Effects of plant- and animal-based-protein meals for a day on serum nitric oxide and peroxynitrite levels in healthy young men

Plant-based diets that replace animal-based proteins with plant-based proteins have received increased attention for cardiovascular protection. Nitric oxide (NO) plays an essential role in the maintenance of endothelial function. However, under higher oxidative stress, NO generation produces peroxynitrite, a powerful oxidant and vasoconstrictor. Diet-replaced protein sources has been reported to decrease oxidative stress. However, the effects of plant-based protein on NO and peroxynitrite have not yet been clarified. Therefore, this study aimed to compare the effects of plant- and animal-based-protein meals for a day on NO, peroxynitrite, and NO/peroxynitrite balance. A crossover trial of two meal conditions involving nine healthy men was performed. Participants ate standard meals during day 1. On day 2, baseline measurements were performed and the participants were provided with plant-based-protein meals or animal-based-protein meals. The standard and test meals consisted of breakfast, lunch, and dinner and were designed to be isocaloric. Plant-based-protein meals contained no animal protein. Blood samples were collected in the morning after overnight fasting before and after the test meals consumption. In the plant-based-protein meal condition, serum NOx levels (the sum of serum nitrite and nitrate) significantly increased, while serum peroxynitrite levels did not change significantly. Animal-based-protein meals significantly increased serum peroxynitrite levels but showed a trend of reduction in the serum NOx levels. Furthermore, serum NO/peroxynitrite balance significantly increased after plant-based-protein meals consumption, but significantly decreased after animal-based-protein meals consumption. These results suggest that, compared with animal-based-protein meals, plant-based-protein meals increase NO levels and NO/peroxynitrite balance, which reflects increased endothelial function.

Pericardial effusion in oncological patients: current knowledge and principles of management

BACKGROUND

This article provides an up-to-date overview of pericardial effusion in oncological practice and a guidance on its management. Furthermore, it addresses the question of when malignancy should be suspected in case of newly diagnosed pericardial effusion.

MAIN BODY

Cancer-related pericardial effusion is commonly the result of localization of lung and breast cancer, melanoma, or lymphoma to the pericardium via direct invasion, lymphatic dissemination, or hematogenous spread. Several cancer therapies may also cause pericardial effusion, most often during or shortly after administration. Pericardial effusion following radiation therapy may instead develop after years. Other diseases, such as infections, and, rarely, primary tumors of the pericardium complete the spectrum of the possible etiologies of pericardial effusion in oncological patients. The diagnosis of cancer-related pericardial effusion is usually incidental, but cancer accounts for approximately one third of all cardiac tamponades. Drainage, which is mainly attained by pericardiocentesis, is needed when cancer or cancer treatment-related pericardial effusion leads to hemodynamic impairment. Placement of a pericardial catheter for 2-5 days is advised after pericardial fluid removal. In contrast, even a large pericardial effusion should be conservatively managed when the patient is stable, although the best frequency and timing of monitoring by echocardiography in this context are yet to be established. Pericardial effusion secondary to immune checkpoint inhibitors typically responds to corticosteroid therapy. Pericardiocentesis may also be considered to confirm the presence of neoplastic cells in the pericardial fluid, but the yield of cytological examination is low. In case of newly found pericardial effusion in individuals without active cancer and/or recent cancer treatment, a history of malignancy, unremitting or recurrent course, large effusion or presentation with cardiac tamponade, incomplete response to empirical therapy with nonsteroidal anti-inflammatory, and hemorrhagic fluid at pericardiocentesis suggest a neoplastic etiology.

Association of Lower Extremity Muscle Strength and Function with Renal Resistive Index in Individuals with and without Chronic Kidney Disease

Age-related loss of lower extremity muscle strength is pronounced in individuals with chronic kidney disease (CKD). In contrast, an increase in intrarenal flow pulsatility results in initial age-related changes in renal hemodynamics, leading to the development of CKD. To date, it remains unclear whether lower extremity muscle strength determines elevated renal flow pulsatility. This study aimed to determine the association of lower extremity muscle strength and function with intrarenal hemodynamics in individuals with and without CKD. One hundred seventy-six individuals without CKD (aged 63 ± 9 years) and 101 individuals with CKD (aged 66 ± 8 years) were included in this study. Using Doppler ultrasound, the renal resistive index (RI) was measured as a parameter of renal hemodynamics. Knee extensor muscle strength (KES), gait speed (GS), and the 30 s chair stand test (30s-CST) were used to measure lower extremity muscle strength and function. Multivariate analyses showed that GS and 30s-CST scores were independent determinants of renal RI, whereas the KES score was not associated with renal RI in individuals with and without CKD. In the two-way analysis of covariance, renal RI was the highest in individuals with CKD who had lower KES, GS, and 30s-CST scores. Reduced lower extremity muscle strength and function are independent determinants of elevated renal flow pulsatility in individuals with and without CKD.

Effects of lactotripeptide ingestion and physical activity intervention on the fatigue status of middle-aged and older adults: a randomized controlled trial

This randomized controlled trial aimed to investigate the effects of eight weeks of lactotripeptide (LTP) ingestion, physical activity (PA) intervention, and combined intervention on the fatigue status of middle-aged and older adults. A total of 78 middle-aged and older adults (63 ± 8 years of age) were randomly assigned to four groups: placebo, LTP, placebo with PA intervention (placebo + PA), and LTP with PA intervention (LTP + PA). All participants ingested the placebo or LTP tablets daily (three tablets/day). The placebo + PA and LTP + PA groups participated in a weekly supervised exercise class and were instructed to increase their moderate- to vigorous-intensity PA at home. The visual analog scale, Brief Fatigue Inventory, Profile of Mood States second edition (POMS2), and Beck Depression Inventory second edition (BDI-II) were administered before and after the intervention. No significant interactions or main effects were observed between LTP ingestion and PA intervention on any of the fatigue scales. The main-effect analyses revealed that the PA intervention improved the total mood disturbance score of the POMS2 (F = 5.22, P = 0.03) and BDI-II score (F = 4.81, P = 0.03). After the post hoc paired comparisons, the total mood disturbance and BDI-II scores improved more with the combined intervention than with the PA intervention alone (percentage difference between the effect of combined intervention and PA intervention alone was 3.7% for total mood disturbance score and 13.7% for BDI-II score). The present study suggests that eight weeks of LTP ingestion and PA intervention did not have a significant effect on fatigue status. However, the PA intervention improved mood status and depressive symptoms, and these effects were enhanced by LTP ingestion.

Association between the intake of plant and animal proteins and the serum fibroblast growth factor-23 level in patients with chronic kidney disease analyzed by the isocaloric substitution model

Fibroblast growth factor-23 (FGF23) is a phosphaturic hormone secreted by the bone in response to dietary phosphate intake. Since the phosphate content in the diet correlates with the protein content, both plant- and animal-based protein intake can increase the serum FGF23 level. However, a higher percentage of energy from plant protein than from animal protein is associated with a lower serum FGF23 level in patients with chronic kidney disease (CKD) in the United States. Since dietary habits differ between Asian and Western populations, we performed a cross-sectional study to determine the association between the percentages of energy from plant and animal proteins and the serum FGF23 level in Japanese CKD patients. In 107 non-dialysis CKD patients (age: 66 ± 9 years; estimated glomerular filtration rate: 56 ± 21 mL/min/1.73 m²), the percentages of energy from plant and animal proteins were assessed using a food frequency questionnaire based on food groups. Venous blood samples were used to measure the serum FGF23, phosphate, 1,25-dihydroxyvitamin D, and intact parathyroid hormone levels. The percentages of energy from plant and animal proteins showed a negative and positive association, respectively, with the serum FGF23 level. Furthermore, isocaloric substitution modeling showed that replacing animal protein with plant protein was associated with a low serum FGF23 level. Our findings suggest that encouraging diets with high plant protein level may prevent an increase in the serum FGF23 level in Japanese CKD patients.

Cerebral and renal hemodynamics: similarities, differences, and associations with chronic kidney disease and aortic hemodynamics

Elevated arterial pulsatility is a common risk factor for cerebrovascular disease and chronic kidney disease (CKD), which suggests that the brain and kidneys may have similar hemodynamic profiles. The objectives of this study were twofold: 1) to compare and contrast the cerebral and renal blood flow parameters in adults without CKD (hereafter, non-CKD adults) and CKD patients and 2) to determine the common predictor(s) of cerebral and renal hemodynamics among pressure pulsatility and several cardiovascular risk factors. In 110 non-CKD adults and 66 CKD patients, cerebral and renal blood flow velocity (BFV) were measured by transcranial Doppler and Duplex ultrasonography, respectively. Pulsatile hemodynamics were assessed by the pulsatility (PI) and resistive (RI) indices. Aortic pulse pressure was measured by tonometry. Compared with non-CKD adults, CKD patients showed greater pulsatility of the BFV (i.e., systolic minus diastolic BFV), PI, and RI in the kidneys but not the brain. However, the cerebral and renal PI and RI values were strongly correlated in both non-CKD adults (both PI and RI values: r_s = 0.695) and CKD patients (both PI and RI values: r_s = 0.640) (all P < 0.001). Multiple linear regression analysis further demonstrated that the cerebral and renal PI and RI associations remained significant after adjustment for potential covariates (e.g., age, sex, the presence of CKD). The aortic pulse pressure was a significant predictor for both cerebral and renal PI and RI values. Collectively, our findings suggest that CKD patients have higher renal flow pulsatility, which is strongly and independently associated with cerebral flow pulsatility and aortic hemodynamics.

POS0670 EVALUATION OF UPADACITINIB IN RHEUMATOID ARTHRITIS PATIENTS WITH INADEQUATE RESPONSE TO FIRST-GENERATION JANUS KINASE INHIBITORS

Background

Janus kinase inhibitors (JAKi) are effective in the treatment of patients with difficult-to-treat rheumatoid arthritis (D2T RA), regardless of previous use of biological disease-modifying antirheumatic drugs (bDMARDs), and receive equal billing with biological therapies in the latest version of the EULAR recommendations for treatment of RA1. However, as with bDMARDs, cases of discontinuation due to intolerance or inadequate response have been observed in patients treated with the so-called first-generation JAKi, leading to the development of a new generation of JAKi that aims to maximize efficacy and improve safety by enhancing kinase selectivity. The results of randomized controlled trials and meta-analyses suggest that the efficacy and safety of Upadacitinib (UPA) treatment are favorable. Although there have been no head-to-head trials between JAKi, a matched-adjusted indirect comparative study has shown a difference in efficacy between JAKi2, suggesting that the new generation of JAKi may be effective in rheumatoid arthritis patients with intolerance or inadequate response to first-generation JAKi. It is already apparent that a clear need exists for a JAK-IR trial to give guidance in those difficult patients who are JAKi non-responders3.

Objectives

To evaluate real world efficacy of a second-generation JAK1-selective JAKi UPA in single-center cohort of RA patients who had discontinued first-generation JAKi.

Methods

Patients with RA who had discontinued tofacitinib and/or baricitinib due to inadequate response or intolerance, regardless of whether they had used bDMARDs or not, were eligible for the study if they had received UPA by October 2021 and had been followed up for at least 12 weeks. Endpoints were Kaplan-Meier survival rate with inadequate response or intolerance as reasons for discontinuation, various disease activity assessments (DAS28-ESR, SDAI, CDAI, etc.), and patient reported outcomes (visual analogue scales (VASs) such as pain and stiffness, HAQ-DI, FACIT-Fatigue Scale, etc.) at 12 weeks. In addition, the reasons for discontinuation were investigated.

Results

Fifty-one patients were included in the study, all of whom had D2T RA and had used at least one bDMARD as well as JAKi. The mean (median) age was 72.7 (77) years, disease duration 18.0 (17) years, number of bDMARDs used 3.34 (3), number of JAKi used 1.3(1), 5 patients with methotrexate, 6 patients with prednisolone, and DAS28-ESR 3.83 (3.9). At 12 weeks, the overall survival rate was 94% (94.6% in 37 cases used as 2nd JAKi and 92.9% in 14 cases used as 3rd JAKi). For reference, there was no significant difference from the 100% of the 15 cases used as the 1st JAKi (P=0.49). DAS28-ESR <3.2 and <2.6 were achieved in 60.8% and 29.4%, VASs for pain and stiffness decreased by a mean of 12.9 mm (9 mm) and 12.1 mm (7 mm), respectively, and FACIT-Fatigue scale improved by a mean of 3.0 (1). The reasons for discontinuation in the three patients were inadequate efficacy in two and leg cramps due to venous thromboembolism in one.

Conclusion

UPA is more selective for JAK1 than first generation JAKi, and is expected to reduce adverse reactions caused by inhibition of JAK family members other than JAK1. The present study suggests that UPA is effective and well tolerated, regardless of the number and type of first-generation JAKi used in the past, albeit for a short period of time. Limitations include the small number of cases and the short time frame for discussing adverse reactions.

References

[1]Smolen JS, Landewé BM, Bijlsma WJ et al., EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2019 update. Ann Rheum Dis 2020;79:685–699.

[2]Christopher JE, Ruta S, Vishvas G et al. A Matching-Adjusted Indirect Comparison of Upadacitinib Versus Tofacitinib in Adults with Moderate-to-Severe Rheumatoid Arthritis. Rheumatol Ther 2021; 8:167–181.

[3]Peter Nash, Clinical use of Jak 1 inhibitors for rheumatoid arthritis. Rheumatology, Volume 60, Issue Supplement_2, May 2021, Pages ii31–ii38

Disclosure of Interests

None declared

Effects of the number of sit-stand maneuver repetitions on baroreflex sensitivity and cardiovascular risk assessments

Sit-stand maneuvers (SSM) have increasingly been used for baroreflex sensitivity (BRS) measurement in physiological research, but it remains unknown as to how many SSM need to be performed to measure BRS and assess its relation with cardiovascular disease (CVD) risk. Therefore, this study aimed to determine 1) the effect of the number of SSM repetitions on BRS and 2) the association between BRS and CVD risk factors. Data were collected from 174 individuals during 5 minutes of spontaneous rest and 5 minutes of repeated SSM at 0.05 Hz (i.e., 15 cycles of 10-second sit and 10-second stand). During SSM, BRS was calculated from the incremental cycles of 3, 6, 9, 12, and 15 SSM using transfer function analysis of heart rate (HR) and systolic blood pressure (SBP). General CVD risk factors, carotid arterial stiffness, and cardiorespiratory fitness were measured. In result, HR and SBP increased during SSM (p<0.05). The BRS remained at a similar level during the resting and SSM conditions, while the coherence function reached its peak after 3 cycles of SSM. BRS with ≥6 cycles of SSM was strongly correlated with age (r=-0.721 to -0.740), carotid distensibility (r=0.625 to 0.629), and cardiorespiratory fitness (r=0.333 to 0.351) (all p<0.001). Multiple regression analysis demonstrated that BRS with ≥6 cycles of SSM explained >60% of the variance in CVD risk factors. Therefore, our findings suggest that repeated SSM significantly strengthens the association between BRS and CVD risk factors. Particularly, BRS with ≥6 cycles of SSM is strongly associated with CVD risk.

Superomedial pedicle skin-reducing mastectomy in ptotic and large-sized breasts with two-stage reconstruction through transaxillary video-assisted technique: An effective surgical and anesthetic approach

Introduction

Skin-reducing mastectomy has been applied to several surgical techniques in which subcutaneous mastectomy is associated with various types of skin reduction, with preservation of a lower dermal flap to reinforce the inferior lateral seat of an implant. The aim of the study is to present a case series of patients with pendulous/ptotic and/or large-sized breasts treated for breast cancer at the Breast Surgery Unit of Istituto Nazionale Tumori IRCCS Fondazione "G. Pascale", Naples, Italy, with the superomedial pedicle skin-reducing mastectomy technique, two-stage reconstruction, and transaxillary video-assisted technique, when a postoperative radiotherapy was indicated. We verified its effectiveness by discussing its results, especially in patients who are candidates for postmastectomy radiotherapy.

Materials and methods

A single-center retrospective study was performed between January 2020 and March 2021 on a prospectively filled database of conservative mastectomies. Of the 64 patients who underwent nipple/skin-sparing mastectomies in the mentioned period, 17 (mean age 46 years, range 30-62 years) were treated with superomedial pedicle skin-reducing mastectomy, with two-stage breast reconstruction through transaxillary video-assisted replacement expander with definitive prosthesis and contralateral symmetrization, selected for postmastectomy radiotherapy.

Results

We had only three minor complications. No flap necrosis, no infections, no breast seromas, and no reconstructive failures were observed. During follow-up of the patients treated with video-assisted reconstruction, there were no cases of infection, hematoma, implant rupture, or suture dehiscence in the reconstructed breast.

Discussion

Skin-reducing mastectomy with superomedial pedicle is a safe and reliable procedure to treat breast cancer in selected patients, i.e., those with pendulous/ptotic and or large-sized breasts. Particularly, in patients who undergo postmastectomy radiotherapy, the two-stage reconstruction with video-assisted transaxillary endoscopic approach can find its main indication, using incisions positioned far from the mammary region, offering numerous advantages.

A randomized, controlled trial of once-weekly teriparatide injection versus alendronate in patients at high risk of osteoporotic fracture: primary results of the Japanese Osteoporosis Intervention Trial-05

In this randomized, controlled trial, treatment with once-weekly subcutaneous injection of teriparatide for 72 weeks was found to be associated with a significant reduction in the incidence of morphometric vertebral fractures compared with alendronate in women with primary osteoporosis who were at high risk of fracture.

INTRODUCTION

To determine whether the anti-fracture efficacy of teriparatide is superior to that of alendronate, a prospective, randomized, open-label, blinded-endpoint trial was performed.

METHODS

Japanese women aged at least 75 years were eligible for the study if they had primary osteoporosis and were at high risk of fracture. Patients were randomly assigned in a 1:1 ratio to receive sequential therapy (once-weekly subcutaneous injection of teriparatide 56.5 μg for 72 weeks followed by alendronate for 48 weeks) or monotherapy with alendronate for 120 weeks. The primary endpoint was the incidence of morphometric vertebral fractures at 72 weeks (at the end of teriparatide treatment).

RESULTS

Between October 2014 and December 2017, 1011 patients (505 in the teriparatide group and 506 in the alendronate group) were enrolled. Of these, 778 patients (351 and 427, respectively) were included in the primary analysis. The incidence of morphometric vertebral fractures was significantly lower in the teriparatide group (56 per 419.9 person-years, annual incidence rate 0.1334) than in the alendronate group (96 per 553.6 person-years, annual incidence rate 0.1734), with a rate ratio of 0.78 (95% confidence interval 0.61 to 0.99, P = 0.04). In both groups, adverse events were most frequently reported in the following system organ classes: infections and infestations, gastrointestinal disorders, and musculoskeletal and connective tissue disorders.

CONCLUSION

Once-weekly subcutaneous injection of teriparatide significantly reduced the incidence of morphometric vertebral fractures compared with alendronate in women with primary osteoporosis who were at high risk of fracture.

TRIAL REGISTRATION

jRCTs031180235 and UMIN000015573, March 12, 2019.

AB0252 EFFICACY OF A SECOND JANUS KINASE INHIBITOR THAT WAS SWITCHED FOR DIFFICULT-TO-TREAT RA IN CLINICAL PRACTICE

Background:

In clinical practice, when refractory rheumatoid arthritis (RA) is present, of which the definition implies previous use of at least two biologic disease-modifying antirheumatic drugs (bDMARDs) (generally tumour necrosis factor inhibitors (TNFis)), the next treatment choice often made is a bDMARD of another class (non-TNFis) [1]. However, patients who are inadequately responding to bDMARDs need new treatment options because subsequent bDMARDs treatment reduces their response [2]. Janus Kinase inhibitors (JAKis) are the first targeted synthetic DMARDs (tsDMARD) licensed for the treatment of RA with comparable efficacy to bDMARDs. Unlike the single cytokine targeting approach of bDMARDs, JAKis are specifically designed to inhibit intracellular signalling molecules common to the receptors of multiple inflammatory cytokines implicated in RA pathogenesis. The choice of therapeutic agents for refractory RA is increasing, and its efficacy is expected. On the other hand, it is also true that some patients discontinued JAKis at a rate that cannot be overlooked because of insufficient efficacy. Difficult-to-treat (D2T) RA is defined as refractory to two or more b/ts DMARDs with different mechanisms of action, with active and progressive disease, as published by Eular(3)

Objectives:

To evaluate real world efficacy of approved JAKis switching in patients with D2T RA who were unable to control their disease activity due to insufficient efficacy despite the sequential use of multiple bDMARDs and JAKis, focusing on the drug retention rate.

Methods:

In our hospital, RA was diagnosed according to the 1987 or 2010 classification criteria, and when two or more bDMARDs (including both TNFis and non-TNFis) were inadequately effective, it was defined as D2T RA. We retrospectively investigated patients who switched to JAKis for D2T RA. The drug retention rate was investigated by the Kaplan-Meier method, and the difference was tested by the Logrank test.

Results:

The 1-year retention rate of JAKis for D2T RA was 50.8% in TOF 38 cases [28 women, age average 70.2 years, disease duration average 12.4 years, past bDMARDs use average 3.5 drugs, MTX combination 9 cases, DAS28 ESR average 4.11] and 66.3% in BAR 35 cases [26 cases, 73.0 years old, 14.8 years, 4.17 agents, 9 cases, 3.68], and there was no significant difference (P = 0.30). Among them, there were 17 cases [11 cases, 70.6 years old, 13.5 years, 4.18 drugs, 2 cases, 3.65] of switching between JAKis, all of which were switching from TOF to BAR. The 1-year retention rate was 45.8% [reason for discontinuation: insufficient effect in 3 cases, adverse events in 6 cases], which was not significantly different but tended to be lower than 72.7% [reason for discontinuation: insufficient effect in 1 case, adverse event in 2 cases, patient’s convenience in 1 case] in 16 patients [13 cases, 76.3 years old, 17.1 years, 3.19 drugs, 7 cases, 3.69] who received BAR as the first JAKi for D2T RA patients (P = 0.089).

Conclusion:

Although the number of cases is small in the retrospective survey, it is suggested that the retention rate of BAR switched to D2T RA may be slightly lower in patients with a history of TOF discontinuation due to insufficient efficacy than in JAKi naive patients. It is expected that the number of new JAKi usage cases will increase in the future, and it is necessary to consider switching between other JAKis in addition to switching from BAR to TOF.

References:

[1]Smolen JS, Landewe R, Bijlsma J et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2016 update. Ann Rheum Dis 2017;76:960_77.

[2]Rendas-Baum R, Wallenstein GV, Koncz T et al. Evaluating the efficacy of sequential biologic therapies for rheumatoid arthritis patients with an inadequate response to tumor necrosis factor-α inhibitors. Arthritis Res Ther 2011;13:R25.

[3]Nagy G, et al. EULAR definition of difficult-to-treat rheumatoid arthritis. Ann Rheum Dis 2021;80:31–35. doi:10.1136/annrheumdis-2020-217344.

Disclosure of Interests:

None declared

POS0088 EFFICACY OF JANUS KINASE INHIBITORS FOR DIFFICULT-TO-TREAT RA IN CLINICAL PRACTICE

Background:

In 20-30% of rheumatoid arthritis (RA) patients, the first biologic disease-modifying antirheumatic drugs (bDMARDs) (generally tumour necrosis factor inhibitors (TNFis)) is ineffective, and among the patients who do respond to therapy, 20% is faced with secondary ineffectiveness within the first 2 years of treatment [1]. In practice, when refractory RA is present, of which the definition implies previous use of at least two bDMARDs (generally TNFis), the next treatment choice often made is a bDMARD of another class (non-TNFis) [2]. On the other hand, patients who are inadequately responding to bDMARDs need new treatment options because subsequent bDMARD treatment reduces their response [3]. Janus Kinase inhibitors (JAKis) are the first targeted synthetic DMARDs (tsDMARD) licensed for the treatment of RA with comparable efficacy to bDMARDs. Unlike the single cytokine targeting approach of bDMARDs, JAKis are specifically designed to inhibit intracellular signalling molecules common to the receptors of multiple inflammatory cytokines implicated in RA pathogenesis.

Objectives:

Difficult-to-treat (D2T) RA is defined as refractory to two or more b/ts DMARDs with different mechanisms of action, with active and progressive disease, as published by Eular(4). We evaluated real world efficacy of approved JAKis and factors that may help to continue them in patients with D2T RA.

Methods:

Patients who had inadequate response to two or more bDMARDs (including both TNFis and non-TNFis) at our hospital by December 2019 were defined as D2T RA, and patients who switched to JAKis were retrospectively investigated. The drug retention rate was determined by Kaplan-Meier method, and the difference was tested by Logrank test. Multiple regression analysis was used as the statistical method to predict continuation of JAKis for more than 1 year, with patient background (age, gender, during the disease, number of bDMARDs used, with or without methotrexate and/or glucocorticoids, disease activity score assessing 28 joints using erythrocyte sedimentation rate’ presence of rheumatoid factor/anti-CCP antibody, matrix metalloproteinase 3 value, Health Assessment Questionnaire disability index) at the time of initiation as an explanatory variable.

Results:

A total of 915 bDMARDs had been administered to 394 RA patients. The retention rate of bDMARDs and the number of bDMARDs used were 89.3% and 1.48 bDMARDs at 1 year, 67.7% and 2.27 bDMARDs at 5 years, and 52.0% and 3.15 bDMARDs at 10 years, respectively. The retention rate of JAKis at 1 year was 60.2% in 65 patients with tofacitinib (TOF) and 67.2% in 70 patients with baricitinib (BAR) (P=0.38). Among them, the drug retention rate in D2T RA patients was 50.8% in 38 TOF patients and 66.3% in 35 BAR patients with no significant difference (P=0.30). There were no patient background factors that significantly predicted continuation at 1 year for any JAKis.

Conclusion:

Despite the limited number of patients and the retrospective nature of the study, TOF and BAR were shown to be effective options for D2T RA, regardless of patient background such as disease activity or number of bDMARDs used. Other JAKis and switches between JAKis need to be investigated in the future.

References:

[1]Schaeverbeke T, Truchetet ME, Kostine M et al. Immunogenicity of biologic agents in rheumatoid arthritis patients: lessons for clinical practice. Rheumatology 2016;55:210_20.

[2]Smolen JS, Landewe R, Bijlsma J et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2016 update. Ann Rheum Dis 2017;76:960_77.

[3]Rendas-Baum R, Wallenstein GV, Koncz T et al. Evaluating the efficacy of sequential biologic therapies for rheumatoid arthritis patients with an inadequate response to tumor necrosis factor-α inhibitors. Arthritis Res Ther 2011;13:R25.

[4]Nagy G, et al. EULAR definition of difficult-to-treat rheumatoid arthritis. Ann Rheum Dis 2021;80:31–35. doi:10.1136/annrheumdis-2020-217344.

Disclosure of Interests:

None declared

Occurrence and clinical course of peri-stent contrast staining: comparison between second-generation drug-eluting stents and third generation drug-eluting stents

Background

Peri-stent contrast staining (PSS) has been reported to be associated with very late stent thrombosis.

The aims of this study was to compare the occurrence rate of PSS between second generation drug-eluting stents (2nd DES) and third generation drug-eluting stents (3rd DES), and to identify clinical characteristics associated with PSS.

Methods and results

This study comprised 1899 patients with 2493 de novo lesions treated with 2nd or 3rd DES from October 2015 to September 2018. Follow-up angiography was available for 1883 lesions (75.5%). There were 725 patients with 968 lesions treated with 2nd DES, and 716 patients with 915 lesions treated with 3rd DES. The occurrence of PSS, types of PSS, and VLST related to PSS were compared between 2nd and 3rd DES implantation. Mean follow-up period was 30±12 months. The occurrence rate of PSS and segmental type of PSS were similar between two groups (2nd DES vs. 3rd DES, 1.5% vs. 1.7%, p=0.73, 47% vs. 50%, p=0.85, and respectively). The VLST related to PSS occurred in only one case in 3rd DES group. (0% vs. 6.3%, p=0.33).

Conclusion

The occurrence rate of PSS and clinical course were similar between 2nd and 3rd DES.

Funding Acknowledgement

Type of funding source: None

Increased fibroblast growth factor-21 in chronic kidney disease is a trade-off between survival benefit and blood pressure dysregulation

Circulating levels of fibroblast growth factor-21 (FGF21) start increasing in patients with chronic kidney disease (CKD) since early stages during the cause of disease progression. FGF21 is a liver-derived hormone that induces responses to stress through acting on hypothalamus to activate the sympathetic nervous system and the hypothalamus-pituitary-adrenal endocrine axis. However, roles that FGF21 plays in pathophysiology of CKD remains elusive. Here we show in mice that FGF21 is required to survive CKD but responsible for blood pressure dysregulation. When introduced with CKD, Fgf21^−/− mice died earlier than wild-type mice. Paradoxically, these Fgf21^−/− CKD mice escaped several complications observed in wild-type mice, including augmentation of blood pressure elevating response and activation of the sympathetic nervous system during physical activity and increase in serum noradrenalin and corticosterone levels. Supplementation of FGF21 by administration of an FGF21-expressing adeno-associated virus vector recapitulated these complications in wild-type mice and restored the survival period in Fgf21^−/− CKD mice. In CKD patients, high serum FGF21 levels are independently associated with decreased baroreceptor sensitivity. Thus, increased FGF21 in CKD can be viewed as a survival response at the sacrifice of blood pressure homeostasis.

P5022Dual-energy CT was effective to evaluate of microvasculopathy in chronic thromboembolic pulmonary hypertension

Background

The existence of microvasculopathy in patients with chronic thromboembolic pulmonary hypertension (CTEPH) had been suggested. However, the impact of microvasculopathy for pathophysiology had been unknown. Recently dual-energy CT (DECT) can produce a sensitive iodine distribution map as blood perfusion in lung fields to quantify lung perfusion, also can suggest the existence of microvasculopathy according to poor subpleural perfusion which was published previously.

Methods

We retrospectively reviewed poor subpleural perfusion (defined as subpleural spaces either not or minimally perfused in all segments) and hemodynamics of 83 treatment-naïve CTEPH patients who underwent DECT from February 2014 to Jan 2019. Patients were divided according to poor subpleural perfusion: a microvasculopathy group (n=44) or a non-microvasculopathy group (n=39).

We assessed cardiopulmonary exercise test, right heart catheterization and DECT parameters as quantitative evaluation of pulmonary blood volume (PBV). PBV was calculated as the average of entire lung iodine density.

Results

PBV value in non-microvasculopathy group showed significant inverse correlation with pulmonary vascular resistance (PVR) (y = 14236 x-1.028 r=−0.530, p<0.01).

PBV, SvO2, and %DLCO/VA were significantly lower (22.0 vs. 26.4, p<0.01, 61.3 vs. 66.0, p<0.01, and 59.2 vs 75.9 p<0.01), and systolic pulmonary arterial pressure, PVR, VE/VCO2 slope, BNP were higher (69.3 vs 60.6 p=0.04, 834 vs 586 p<0.01, 45.5 vs. 37.8, p=0.02, and 440 vs 122 p=0.04) in microvasculopathy group, while the other parameters were similar between the two groups.

Multivariate analysis revealed that %DLCO/VA was the only predictor of microvasculopathy (OR,0.895 [95% CI, 0.835 - 0.960]; P<0.01).

Conclusion

Pulmonary blood flow of patients in non-micorvasculopathy group showed inverse correlation with PVR. DECT was effective to assess the microvasculopathy in CTEPH. In our experience, less than 60% of non-operable CTEPH patients have microvasculopathy.

Mechanical regulation of bone homeostasis through p130Cas-mediated alleviation of NF-κB activity

Mechanical loading plays an important role in bone homeostasis. However, molecular mechanisms behind the mechanical regulation of bone homeostasis are poorly understood. We previously reported p130Cas (Cas) as a key molecule in cellular mechanosensing at focal adhesions. Here, we demonstrate that Cas is distributed in the nucleus and supports mechanical loading-mediated bone homeostasis by alleviating NF-κB activity, which would otherwise prompt inflammatory processes. Mechanical unloading modulates Cas distribution and NF-κB activity in osteocytes, the mechanosensory cells in bones. Cas deficiency in osteocytes increases osteoclastic bone resorption associated with NF-κB-mediated RANKL expression, leading to osteopenia. Upon shear stress application on cultured osteocytes, Cas translocates into the nucleus and down-regulates NF-κB activity. Collectively, fluid shear stress-dependent Cas-mediated alleviation of NF-κB activity supports bone homeostasis. Given the ubiquitous expression of Cas and NF-κB together with systemic distribution of interstitial fluid, the Cas-NF-κB interplay may also underpin regulatory mechanisms in other tissues and organs.

Immunogenomic profiles associated with response to neoadjuvant chemoradiotherapy in patients with rectal cancer

BACKGROUND

Accumulating evidence suggests that radiotherapy success has an immune-associated component. The immunogenomic profiles associated with responses to chemoradiotherapy (CRT) were assessed in patients with locally advanced rectal cancer in this study.

METHODS

CD8+ tumour-infiltrating lymphocyte (TIL) and stromal lymphocyte densities were assessed by immunohistochemistry using pretreatment biopsies from patients with advanced rectal cancer who had preoperative CRT. Whole-exome sequencing and gene expression microarray analysis were conducted to investigate the genomic properties associated with the response to CRT and CD8+ TIL density. Response to CRT was determined based on Dworak tumour regression grade (TRG); tumours with complete (TRG 4) or near-complete (TRG 3) regression were grouped as good responders, and those with TRG 1 as non-responders.

RESULTS

Immunohistochemical examinations (275 patients) showed that pre-CRT CD8+ TIL density was associated with better response to CRT and improved recurrence-free survival, whereas pre-CRT stromal CD8+ cell density was not associated with either response to CRT or recurrence-free survival. Whole-exome sequencing (74 patients) showed that the numbers of single-nucleotide variations (SNVs) and neoantigens predicted from SNVs were higher in good responders than in non-responders, and these correlated positively with CD8+ TIL density (r_S  = 0·315 and r_S  = 0·334 respectively). Gene expression microarray (90 patients) showed that CD8A expression correlated positively with the expression of programmed cell death 1 (PDCD1) (r_S  = 0·264) and lymphocyte-activation gene 3 (LAG3) (r_S  = 0·507).

CONCLUSION

Pre-CRT neoantigen-specific CD8+ T cell priming may be a key event in CRT responses where immune checkpoint molecules could be useful targets to enhance tumour regression.

Beyond the physician's perspective: A review of patient-reported outcomes in dermatologic surgery and cosmetic dermatology

Patient-reported outcome measures (PROMs) are utilized in health care to quantify the patient's perspective of a health condition or treatment on outcomes, such as health-related quality of life (HRQoL) and patient satisfaction. In dermatology, this is particularly relevant because the patient's perspective is critical in evaluating the outcome of cosmetic procedures as well as skin cancer treatment. We review seven validated PROMs that have been reported in the dermatologic surgery and cosmetic dermatology literature. For patients undergoing cosmetic procedures, the use of PROMs provides additional valuable outcome data beyond physician assessment. For patients with skin cancer, women experience a unique and often greater impact on HRQoL during treatment, which has been captured through PROMs. The recent development of multi-module instruments, such as the FACE-Q and FACE-Q Skin Cancer, have facilitated comprehensive assessments of treatment that impact multiple domains of HRQoL. The use of PROMs allows for dermatologists to reliably capture important disease- and treatment-related concerns, thus improving the patient experience.

Preliminary Study on Prevalence and Associated Factors with Sarcopenia in a Geriatric Hospitalized Rehabilitation Setting

The reported prevalence of sarcopenia has shown a wide range, crucially based on the diagnostic criteria and setting. This cross-sectional study evaluated the prevalence of sarcopenia and sought to identify factors associated with sarcopenia on admission in a specialized geriatric rehabilitation setting based on the newly developed the Asian Working Group for Sarcopenia algorithm. Among 87 participants (mean age, 76.05 ± 7.57 years), 35 (40.2%) were classified as showing sarcopenia on admission. Prevalence was high, particularly among participants ≥80 years old, with tendencies toward lower body mass index, smoking habit, lower cognitive function, and greater functional impairment compared with the non-sarcopenic group. Identification of sarcopenia in elderly patients before rehabilitation and consideration of risk factors may prove helpful in achieving rehabilitation outcomes.