5):827-833. Epub 2016 Apr 6. PMID: 27049238.

Disclosure of Interests:

None declared

POS0204 AUTOANTIBODIES AND SYSTEMIC LUPUS ERYTHEMATOSUS INDUCED BY ANTI-TUMOUR NECROSIS FACTOR ALPHA THERAPY IN RHEUMATOID ARTHRITIS

Background:

Anti-tumour necrosis factor alpha (anti-TNF-α) therapy is commonly used to treat inflammatory conditions such as rheumatoid arthritis (RA). Autoantibodies namely antinuclear antibodies (ANA) induced by these treatments are well established. However, anti-TNF-α-induced systemic lupus erythematosus (SLE) is rarely described and its incidence is yet unknown.

Objectives:

This study aimed to determine the prevalence of ANA seroconversion and to characterize the development of SLE induced by anti-TNF-α therapy in patients with RA over time.

Methods:

An observational retrospective cohort study was conducted with at least one year of follow-up. Patients with diagnosis of RA, according to American College of Rheumatology criteria (ACR), and registered on Rheumatic Diseases Portuguese Register (Reuma.pt) who started their first anti-TNFα between 2003 and 2019 were included. Patients with positive ANA (titer ≥100) and/or positive double-strand DNA (dsDNA) antibodies and/or with a diagnosis of SLE at their first visit were excluded. Demographic, clinical and laboratory data were obtained by consulting Reuma.pt. As there are no recognized criteria for drug-induced SLE, the diagnosis of SLE induced by anti-TNF-α was considered if there is a temporal relationship between clinical manifestations and anti-TNF-α-therapy, the presence of at least 1 serologic ACR criteria (ANA or anti-dsDNA) and at least 1 nonserologic ACR criteria (arthritis, serositis, hematologic disorder or malar rash) [1]. Continuous variables are presented with mean, standard deviation, median, quartile 1 and quartile 3. Categorical variables are presented with absolute and relative frequencies.

Results:

A total of 211 patients (mean age of 49.9±10.9 years old; 84.4% female) were included with a median follow-up time of 6 [3-14] years. We found a seroconversion rate for ANA of 75.4% (n=159) with median treatment duration of 31 [8.5-70.5] months. The most common titre was 1/100 with diffuse and speckled patterns. ANA seroconversion was higher for etanercept (47.8%, n=76) than with adalimumab (23.9%, n=38), infliximab (13.8%, n=22), golimumab (12.6%, n=20) or certolizumab (1.9%, n=3). SLE induced by anti-TNF-α occurred in two patients (0.9%) with erosive and seropositive (rheumatoid factor and anti-citrullinated protein antibodies) RA previously treated with two conventional synthetic disease-modifying antirheumatic drugs, including methotrexate. The first patient, a female with 66 years old and 17 years of disease duration, developed SLE after 16 months of infliximab, with constitutional symptoms, abrupt worsening of polyarthritis, ANA titer of 1/320 diffuse pattern and positive dsDNA (248 UI/mL) antibodies. The second patient, a woman with 43 years old and 11 years of disease duration, developed SLE after 41 months of adalimumab with malar rash and ANA titer of 1/320 diffuse pattern, positive dsDNA (285 UI/mL), positive anti-histone antibodies and hypocomplementemia. In these two cases, anti-TNF-α therapy was stopped and recovery was spontaneous without treatment. The first patient switched to adalimumab and the second switched to golimumab without recurrence of SLE for more than ten years.

Conclusion:

We found a high rate of ANA seroconversion induced by anti-TNFα therapy in patients with RA. However, similar to previous literature, only 0.9% of patients developed SLE with mild manifestations without major organ involvement. Although the drug with the highest ANA seroconversion rate was etanercept, those responsible for induced SLE were infliximab and adalimumab. Patients improved after discontinuation of therapy and tolerated an alternative anti-TNF-α drug without recurrence of induced SLE over time. Therefore, ANA and SLE induced by anti-TNF-α should be considered and reported in the follow-up of RA patients. Further research is needed to explore the impact of this adverse event on the outcomes of treatment over time.

References:

[1]Hochberg MC. Arthritis Rheum. 1997;40(9):1725.

Disclosure of Interests:

None declared

AB0483 CAN WE PREDICT WHICH PATIENTS WITH SPONDYLOARTHRITIS WILL NEED DOSE ESCALATION OF SECUKINUMAB TO 300 mg MONTHLY?

Background:

Secukinumab is a fully human monoclonal antibody against interleukin-17A, approved in several countries for the treatment of ankylosing spondylitis (AS) and psoriatic arthritis. It is known that some patients benefit from increasing the monthly dose of secukinumab from 150mg, the most commonly used dose, to 300mg. However, the baseline clinical characteristics that differentiate these patients are not yet fully understood.

Objectives:

This study aimed to investigate whether there are any variables at the beginning of biologic therapy that might predict a greater probability of having to increase the dose of secukinumab to 300mg in order to obtain a response to treatment.

Methods:

This is a retrospective cohort study, including all the spondyloarthritis and psoriatic arthritis patients under secukinumab at our Rheumatology Department and registered in the national database (Reuma.pt).

Demographic, clinical and laboratorial characteristics and disease activity measures were collected from the first visit before the patient began secukinumab. For comparison between the 2 groups, continuous variables were analyzed using Mann-Whitney U and T-tests and categorical variables were analyzed using a Chi-square test. Multivariate regression analyses assessed the impact of selected variables on the need to increase the dose of secukinumab to 300mg.

Results:

Thirty-two patients with a mean age of 53±11.96 years were included, 19 (58%) were females and 16 (48.5%) had psoriasis. Twenty-seven (81.8%) patients were under a nonsteroidal anti-inflammatory drug (NSAID), 11(33.3%) were under corticosteroid and 11(33.3%) were under conventional synthetic disease-modifying antirheumatic drug (csDMARD); 25 (75,8%) had previously been treated with a biological disease-modifying antirheumatic drug (bDMARD). The mean patient baseline VAS and physician baseline VAS were 74,39±19,77 and 47,55±23,38, respectively; the mean erythrocyte sedimentation rate (ESR) and C-Reactive Protein (CRP) were 26,33±22,62 mm/hr and 10,81±16,88 mg/dL, respectively; the mean swollen joint count (SJC) and tender joint count (TJC) were 1,30±1,63 and 3,67±3,14, respectively; the mean Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) and Ankylosing Spondylitis Disease Activity Score (ASDAS) were 6,18±2,06 and 3,41±0,84, respectively; the mean Bath Ankylosing Spondylitis Metrological Index (BASMI) and Bath Ankylosing Spondylitis Functional Index (BASFI) were 4,22±1,58 and 6,28±2,53, respectively; the mean Maastrich Ankylosing Spondylitis Enthesitis Score (MASES) was 2,85±3,23.

Nineteen patients (57.6%) had the dose of secukinumab increased to 300mg. At the baseline visit, the group of patients which had their secukinumab monthly dose increased to 300mg were more frequently men (12 vs 2, p=0.005) and had psoriasis (12 vs 4, p=0.049). On the other hand, these patients also exhibited lower MASES values (2±1.089 VS 4±0.501, p=0.022).

A regression analysis was conducted, estimating the relationships between the outcome binary variable of the monthly dose of secukinumab and the following predictors: gender, psoriasis, MASES value and use of corticosteroid. Female gender (OR 0.070, CI95% 0.005-0.890; p=0.040) and absence of psoriasis (OR 0.104, CI95% 0.011-0.952; p=0.045) were predictors for maintaining secukinumab at a dose of 150mg monthly.

Conclusion:

Our data suggest that the most common characteristics of patients in need of increasing the monthly dose of secukinumab from 150 to 300 mg to achieve a better treatment response are: male gender, coexistence of psoriasis and lower MASES value at baseline. The first two variables remained statistically significant in a multivariate model of regression analysis. Nonetheless, we insist it is of paramount importance to conduct larger studies to confirm these findings.

References:

[1]Deodhar A, et all. Long-term safety of secukinumab in patients with moderate-to-severe plaque psoriasis, psoriatic arthritis, and ankylosing spondylitis. Arthritis Res Ther. 2019 May 2;21(1):111.

Disclosure of Interests:

None declared.

AB0816 PREDICTORS OF RESPONSE TO THE FIRST BDMARD IN BIOLOGIC-NAÏVE PATIENTS WITH SPONDYLOARTHRITIS: A COHORT STUDY

Background:

Several markers of response to biologic disease-modifying antirheumatic drugs (bDMARDs) have been identified in Rheumatoid Arthritis. However, data on predictors of response in Spondyloarthritis (SpA) are more limited.

Objectives:

To identify predictors of response to bDMARDs in a SpA population.

Methods:

Monocentric retrospective study including all the SpA patients (ASAS classification criteria) followed at our Rheumatology Department, registered in the national database and treated with bDMARD between July 2001 and August 2020. Demographic, clinical and laboratorial data at baseline and disease activity measures at 6 and 12 months of bDMARD were collected. Mann-Whitney U test and chi-square tests were used to the comparison analysis between groups (continuous and categorical variables, respectively) and univariate logistic regression was used in the prediction analysis.

Results:

A total of 325 patients were included, 178 (54.8%) males, 76 (23.4%) smokers and 164 (50.5%) HLA-B27 positive. Concerning SpA subtypes: 236 (72.6%) had Ankylosing Spondylitis, 31 (9.5%) had Inflammatory Bowel Disease Associated SpA and 58 (17.9%) had Undifferentiated SpA. The mean age at the start of the first bDMARD was 41.7 years (±12.2) and the median disease duration was 12.1 years (0.5-52.7). The mean ASDAS-CPR (Ankylosing Spondylitis Disease Activity Score with C-reactive protein) was 4.0 (±0.8) and most patients (57.2%) exhibited very high disease activity at baseline as evaluated by ASDAS-CRP. Ninety-five (29.2%) patients were taking NSAIDs (nonsteroidal anti-inflammatory drugs) and 131 (40.3%) were under csDMARDs (conventional synthetic disease-modifying antirheumatic drugs), being sulfasalazine the most frequent (28.3%). All patients started iTNF (tumor necrosis factor inhibitors): adalimumab (30.2%) and golimumab (24.6%) were the most frequently started bDMARDs.

At 6 and 12 months of bDMARD, 63.5% and 65.7% of the patients had ASDAS response (clinically important improvement or major improvement). Variables that showed statistically significant differences at baseline between those different groups are presented at Table 1.

Table 1.

Baseline characteristics that showed statistically significant differences at baseline between groups of patients with vs without ASDAS responses at 6 and 12 months of bDMARD. (bDMARD: biologic disease-modifying antirheumatic drug; BMI: body mass index; CRP: C-reactive protein; ESR: erythrocyte sedimentation rate).

ASDAS response at 6 monthsASDAS response at 12 monthsyesnop-valueyesnop-valueAge at start of bDMARD (mean±SD)39.6±12.2 years44.2±10.7 yearsp=0.01240.7±12.8 years44.2±10.9 yearsp=0.035Age at SpA diagnosis (mean±SD)32.2±11.1 years35.8±11.9 yearsp=0.02331.3±10.7 years35.4±11.2 yearsp=0.010BMI (mean±SD)25.7±4.3kg/m228.7±6.0 kg/m2p=0.04525.6±4.3 kg/m228.5±5.7 kg/m2p=0.005CRP (mean±SD)3.2±3.5 mg/dL1.1±1.2 mg/dLp<0.0013.4±3.5 mg/dL1.4±1.6 mg/dLp<0.001ESR (mean±SD)36±2225±20p<0.00138±2427±17p=0.001ASDAS-CRP(mean±SD)4.1±0.83.5±0.4p<0.0014.2±0.83.6±0.8p<0.001HLA-B27+61.5%26%p=0.00660.1%44.4%p=0.033Males62.3%35.7%p=0.00462.3%37.5%p=0.001

Body mass index (BMI) (OR 0.89 [0.80-0.99], 95% CI) and ASDAS-CRP at baseline (OR 2.8 [1.2-6.6], 95% CI) predicted ASDAS response at 6 months; moreover, only BMI (OR 0.91 [0.83-0.99], 95% CI) predicted ASDAS response at 12 months of bDMARD.

Conclusion:

Our results demonstrate that a higher baseline disease activity predicts the response to bDMARDs in SpA. Interestingly, BMI at baseline also predicts ASAS response at 6 and 12 monthes of treatment with bDMARD, in line with some data that suggest an association between BMI and disease activity in SpA.

Disclosure of Interests:

None declared

AB0416 THE IMPACT OF FATIGUE ON SYSTEMIC SCLEROSIS PATIENTS

Background:

Fatigue is a frequent and commonly undervalued symptom among rheumatic disease, including Systemic Sclerosis (SSc).1,2

Objectives:

To determine the prevalence of severe fatigue in a SSc cohort and to evaluate how it correlates with disability, quality of life and mental illness.

Methods:

A cross-sectional study was conducted evaluating a cohort of SSc patients. Fatigue was evaluated using Functional Assessment Chronic Illness Therapy (Fatigue) (FACIT-F) questionnaire. A value < 30 was defined as severe fatigue. Health Assessment Questionnaire (HAQ), Scleroderma HAQ (SHAQ), 36-Item Short Form Health Survey (SF-36), EuroQol-5D (EQ-5D) and Hospital Anxiety and Depression Scale (HADS) questionnaires were also filled. Clinical data was obtained and analysed.

Results:

We included 20 patients, 17 females [n = 17 (85%)], median (min, max) age was 52.5 (28, 75) years-old. Regarding disease classification, 13 (65%) had limited SSc, 4 (20%) had diffuse SSc and 3 (15%) had early SSc. The median FACIT-F score was 34 (3, 48). The prevalence of severe fatigue was 40% (n = 8). Fatigue had a moderate negative correlation with HAQ (τ = -0.641; p < 0.001) and a weak negative correlation with lung (τ = -0.345; p = 0.039) and gastrointestinal (τ = -0.419; p = 0.011) involvements and with patient global assessment (τ = -0.325; p = 0.047) subtopics of SHAQ. A moderate positive correlation was found between FACIT-F and EQ-5D (τ =0.625; p < 0.001) and physical functioning (τ = 0.560; p = 0.001) and vitality (τ = 0.777; p < 0.001) domains of SF-36. The remaining SF-36 domains had a weak positive correlation with FACIT-F (Table 1). Regarding mental illness, there was a moderate negative correlation between FACIT-F and HADS-D (τ = -0.638; p < 0.001) and HADS-A (τ =-0.535; p = 0.001).

Conclusion:

Severe fatigue is frequent among SSc patients. The greater the fatigue, the greater the disability, the lower the quality of life and the worse the score on the scale of depression and anxiety.

References:

[1]F. Basta, A. Afeltra, D.P.E. Margiotta. Fatigue in systemic sclerosis: a systematic review. Clin Exp Rheumatol 2018; 36 (Suppl. 113): S150-S160

[2]Sarah Hewlett, Emma Dures, And Celia Almeida. Measures of Fatigue. Arthritis Care & Research Vol. 63, No. S11, November 2011, pp S263–S286

Table 1.

Correlation of FACIT-F with measures of disability, quality of life and mental illness

VariablesKendall’s τ coefficientp-valueHAQ-0.6410.000SHAQ - GI involvement-0.3450.039 - Lung involvement-0.4190.011 - Vascular involvement-0.2150.192 - Digital ulcers0.1020.549 - Patient global assessment-0.3250.047EQ-5D0.6250.000SF-36 - Physical functioning0.5600.001 - Role physical0.4910.003 - Bodily pain0.4630.006 - General health0.3410.045 - Vitality0.7770.000 - Social functioning0.4430.009 - Role emotional0.3500.041 - Mental health0.3760.024HADS-D-0.6380.000HADS-A-0.5350.001

Disclosure of Interests:

None declared

AB0417 COMPARATIVE ANALYSIS OF THE FREQUENCY OF GASTRO-INTESTINAL SYMPTOMS IN THE CLINICAL EVALUATION VERSUS WITH UCLA SCTC GIT 2.0

Background:

It is estimated that the gastrointestinal (GI) tract is involved in about 90% of patients with Systemic Sclerosis (SSc).1 The UCLA Scleroderma Clinical Trials Consortium Gastrointestinal Tract 2.0 (UCLA SCTC GIT 2.0) questionnaire has been validated in several countries as a useful tool in the assessment of GI symptoms in this pathology.2

Objectives:

To assess whether the application of the questionnaire has an added value in clinical practice by comparing the frequency of GI symptoms found during the clinical evaluation in the consultation vs. application of the questionnaire.

Methods:

A cross-sectional study was carried out in a cohort of patients with SSc. During the consultation, patients were asked about the presence of GI symptoms and the UCLA SCTC GIT 2.0 questionnaire was handed in for completion. Subgroups that analyse reflux, bloating, dirt, diarrhea and constipation were evaluated and their responses were transformed into dichotomous variables (present/absent). Clinical data was obtained and analysed.

Results:

27 patients were included, most of them female [n = 23 (85.2%)], with an average age of 53.3 ± 13.5 years. All patients met the classification criteria of Leroy/Medsger of 2001 or ACR/EULAR of 2013: 14 (51.9%) had limited ES, 6 (22.2%) had Overlap Syndrome, 4 (14.8%) had diffuse ES and 3 (11.1%) had early SS. The prevalence of symptoms in all evaluated subgroups was higher in the questionnaire than in the clinical evaluation, with a statistically significant difference in the reflux subgroup [n = 16 (59.3%) vs. n = 13 (48.1%), p = 0.018]. In the remaining subgroups, this difference, although not statistically significant, was also found [abdominal distension n = 20 (74.2%) vs. n = 1 (3.7%), p = 1.0; dirt n = 2 (7.4%) vs. n = 0 (0%); diarrhea n = 22 (91.7%) vs. n = 3 (11.1%), p = 1.0; constipation n = 11 (40.7%) vs. n = 4 (14.8%), p = 0.273]. In the clinical evaluation, 12 patients said they were asymptomatic from the GI point of view, but all of them reported some GI symptoms when filling out the questionnaire. The subgroups in which the disagreement between the answers during the clinical evaluation and the filling out of the questionnaire were more frequent were distension [n = 19 (70.4%) and diarrhea [n = 19 (79.2%)].

Conclusion:

The results of the present study reinforce the usefulness of the UCLA SCTC GIT 2.0 questionnaire, usually more applied in clinical trials, in clinical practice, concluding that it allows to find more GI symptoms in patients with SSc than the clinical evaluation in a consultation, this difference being statistically significant in the subgroup that evaluates reflux. The considerable difference found in the subgroups that assess symptoms of the low GI tract, such as diarrhea and constipation, although non statistical significant, may be due to the fact that the patient does not feel comfortable talking about it, a struggle that can be overcome with application of the questionnaire. On the other hand, this tool can also be a means of quantifying the severity of symptoms, monitoring their progress and making the consultation time more profitable. More studies with larger samples are needed to continue studying its role in clinical practice.

References:

[1]Kirby DF and Chatterjee. Evaluation and management of gastrointestinal manifestations in scleroderma. Curr Opin Rheumatol 2014, 26:621–629

[2]Pope J. Measures of Systemic Sclerosis (Scleroderma). Arthritis Care & Research Vol. 63, No. S11, November 2011, pp S98–S111

Disclosure of Interests:

None declared

AB0415 ANXIETY AND DEPRESSION IN SSc – ASSESSING FUNCTION, QUALITY OF LIFE AND GASTROINTESTINAL INVOLVEMENT

Background:

Systemic Sclerosis (SSc) is a chronic disease with multi-organ manifestations that may contribute to disability and low quality of life.1 Therefore, anxiety and depression are more frequent in SSc patients than in general population.2

Objectives:

To assess the prevalence of anxiety and depression in a SSc cohort and to evaluate its correlation with function, quality of life and assessment of gastrointestinal (GI) involvement scores.

Methods:

A cross-sectional study was conducted evaluating a cohort of SSc patients. All patients answered to the Hospital Anxiety and Depression Scale (HADS) questionnaire. A cut-off score < 8 was considered normal. Health Assessment Questionnaire (HAQ), Scleroderma HAQ (SHAQ), 36-Item Short Form Health Survey (SF-36), EuroQol-5D (EQ-5D) and University Of California, Los Angeles, Scleroderma Clinical Trials Consortium Gastrointestinal Scale (UCLA SCTC GIT) 2.0 questionnaires were also obtained. Clinical data was obtained and analyzed.

Results:

We included 20 patients, 17 females [n = 17 (85%)], median (min, max) age was 52.5 (28, 75) years-old. Regarding disease classification, 13 (65%) had limited SSc, 4 (20%) had diffuse SSc and 3 (15%) had early SSc. A score ≥ 8 was found in 14 (70%) patients on HADS-A [median (min, max) = 9 (2, 19)] and in 12 (60%) patients on HADS-D [median (min, max) = 8 (1, 15)]. Depressive patients had significantly worst scores on the measures of function, such as HAQ and lung and gastrointestinal involvements and patient global assessment of SHAQ, of quality of life, such as EQ-5D and physical functioning, role physical, bodily pain, vitality, social functioning and mental health domains of SF-36, and on the UCLA SCTC GIT 2.0 scale. Anxious patients had significantly worst scores on social functioning and mental health domains of SF-36 and on the UCLA SCTC GIT 2.0 scale (Table 1).

Conclusion:

The prevalence of depression and anxiety on SSc patients is high and should not be neglected. Overall disability and multiorgan manifestations, particularly GI involvement, may contribute to a low quality of life and consequently to depression and anxiety.

References:

[1]Firestein & Kelley’s Textbook of Rheumatology 2-Volume Set, 11th Edition

[2]Brett D. Thombs et al. Depression in Patients With Systemic Sclerosis: A Systematic Review of the Evidence. Arthritis & Rheumatism (Arthritis Care & Research) Vol. 57, 2007, pp 1089–1097

Table 1.

Function, quality of life and gastrointestinal (GI) involvement assessment according to HADS score.

Results, median [min, max]HADS-D ≥ 8 (n = 12)HADS-D < 8 (n = 8)P-valueHADS-A ≥ 8 (n = 14)HADS-A < 8 (n = 6)P-valueSHAQ- GI involvement26.5 [0, 90]2 [0, 40]0.00918.5 [0, 90]2.5 [0, 40]0.091- Lung involvement48.5 [5, 90]2.5 [0, 30]0.00118 [0, 90]3 [0, 65]0.126- Patient global assessment67.5 [30, 100]4 [0, 85]0.01153.5 [2, 100]41.5 [0, 85]0.509HAQ1.375 [0.5, 2]0.1875 [0, 1]0.0011.25 [0, 2]0.875 [0, 1.125]0.147EQ5D0.3667 [-0.0573, 0.6937]0.6752 [0.2870, 1]0.0060.4640 [-0.0573, 0.7667]0.6752 [0.287, 1]0.075SF36- Physical functioning25 [15, 75]75 [50, 100]0.00140 [15, 100]72.5 [25, 85]0.106- Role physical31.25 [0, 75]72.875 [31.25, 100]0.02537.5 [0, 100]65.625 [31.25, 100]0.214- Bodily pain41 [0, 74]68 [20, 88]0.01141 [0, 88]61.5 [20, 74]0.428- Vitality25 [0, 43.75]65.625 [25, 75]0.00137.5 [0, 75]65.625 [12.5, 75]0.135- Social functioning37.5 [12.5, 87.5]87.5 [50, 100]0.00250 [12.5, 100]87.5 [87.5, 100]0.003- Mental health45 [25, 80]65.7 [51.4, 85]0.01245 [25, 75]77.5 [51.4, 85]0.005UCLA SCTC GIT 2.0- Reflux0.38 [0, 1.25]0 [0, 1.25]0.0240.25 [0, 1.25]0 [0, 1]0.139- Distension1 [0.5, 2]0.25 [0, 1.5]0.0171 [0.25, 2]0.125 [0, 1]0.024- Total0.44[0.1, 0.99]0.04 [0, 0.97]0.0100.34 [0.04, 0.99]0.02 [0, 0.44]0.018

Disclosure of Interests:

None declared

AB0606 SYSTEMIC SCLEROSIS – ARE PATIENTS WITH CALCINOSIS DIFFERENT FROM THOSE WHO DO NOT HAVE IT?

Background:

Systemic Sclerosis (SS) is a heterogenous disease with a broad range of organ involvement. Calcinosis is a common problem and although it may affect almost any body tissue, it is typically seen in the limbs.1Its presence relates with higher risk of digital ulcers and infection.2It is still unknown whether patients with calcinosis also have other clinical features that differentiate them from the remaining.

Objectives:

To determine the prevalence of calcinosis in a SS cohort and to evaluate if its presence relates with specific clinical features.

Methods:

A cross-sectional study was conducted evaluating a cohort of SS patients. Plain radiographs were taken to assess calcinosis at elbows, hands, knees and feet. Clinical data was obtained and analyzed using IBM SPSS Statistics 26®.

Results:

We included 25 patients, 21 females [n= 21 (84%)], median (min, max) age was 58 (27, 75) years-old. Regarding disease classification, 16 (64%) had limited SS, 4 (16%) had diffuse SS, 3 (12%) had overlap syndrome and 2 (8%) had early SS. Ten (40%) patients had radiological calcinosis in at least one site, seven of which (70%) were subclinical. The most affected areas were knees and hands [n=6 (24%)]. Table 1 summarizes the clinical characteristics of patients with and without calcinosis. Limited SS was significantly more prevalent in the calcinosis group [n=9 (90%) vs. n=7 (46.7%), p=0.04]. All patients had Raynaud phenomenon [n=10 (100%) vs. 15 (100%)]. Current or past digital ulcers [n=5 (50%) vs. n=6 (40%), p=0.697], telangiectasias [n=9 (90%) vs. n=11 (73.3%), p=0.615], pulmonary hypertension [n=2 (20%) vs. n=1 (6.7%), p=0.550] and esophageal involvement [n=6 (60%) vs. n=6 (40%), p=0.428] were more frequent in the calcinosis group but with no statistical significance. Although late capillaroscopic pattern was more frequent in the calcinosis group, there was no statistical significance difference [n=4 (40%) vs. n=1 (6.7%), p=0.121]. Seropositivity for centromere-B antibodies was more frequent in the calcinosis group but with no statistical significance [n=7 (70%) vs. n=8 (53.3%), p=0.678].

Table 1.

Demographic and clinical data of patients with and without calcinosis.

Demographic and clinical dataCalcinosis (n=10)No calcinosis (n=15)p-valueFemale gender, n (%)9 (90)12 (80)0.626Age (years), median [min,max]68.5 [27, 75]52 [36, 73]0.129Cutaneous classificationLimited, n (%)9 (90)7 (46.7)0.04Diffuse, n (%)1 (10)3 (20)0.626Early, n (%)0 (0)2 (13.3)0.500Overlap, n (%)0 (0)3 (20)0.250Clinical manifestationsCurrent or previous digital ulcers, n (%)5 (50)6 (40)0.697Interstitial lung disease, n (%)2 (20)4 (26.7)1.000Pulmonary hypertension, n (%)2 (20)1 (6.7)0.550Arthritis, n (%)2 (20)3 (20)1.000Calcinosis, n (%)3 (30)0 (0)0.052Esophageal involvement, n (%)6 (60)6 (40)0.428NFC patternsNon specific abnormalities, n (%)1 (10)3 (20)0.626Early scleroderma, n (%)1 (10)1 (6.7)1.000Active scleroderma, n (%)3 (30)10 (58.8)0.111Late scleroderma, n (%)4 (40)1 (6.7)0.121AutoantibodiesCentromere B, n (%)7 (70)8 (53.3)0.678Scl-70, n (%)1 (10)4 (26.7)0.615

Conclusion:

The prevalence of calcinosis was similar to that reported in literature (18-49%). This study confirmed the association, already found in previous studies, between calcinosis and the limited form of SS and raises attention for the importance of calcinosis radiographic screening since there was a high prevalence of subclinical calcinosis.1Although there were some clinical differences between patients with and without calcinosis, given the small cohort, statistical significance was not obtained. Larger studies are needed to increase statistical power.

References:

[1]Valenzuela A et al. Calcinosis in scleroderma. Curr Opin Rheumatol. 2018 Nov;30(6):554-561.

[2]Bartoli F et al. Calcinosis in systemic sclerosis: subsets, distribution and complications. Rheumatology (Oxford). 2016 Sep;55(9):1610-4.

Disclosure of Interests:

None declared

FRI0165 RISK OF CKD IN MEMBRANOUS AND PROLIFERATIVE LUPUS NEPHRITIS - ANALYSIS OF A NATIONWIDE MULTICENTRE COHORT

Background:

Lupus nephritis (LN) is one of the most severe manifestations of Systemic Lupus Erythematosus.

Objectives:

1) To compare proliferative (PLN), membranous (MLN) and mixed LN regarding clinical and laboratory presentation. 2) To investigate predictors of progression to chronic kidney disease (CKD).

Methods:

Multicentre observational study, with retrospective analysis of a prospective cohort, using data from the Portuguese registry of rheumatic diseases – Reuma.pt. Patients with biopsy-proven PLN, MLN and mixed LN were included. Groups were compared using Pearson’s Chi-Square for categorical variables and One-Way ANOVA or Kruskal-Wallis for numerical variables. COX regression analysis was used to investigate predictors of CKD (defined as estimated glomerular filtration rate [eGFR] lower than 60 mL/min/1.73m2for at least 3 months) and Kaplan-Meier curves were drawn.

Results:

236 patients were included. Median follow-up was 8 years (IQR 11; maximum 35 years). As seen in table 1, the level of proteinuria did not differ between groups; however, MLN patients presented with significantly lower serum creatinine. Levels of complement C3 and C4 were reduced in PLN but normal in MLN patients, and there were fewer patients with positive anti-dsDNA antibodies in the MLN group (p<0.001). On univariable COX regression, mixed histology was associated with progression to CKD (HR 26 [95% CI 3 - 255], p 0.005) (figure 1), however, it lost significance after adjusting for eGFR. In fact, eGFR≤75 at one year after the renal biopsy (HR 21 [95% CI 7 - 65], p<0.001) was the strongest predictor of CKD, even after adjusting for hypertension or histology.

Table 1.

Comparative description of the Reuma.pt cohort of patients with proliferative, membranous and mixed LN

PLNMLNMixedPTotal, N186428Females, N (%)157 (85)39 (95)4 (50)0.004EthnicityWhite European, N (%)163 (90)31 (78)7 (88)0.115Other, N (%)19 (10)9 (23)1 (13)Age LN diagnosis(y), median (IQR)30 (20)34 (16)42 (25)0.409SLEDAI at LN diagnosis, median (IQR)16 (9)10 (10)21 (17)0.006*uPCR at LN diagnosis, median (IQR)1675 (2598)1698 (2153)2160 (3320)0.629Creatinine at LN diagnosis, median (IQR)0.80 (0.32)0.70 (0.20)1.00 (0.95)0.006*eGFR at LN diagnosis, mean ± SD98 ± 33112 ± 1782 ± 450.019*Albumin at LN diagnosis, mean ± SD34 ± 734 ± 730 ± 60.390C3 at LN diagnosis, mean ± SD0.65 ± 0.260.90 ± 0.350.53 ± 0.30<0.001*Positive anti-dsDNA LN diagnosis, N (%)115 (91)11 (48)6 (86)<0.001*Use of antimalarials, N (%)166 (94)36 (92)8 (100)0.688Use of immunosuppressants, N (%)163 (94)33 (87)8 (100)0.245Use of corticosteroids, N (%)145 (84)33 (85)7 (100)0.511CKD after LN diagnosis, N (%)27 (15)1 (3)3 (38)0.018*ESRD, N (%)7 (4)1 (3)2 (25)0.016Deaths, N (%)14 (8)2 (5)00.610

uPCR: urinary protein-creatinine ratio, mg/g; y: years; Creatinine presented in mg/dL, eGFR in mL/min/1.73m2,albumin in g/L and C3 in g/L

Note: Baseline data (LN diagnosis) in grey; other data refer to the course of disease

*Significant difference between the proliferative and membranous groups

Figure 1.

Kaplan-Meir curves showing cumulative survival free of CKD in patients with PLN, MLN and mixed LN

Conclusion:

Our results support previous findings from single-centre studies suggesting that MLN has a different serological profile than PLN, possibly reflecting different pathogenesis. Renal function at one year predicts long-term outcome in LN.

Disclosure of Interests:

Filipa Farinha: None declared, Sofia C Barreira: None declared, Maura Couto: None declared, Margarida Cunha: None declared, Diogo Fonseca: None declared, Raquel Freitas: None declared, Luís Inês: None declared, Mariana Luis: None declared, Carla Macieira: None declared, Ana Rita Prata: None declared, Joana Rodrigues: None declared, Bernardo Santos: None declared, Rita Pinheiro Torres: None declared, Ruth J. Pepper: None declared, Anisur Rahman: None declared, Maria Jose Santos Speakers bureau: Novartis and Pfizer

Ewing Sarcoma With Emphasis on Extra-skeletal Ewing Sarcoma: A Decade's Experience From a Single Centre in India

INTRODUCTION

The diagnosis of Ewing sarcoma family of tumours (ESFT) is challenging, especially in adults and in extra-skeletal or visceral location. Several morphologic mimics with varied treatment options and prognosis confer diagnostic dilemmas. Application of ancillary diagnostic modalities in surgical pathology in clinical routine has enabled accurate diagnosis of ESFT in bone, soft tissues, and viscera.

AIM

The study aims to assess the clinicopathological features including molecular test results of ESFT with emphasis on sex, age, and location, especially extra-skeletal soft tissue and visceral location.

MATERIAL AND METHODS

Data of clinicopathological, molecular tests (wherever performed), diagnosis rendered in 302 ESFT over a decade from our centre were reviewed. Statistical comparison of skeletal and extra-skeletal tumours with reference to age and sex was done using SPSS package. The P value of <.05 was considered significant.

RESULTS

The cohort included 302 ESFTs with 49% skeletal and 51% extra-skeletal tumours. Thigh was most common site among skeletal tumours; chest wall, paraspinal location, and retroperitoneum among soft tissues (39.4%); and kidney, ovary, and cervix among visceral tumours (11.3%). Fluorescence in situ hybridisation for EWSR1 gene rearrangement was positive in 54 patients and reverse-transcriptase polymerase chain reaction in 19 patients. Predominance of male sex, younger age and location in extremities among skeletal tumours and lack of gender predilection, higher age and axial location in extra-skeletal tumours were noted, which were statistically significant. Molecular tests were performed more frequently in extra-skeletal tumours, especially in visceral tumours to establish the diagnosis.

CONCLUSIONS

The study showed statistically significant differences in the age, sex, and location between skeletal and extra-skeletal ESFT. The increased percentage of extra-skeletal tumours especially in viscera was attributed to the increased awareness and availability of ancillary techniques.

Anaplastic lymphoma kinase status in lung cancers: An immunohistochemistry and fluorescence in situ hybridization study from a tertiary cancer center in India

BACKGROUND AND OBJECTIVES

Fluorescence in situ hybridization (FISH) and immunohistochemistry (IHC) have shown good concordance for the detection of echinoderm microtubule-associated protein-like 4 and anaplastic lymphoma kinase (ALK) rearrangement. Since studies reporting FISH/IHC concordance, clinicopathological features, and clinical outcomes of ALK-positive patients from India are lacking, this study was undertaken.

MATERIALS AND METHODS

This is a retrospective, observational study of patients with adenocarcinoma of the lung on whom ALK test was performed between March 2013 and December 2015. ALK status was assessed in 341 patients by FISH using Vysis ALK Dual Color Break Apart Rearrangement Probe and IHC using ALK D5F3 clone. Clinicopathological features were noted. Patients were managed as per the standard guidelines. Clinical outcomes - response rate (RR) and progression-free survival (PFS) - were measured.

RESULTS

ALK rearrangement was positive in 37 patients (10.9%). ALK positivity was observed more commonly in younger patients with no predilection for any gender or any specific histological subtype. ALK by IHC was highly sensitive (100%), compared to FISH with concordance rate of 94.4%. Thirty one of thirty seven (31 of 37) patients received therapy of which 3 patients received palliative chemotherapy and 28 patients received tyrosine kinase inhibitors (crizotinib/ceritinib). Overall RR observed was 77.4%, and median PFS had not been reached at a median follow-up of 12.5 months.

INTERPRETATION AND CONCLUSIONS

We report higher frequency of ALK positivity (10.9%) in patients with adenocarcinoma of the lung. ALK by IHC is more sensitive than FISH for ALK detection with high concordance. These patients had good clinical outcome with TKIs targeting ALK fusion protein.

Presence of Tomato yellow leaf curl virus Infecting Squash (Curcubita pepo) in Cuba

In a survey conducted in Havana Province during January and February 2003, symptoms of curling and light yellowing of leaves were found in squash plants (Curcubita pepo). DNA from leaves of six symptomatic squash plants was extracted (1) and hybridized at high stringency with specific probes of the intergenic region of Tomato yellow leaf curl virus (TYLCV, genus begomovirus) isolated in Cuba by using a nonradioactive hybridization kit (AlkPhos Direct Labeling and Detection Systems; Amersham Pharmacia Biotech Inc., Piscataway, NJ). Three samples were positive in the nonradioactive analyses. The same samples were positive using polymerase chain reaction (PCR) when the DNA was analyzed with degenerate primers PAL1v1978/PAR1c715 for DNA-A (5), specific primers, ORITY1/ORITY2, for the intergenic region (2), and overlapping specific primers for TYLCV (3). Fragments of 1.4, 0.750, and 2.8 kb were cloned using pGem-T Easy (Promega, Madison, WI), and the six clones obtained were sequenced using the Terminator Cycle Sequencing Kit in a SEQ 4 × 4 machine (Amersham Pharmacia Biotech Inc.). Sequences of three fragments exhibited 95 to 97% homology with TYLCV (GenBank Accession Nos. AF414089 and AF260331). Additionally, we did not obtain a PCR product when DNA was amplified using degenerate primers PBV1c800/PBC1v2039 for DNA-B (4). These results suggest that TYLCV is present in squash in field plantations, and these plants may serve as a virus reservoir for other crops such a tomatoes. References: (1) S. L. Dellaporta et al. Plant. Mol. Biol. Rep. 1(4):19, 1983. (2) Y. Martínez et al. Rev. Prot. Veg. 18(3):168, 2003. (3) M. K. Nakhla et al. Plant Dis. 78:926, 1994. (4) M. Rojas et al. Plant Dis. 77:340, 1993.

First Report of Tomato yellow leaf curl virus Associated with Beans, Phaseolus vulgaris, in Cuba

Beans with yellow mosaic and/or leaf crumple symptoms were collected in three fields in the southern area of the province of Havana, Cuba in December 2001 and February 2002. DNA was extracted from the fresh bean leaves of 25 samples (1). Dot blot hybridization was performed at high stringency with a specific probe for Tomato yellow leaf curl virus (TYLCV). The specific probe was prepared by alkaline phosphatase labeling of the polymerase chain reaction (PCR) fragment amplified with primer pair, PTYIRv21/PTYIRc287, containing the intergenic region (IR) of TYLCV, and chemiluminescent hybridization was completed as described by the manufacturer (AlkPhos Direct Labeling and Detection Systems, Amersham Pharmacia Biotech Inc., Piscataway, NJ). Four of the samples had positive hybridization signals. PCR was performed with overlapping primers for TYLCV (2) with the DNA extract from sample 01-44, which gave a positive hybridization signal with the TYLCV probe, and a 2.8-kb fragment was obtained. This fragment was cloned in pGem T-Easy (pBeTY44) and partially sequenced. Greater than 96% nt identity was obtained for the 591 nt of the IR and 504 nt of the N-terminus of the Rep gene with TYLCV (GenBank Accession No. AF260331). Also, PCR was completed on 11 of the 25 samples with the degenerate primer pair PAL1v1978/PAR1c715 for DNA-A (3). Eight samples gave fragment sizes of 1.4 kb and one sample gave a fragment of 1.3 kb. The 1.3-kb fragment from sample number 01-50 was cloned in pGem T-Easy (pBeBG50) and partially sequenced. Pairwise nucleotide comparisons with Bean golden yellow mosaic virus (BGYMV, GenBank Accession No. M91604) were 95% for 719 nt of the N-terminus of the Rep gene. These results are consistent with the association of both TYLCV and BGYMV in beans and have important implications for future disease management strategies. References: (1) G. P. Accotto et al. Eur. J. Plant. Pathol. 106:179, 2000. (2) M. K. Nakhla et al. Plant Dis. 78:926, 1994. (3) M. Rojas et al. Plant Dis. 77:340, 1993.

First Report of Tomato yellow leaf curl virus Infecting Pepper Plants in Cuba

The begomovirus Tomato yellow leaf curl virus (TYLCV) is one of the major threats to tomato production in tropical and subtropical regions worldwide. TYLCV was found in Cuba in 1994 and later became the most serious constraint to tomato production (2). During a field survey in 2001, pepper plants (Capsicum annuum) were observed in a greenhouse in Camagüey Province, showing mild interveinal yellowing and curling of leaves. Total nucleic acids were extracted from these plants and from pepper samples collected in previous years that showed similar symptoms. Polymerase chain reaction (PCR) was performed on extracts using a primer pair (TY-1/TY-2) (1) specific for the capsid protein (CP) gene of begomoviruses and a second primer pair (IR2353+: CTGAATGTTTGGATGGAAATGTGC; IR255-:GCTCGTAAGTTTCCT CAACGGAC) designed to amplify the part of the genome encompassing the intergenic region (IR) of the Cuban isolate of TYLCV-IS (2). With these primer pairs, amplicons of the expected size were obtained from five samples (one collected in 1995 in Havana Province, two in 1999 in Sancti Spiritus, and two in 2001 in Camagüey.) The CP fragment was digested with RsaI, while the IR amplicon was digested with AvaII and EcoRI. In all cases the patterns obtained corresponded to digestion patterns for identical PCR fragments obtained from TYLCV-infected tomatoes. The IR amplicon sequence from one sample showed ≈99% identity with the corresponding region of the TYLCV-IS isolated from tomato in Cuba. To our knowledge, this is the first report of TYLCV-IS infection in peppers in Cuba. References: (1) G. P. Accotto et al. Eur. J. Plant. Pathol. 106:179, 2000. (2) Y. Martínez et al. J. Phytopathol.144:277, 1996.

The acetylcholinesterase gene Ace: a diagnostic marker for the Pipiens and Quinquefasciatus forms of the Culex pipiens complex

The taxonomy of the Culex pipiens complex remains a controversial issue in mosquito systematics. Based on morphologic characters, 2 allopatric taxa are recognized, namely Cx. pipiens (including the form "molestus") in temperate areas and Cx. quinquefasciatus in tropical areas. Here we report on variability at the nucleotide level of an acetylcholinesterase gene in several strains and natural populations of this species complex. Few polymorphisms were found in coding regions within a subspecies but many polymorphisms were observed between subspecies in noncoding regions. We describe a method based on a restriction enzyme polymorphism in polymerase chain reaction-amplified DNA, in which the presence or absence of one restriction site discriminates Cx. pipiens, Cx. quinquefasciatus, and their hybrids. This technique reliably discriminates mosquitoes from more than 30 worldwide strains or populations. Polymerase chain reaction amplification of specific alleles may also be a useful tool for characterizing specific alleles of each sibling taxon.

Intracystic (encysted) papillary carcinoma of the breast: a clinical, pathological, and immunohistochemical study

Intracystic papillary carcinoma (IPC) of the breast is a rare tumor with predilection for elderly women and distinctive pathological features that must be distinguished from ductal carcinoma in situ (DCIS) of papillary type and from invasive papillary carcinoma. The clinical, radiological, and pathological features of 29 cases of IPC are reported. The cases were divided into three groups (IPC alone, associated with DCIS, or associated with invasive carcinoma) and studied in terms of their size, predominant architectural pattern, nuclear grade, and presence of necrosis. Immunohistochemical studies were performed to evaluate the c-erbB2 oncoprotein, estrogen receptors, and ki-67 antigen expression. The median age of the patients was 75 years. Microscopically, nine tumors (31.0%) were IPC alone, nine (31.0%) had IPC associated with DCIS, and 11 (38.0%) were IPC associated with invasive carcinoma. Most of the IPC cases had low or intermediate nuclear grade, no necrosis, strongly expressed estrogen receptor, and was negative for c-erbB-2. Nuclear grade 3 and necrosis were found only in cases of IPC associated with invasive carcinoma. The median Ki-67 antigen expression was 10.6%. One patient with IPC alone had a recurrence 5 years later. Lymph node metastases were found in one patient who had the tumor with the biggest invasive area. IPC is a low-grade carcinoma with overall good prognosis. However, there is a high frequency of DCIS or invasive carcinoma associated with it, and the prognosis of these cases is related to the type, grade, and size of the associated lesions.