Integrative phylogenetic, phylogeographic and morphological characterisation of the Unio crassus species complex reveals cryptic diversity with important conservation implications

The global decline of freshwater mussels and their crucial ecological services highlight the need to understand their phylogeny, phylogeography and patterns of genetic diversity to guide conservation efforts. Such knowledge is urgently needed for Unio crassus, a highly imperilled species originally widespread throughout Europe and southwest Asia. Recent studies have resurrected several species from synonymy based on mitochondrial data, revealing U. crassus to be a complex of cryptic species. To address long-standing taxonomic uncertainties hindering effective conservation, we integrate morphometric, phylogenetic, and phylogeographic analyses to examine species diversity within the U. crassus complex across its entire range. Phylogenetic analyses were performed using cytochrome c oxidase subunit I (815 specimens from 182 populations) and, for selected specimens, whole mitogenome sequences and Anchored Hybrid Enrichment (AHE) data on ∼ 600 nuclear loci. Mito-nuclear discordance was detected, consistent with mitochondrial DNA gene flow between some species during the Pliocene and Pleistocene. Fossil-calibrated phylogenies based on AHE data support a Mediterranean origin for the U. crassus complex in the Early Miocene. The results of our integrative approach support 12 species in the group: the previously recognised Unio bruguierianus, Unio carneus, Unio crassus, Unio damascensis, Unio ionicus, Unio sesirmensis, and Unio tumidiformis, and the reinstatement of five nominal taxa: Unio desectusstat. rev., Unio gontieriistat. rev., Unio mardinensisstat. rev., Unio nanusstat. rev., and Unio vicariusstat. rev. Morphometric analyses of shell contours reveal important morphospace overlaps among these species, highlighting cryptic, but geographically structured, diversity. The distribution, taxonomy, phylogeography, and conservation of each species are succinctly described.

Health literacy and diabetic retinopathy

Health literacy (HL) is defined as a cognitive and social skill that determines the motivation and ability of individuals to understand and use information to promote and maintain proper health. Inadequate HL has been associated with worse outcomes in diabetes control, poor self-care, and higher hospitalization rates for some chronic diseases. We hypothesized that HL influences the prevalence of diabetic retinopathy (DR) among individuals with type 2 diabetes mellitus (T2DM) and that inadequate glycemic control would mediate this association. This was a cross-sectional study carried out with 288 participants of the "Brazilian Diabetes Study" cohort. Inclusion criteria were people diagnosed with T2DM aged between 40 and 70 years and ability to read and write. In the adequate HL group, DR was found in 16.5% of participants and in the inadequate HL group, it was found in 32.8% (P=0.0081). Individuals with inadequate HL had a higher risk of having DR, and this association was still statistically significant after adjusting for HbA1c, low-density lipoprotein cholesterol, systolic blood pressure, and diastolic blood pressure. In conclusion, HL is related to DR without the mediation of classical clinical variables.

Identifying strategic opportunities through the development of a roadmap for additive manufacturing: The example of Portugal

Additive Manufacturing (AM) demonstrates significant potential with rapid growth and widespread industrial adoption. To support the integration and innovation of AM technologies, the development of guidance tools and support methods are crucial, and a technological roadmap can assist in this effort. Despite its widespread use in production processes, the need for further research on the potential impact of AM remains significant. The full impact of AM is still uncertain and lacks consensus, highlighting the need for increased knowledge and investment from the scientific community and organizations. While the benefits of AM are recognized, the challenges of its adoption are not entirely known. AM will bring changes in the way organizations create, distribute, and derive value. Thus, in this article, a roadmap for AM is proposed and presented as a tool to map technological knowledge on the implementation and evolution of AM and serve as a strategic guide for organizations. The methodology for its elaboration involves three phases: planning and preparation, roadmap development, and review and update. Through a literature review, database and project consultation, and questionnaires to Portuguese companies that use AM in their production process it was possible to characterize the AM technology and through the visual format, based on a time horizon, summarize in a common framework all the information about the current and future state of AM in Portugal. The results of this study show that research and development initiatives are essential to promote the evolution of knowledge of the AM technology. Throughout this study and with the development of the roadmap it is anticipated that in the near future the AM will be widely used for prototyping and manufacturing of components and may be used for direct production in the short to medium term. It was also found that the main obstacles to the implementation of AM are the economic/productivity factors and the shortage of professionals with knowledge and skills in the area.

AB1173 INCIDENT CASES OF COVID-19 AND VACCINATION ADHERENCE IN A MULTICENTRIC COHORT OF INFLAMMATORY ARTHRITIS IN BRAZIL

Background

The SARS-CoV-2 virus has caused a worldwide health crisis. Patients with inflammatory arthritis are at higher risk of hospitalization and death by COVID-19 due to comorbidities or immunosuppressive treatments. Vaccination is one the most important strategies to control the pandemic.

Objectives

To evaluate the incident cases of SARS-CoV-2 infection in a multicentric cohort of inflammatory arthritis in Brazil.

Methods

BiobadaBrasil is a multicentric registry-based cohort study of Brazilian patients with rheumatic diseases starting their first bDMARD or tsDMARD (1). The present analysis is a retrospective evaluation of adult patients with inflammatory arthritis (rheumatoid arthritis – RA, spondylarthritis -SpA and psoriatic arthritis-PsA) that were alive since the beginning of the COVID-19 pandemics in Brazil in February 2020. We evaluated the incidence and severity of COVID-19 infection and the adherence to anti- SARS-CoV-2 vaccines schedules, up to January 2022.

Results

A total of 300 patients were interviewed and 69 (23.0%) reported confirmed anti-SARS-CoV infection and 5 (1.7%) had a second infection. Among known infected patients, 18.8% need hospitalization and oxygen support, 7.2% were admitted at ICU, and 5.8% died. After COVID-19 infection, 31.8% reported worsening of disease activity but only 6.1% had modification in medication due to disease activity. Distribution of cases followed the pattern of waves observed in Brazil (Figure 1). Regarding vaccination, 285 (95%) reported to have received at least one dose of any anti-SARS-CoV-2 vaccine: 43% received the first with the adenovirus ChAdOx1 nCoV-19 (AstraZeneca) adenovirus vaccine, 32% received the Sinovac-CoronaVac inactivated vaccine, 22% received the BNT162b2 (Pfizer-BioNtech) mRNA vaccine and 3% received the BNT162b2 (Pfizer-BioNtech) adenovirus vaccine. Almost all (98.1%) of these patients had already received the second dose of vaccine and after the first and second vaccine doses, 6% and 4% of patients, respectively, reported worsening of articular disease activity, while, after the third dose, no patient reported disease activity worsening.

Figure 1.

Conclusion

During the pandemics, patients with inflammatory arthritis had a pattern of distribution of cases very similar to general population. Adherence to vaccination is high and well tolerated.

References

[1]Bredemeier et al. J Rheumatol 2021;48:1519-27

Disclosure of Interests

None declared

POS0650 THE IMPACT OF OLD AGE ON THE PERSISTENCE AND SAFETY OF TREATMENT WITH BIOLOGIC AGENTS OR JAK INHIBITORS IN RHEUMATOID ARTHRITIS

Background

The effect of age on persistence and safety of treatment with biologic disease modifying anti-rheumatic drugs (bDMARDs) in rheumatoid arthritis has been a subject to research interest. Two recently published studies did not observe significantly different survival of treatment with bDMARDs among older age (≥ 65 years) individuals (1,2); incidence of serious adverse events was higher in these patients (2).

Objectives

to evaluate association of the age with treatment survival and overall safety among patients receiving one or multiple courses of bDMARDs or targeted synthetic (ts-) DMARDs.

Methods

BiobadaBrasil is a multicentric registry-based cohort study of Brazilian patients with rheumatic diseases starting their first bDMARD or tsDMARD (3). The present analysis includes RA patients recruited from Jan 2009 to Oct 2019, followed-up over one or multiple (up to six) courses of treatment necessarily involving a bDMARD or tsDMARD (latest date, Nov 19, 2019). Treatment course is defined as a period during which the medication scheme does not change, except for dose adjustments. Primary outcome was the incidence treatment interruption for any reason (except for pregnancy or disease remission), while interruption due to adverse events (AEs; including death) and due to inefficacy served as secondary outcomes. Incidence of serious adverse events (SAEs) also served as a secondary outcome. Extended (frailty) multivariate Cox proportional hazards models and negative binomial regression with generalized estimating equations (to calculate incidence rate ratios [IRRs]) were used for statistical analyses (both types of analyses including time-varying covariates over multiple courses of treatment).

Results

In total, 1316 patients (2335 treatment courses, 6508 patient-years [PY]) were enrolled. Of these, 160 patients (643 PY; 237 treatment courses) were ≥ 65 years old, mean age at starting treatment = 71 ± 5 yrs (84% female). Old age was not significantly associated with treatment interruption for any reason, but presented higher risk of interruption due to adverse events (after multivariate adjustment) and lower risk of stopping because of inefficacy (see Table 1). Older patients presented higher incidence of SAEs than younger ones (16.0 vs 8.4/100 PY, respectively; multivariate IRR: 2.06, 95% CI: 1.51 to 2.80, P<0.001). Among old patients, tocilizumab (HR: 2.73, 95% CI: 1.13 to 6.64, P=0.026), etanercept (2.13, 1.12 to 4.07, P=0.022), and infliximab (2.39, 1.19 to 4.79, P=0.014) presented higher risk of treatment termination as compared with adalimumab. In this subgroup (age ≥65 yrs), there was no significant difference in the risk of SAEs between different bDMARDs/tsDMARDs.

Table 1.

Univariate and multivariate hazard ratios (HRs) of interruption of treatment course comparing older (≥65 years) versus younger patients (reference category). Results are HRs, 95% CIs, and P values.

Cause of interruption (n of events)Crude analysisAdjusted covariates*Interruption - any reason (1321)0.96 (0.75 to 1.23), P=0.7601.09 (0.82 to 1.43), P=0.550Interruption - adverse events (368)1.33 (0.75 to 0.89), P=0.1601.59 (1.07 to 2.35), P=0.020Interruption - inefficacy (680)0.56 (0.39 to 0.80), P=0.0020.57 (0.38 to 0.87), P=0.009

* Age, baseline DAS28, disease duration, gender, smoking, RF or anti-CCP, previous malignancy, interstitial lung disease, diabetes, hypertension, hypercholesterolemia, renal failure, ischemic cardiomyopathy, COPD, heart failure, concomitant use of each cs-, b-, and tsDMARDs, corticosteroids, starting year, osteoporosis, hepatitis B,C, treatment sequence.

Conclusion

The overall risk of treatment interruption with biologic or targeted synthetic DMARDs is not higher in older patients. Higher risk of interruption due to AE was balanced by a lower risk of stopping treatment due to inefficacy. Older patients had a higher incidence of SAEs.

References

[1]Mathieu et al. Rheumatol Int 2021;41:879-85.

[2]Freitas et al. Drugs Aging 2020;37:899-907.

[3]Bredemeier et al. J Rheumatol 2021;48:1519-27.

Disclosure of Interests

None declared

POS0242 THE EFFECT OF ANTIMALARIALS ON THE OVERALL SAFETY AND PERSISTENCE OF TREATMENT WITH BIOLOGIC AGENTS OR JAK INHIBITORS IN RHEUMATOID ARTHRITIS

Background

Antimalarials (AM) are frequently part of the initial scheme of conventional synthetic DMARDs in the treatment of rheumatoid arthritis (RA), and have been associated with lower incidence of diabetes and better lipid profile in these patients (1). However, the role of AM in schemes involving biologic (b-) or targeted synthetic (ts-) DMARDs has been much less extensively studied. In addition, a recent large scale study (2) and a consensus article (1) casted doubt on the long-term cardiovascular safety of AM.

Objectives

To evaluate the association of concomitant use of AM with the overall safety and survival of

treatment course among patients receiving one or multiple courses of bDMARDs or tsDMARDs

Methods

BiobadaBrasil is a multicentric registry-based cohort study of Brazilian patients with rheumatic diseases starting their first bDMARD or tsDMARD (3). The present analysis includes RA patients recruited from Jan 2009 to Oct 2019, followed-up over one or multiple (up to six) courses of treatment (latest date, Nov 19, 2019). A treatment course is defined as a period during which the medication scheme does not change. The primary outcome was the incidence of serious adverse events (SAEs). Total and system-specific adverse events (AEs), treatment interruption for any reason, interruption due to AEs and due to inefficacy served as secondary outcomes. Negative binomial regression with generalized estimating equations (to calculate the incidence rate ratios [ÌRRs]) and extended (frailty) Cox proportional hazards models were used for statistical analyses (both types of analyses including time-varying covariates over multiple courses of treatment).

Results

In total, 1316 patients (2335 treatment courses, 6711 patient-years [PY]) were enrolled. The overall incidence of serious adverse events was 9.2/100 PY. AM were used over 354 courses (1254.5 PY) of therapy. The IRRs for the primary and secondary outcomes are presented in Table 1. AM were also associated with better treatment course survival (Figure 1), reducing the risk of interruption due to AEs (multivariate hazard ratio: 0.56, 95% CI: 0.39 to 0.81, P=0.002) and inefficacy (0.65, 0.48 to 0.87, P=0.003).

Figure 1.Table 1.

Univariate and multivariate incidence rate ratios (IRRs) of adverse events comparing use versus non-use (reference category) of antimalarials. Results are IRRs, 95% CIs, and P values.

Type of adverse event (n of events)Crude analysisAdjusted covariates*Serious adverse events (617)0.60 (0.41 to 0.87), P=0.0070.51 (0.37 to 0.69), P<0.001Any adverse event (3494)0.65 (0.54 to 0.77), P<0.0010.68 (0.57 to 0.81), P<0.001Cardiovascular‡Serious (52)1.04 (0.49 to 2.20), P=0.9241.06 (0.45 to 2.50), P=0.891Total (163)0.90 (0.59 to 1.38), P=0.6420.93 (0.59 to 1.45), P=0.737InfectionsSerious (277)0.78 (0.44 to 1.39), P=0.4040.53 (0.34 to 0.83), P=0.006Total (1400)0.77 (0.61 to 0.98), P=0.0330.75 (0.60 to 0.94), P=0.014Hepatic‡Total (66)0.20 (0.07 to 0.64), P=0.0070.16 (0.04 to 0.57), P=0.005Glicemic control-relatedTotal (34)0.74 (0.29 to 1.92), P=0.5400.73 (0.26 to 2.00), P=0.535DyslipidemiaTotal (83)0.60 (0.31 to 1.13), P=0.1140.55 (0.28 to 1.06), P=0.074

*Age, baseline DAS28, disease duration, gender, smoking, seropositivity (RF or anti-CCP), previous malignancy, interstitial lung disease, diabetes, hypertension, hypercholesterolemia, renal failure, ischemic cardiomyopathy, COPD, heart failure, concomitant use of each cs-, b-, and tsDMARDs, corticosteroids, starting year, osteoporosis, hepatitis B and C, and treatment sequence. ‡ Excluding infections.

Conclusion

Among RA patients on treatment with bDMARDs or tsDMARDs, concomitant use of antimalarials reduced the incidence of serious and total AEs, including infections and hepatic AEs, and prolonged treatment course survival. No significant increase in the risk of cardiovascular AEs was observed.

References

[1]Desmarais et al. Arthritis Rheumatol 2021;73:2151-60.

[2]Lane et al. Lancet Rheumatol 2020;2:e698–e711

[3]Bredemeier et al. J Rheumatol 2021;48:1519-27.

Disclosure of Interests

None declared

POS0747 MAPPING THE NATIONWIDE CLINICAL PROFILE AND PATTERNS OF CARE OF SLE IN BRAZIL – FINDINGS FROM THE MACUNAÍMA STUDY

Background:

Systemic lupus erythematosus (SLE) is an autoimmune disease with wide clinical variability. Brazil has vast regional diversity, both from an ethnic and socio-cultural point of view.

Objectives:

To map the clinical profile of SLE in Brazil and explore how this distribution is associated with regional disparities.

Methods:

This cross-sectional study (GSK Study 207353) evaluated 300 Brazilian patients ≥18 years old with SLE (American College of Rheumatology [ACR] criteria, 1997) who had been under SLE care for ≥1 year. Five SLE reference teaching facilities were selected, one in each of the following Brazilian regions: North (NO), Northeast (NE), Midwest (CO), Southeast (SE), and South (SU). Each region included 60 patients. Clinical and demographic characteristics, and patterns of care were measured through questionnaires completed by physicians or nurses. The SLE Disease Activity Index (SLEDAI) score described disease activity and the Systemic Lupus International Collaborating Clinics/ACR Damage Index (SDI) described damage accrual. To assess the potential association between regional disparities and clinical outcomes, a hospitalisation profile was described. A bootstrapping approach of logistic regression was used to explore potential factors associated with hospitalisation.

Results:

Overall, 92.3% of patients were female, with a mean (standard deviation; SD) age of 41.8 (12.7) years and a mean (SD) disease duration of 11.8 (7.9) years. Overall, 161 (53.7%) patients were of Latino origin; in the NO this proportion was 88%. White patients predominated in the SU (58.3%); and black patients in the SE (31.7%). The mean (SD) number of years of schooling was 11.3 (4.6), and was highest in the NO (14.2 [3.6]) and lowest in the SU (9.0 [4.0]; p<0.001). With regard to the distribution of the SLE clinical profile according to ACR criteria, arthritis was found in 221 patients and predominated in all regions (mean 73.7%), with a lower prevalence in the CO (40%; p<0.001; Figure 1A). The mean (SD) SLEDAI score was 4.33 (5.39) at the time of interview. The main contributing factors to disease activity, according to SLEDAI, were complement consumption (18%), arthritis (15.3%), and alopecia (15%). The SDI scale was scored for cataracts (15%), proteinuria (8.7%), and thrombosis (7.3%). Among the associated comorbidities, hypertension was predominant in the NO (35%; p=0.001). Smoking predominated in the SU (23%; p<0.001); obesity (27%; p=0.059) and dyslipidemia (35%; p=0.023), in the SE. Regarding patterns of care (Figure 1B), antimalarials were most frequently prescribed in the SE (88.3%) and the SU (91.7%). Corticosteroids prevailed in the NO (96.7%). The mean (SD) time between home and care facility was 4.5 (12.6) hours. Patients in the NO reported the longest transport time to reach the care facility (11.5 [25.4] hours; p<0.001). The hospitalisation rate during the study period was 21.3% across all regions, with no statistical difference between centres (p=0.651). Reasons for hospitalisation included disease activity (36 [12%]), infection (19 [6.3%]), surgery (10 [3.3%]), and management of clinical morbidities (6 [2.0%]). Hospitalisation was associated with ethnicity (p<0.016), occupational status (p<0.001), age (p=0.02), and the use of hydroxychloroquine (HCQ) or chloroquine (CQ; p<0.001).

Conclusion:

This nationwide study highlights ethnic, social, and patterns-of-care disparities among Brazilian patients with SLE. The modelling shows evidence that such disparities contribute to the divergent clinical spectrum observed in Brazil.

Funding:

GSK

Figure 1.

Distribution of the A) Brazilian SLE clinical profile according to the ACR Classification Criteria and B) Brazilian prescriptive profile for SLE treatment according to the use of immunosuppressive drugs, biological agents, and corticosteroids during the study (12 months)

ANA, antinuclear antibody

Acknowledgements:

Medical writing assistance was provided by Helen Taylor, Fishawack Indicia Ltd., UK, part of Fishawack Health, and was funded by GSK.

Disclosure of Interests:

Mirhelen Abreu Grant/research support from: GSK, Amgen, Biogen, Libbs, Odirlei Monticielo Speakers bureau: GSK, AbbVie, UCB, Roche, Novartis, Consultant of: GSK, AbbVie, Janssen, Vander Fernandes Speakers bureau: Janssen, Novartis, Roche, AbbVie, Pfizer, Grant/research support from: Novartis, GSK, Pfizer, Alexandre Cristovão Maiorano: None declared, Fernando dos Santos Beserra: None declared, Flavia Lamarao Employee of: GSK, Nathalie David Shareholder of: GSK, Employee of: GSK, Bruna de Veras Employee of: GSK, Blanca Bica: None declared, Domingos Sávio Nunes de Lima Grant/research support from: GSK, Marta Maria das Chagas Medeiros: None declared

POS1430 EPIDEMIOLOGY OF LUPUS NEPHRITIS IN BRAZIL: FINDINGS FROM THE MACUNAÍMA STUDY - A NATIONWIDE MULTICENTRIC STUDY

Background:

Lupus nephritis (LN) is one of the most serious organic manifestations of systemic lupus erythematosus (SLE). Ethnicity can contribute to disparities in the prevalence and disease activity of LN.

Objectives:

To assess the prevalence of LN in Brazilian patients with SLE and to determine factors associated with LN activity across the country.

Methods:

This cross-sectional study (GSK Study 207353) was carried out through face-to-face interviews and review of medical records (12-month study period). Adult patients with SLE (American College of Rheumatology [ACR] criteria, 1997) were included. Five SLE reference teaching centres were selected: North (NO), Northeast (NE), Midwest (CO), Southeast (SE), and South (SU). Patients with another disease whose morbidity surpassed SLE were excluded. LN was defined as reported in the medical record or history of confirmed renal biopsy; disease activity by pre-defined changes in SLE Disease Activity Index (SLEDAI) or the patient’s kidney disease during the study. Activity was assessed during (T0), 6 months before (T6), and 12 months before (T12) the interview. Systemic Lupus International Collaborating Clinics/ACR Damage Index score mapped damage accrual. Two pairings were performed, aiming to discriminate factors associated with LN and its activity, respectively. Matching technique was used to select similar individuals based on propensity scores, obtained from a logistic regression model. A bootstrapping method explored characteristic variables associated with the risk of progressing to LN.

Results:

Overall, 300 Brazilian patients with SLE were included in the study. Two groups were paired: LN group (N=150) and non-LN group (N = 141). The prevalence of LN in the paired sample (N=291) was 51.5%, with a disparity between centres (p<0.001; Figure 1A). Most patients were female (LN: 92.7%; non-LN: 94.3%) and the mean (standard deviation [SD]) age for the LN and non-LN groups was 39.46 (11.86) and 43.96 (12.18), respectively. History of serositis was associated with the presence of LN (42 [28.0%] vs 21 [14.9%] non-LN; p=0.010). Type IV histological class predominated in both groups, with no disparity between centres. Social disparities were noted between groups. Non-active workers prevailed among the LN group (115 [76.7%] vs 98 [69.5%] for non-LN, p=0.024).

When pairing for disease activity at T12, 73 (50.3%) patients with LN (N=145) had active disease. There was regional disparity in terms of disease activity (Figure 1B), with a predominance of active LN in the NO (28 [68.3%]) and SU (16 [55.2%], p=0.026). Type IV histological class was the component most associated with active LN (active: 32 [43.8%]; non-active: 11 [15.3%], p<0.001). Variation in SLEDAI during the study period discriminated between active and non-active LN. The mean (SD) SLEDAI score at T12 was substantially higher in those with active LN compared with non-active LN (7.18 [4.83] vs 2.47 [4.63], p<0.001). As for the pattern of care, corticosteroids users prevailed in those with active LN (62 [84.9%] vs 45 [62.5%] for non-active LN, p=0.004). There was no disparity in the use of immunosuppressants, with the exception of cyclophosphamide use, noted among 16 (21.9%) patients with active LN and 6 (8.3%) patients with non-active LN (p=0.041). Psychotropic or anticonvulsant use was higher in patients with non-active LN (32 [44.4%] vs 17 [23.3%] patients with active LN, p=0.012). Consultation with a neurologist was verified in 15 (20.8%) patients with non-active LN and 6 (8.2%) with active LN (p=0.055). Hospitalisation occurred in 17 patients with non-active (23.6%) and active (23.3%) LN.

Conclusion:

Disparities in the prevalence of LN and its activity were evident between the regions across Brazil, highlighting differences in clinical factors, regional factors, and patterns of care.

Funding:

GSK

Figure 1.

Prevalence of A) LN among regional centres, comparing them to disease activity profile and prescriptive practice, and B) Active and non-active LN according to prescriptive practiceCQ, chloroquine; HCQ, hydroxychloroquine*At T12

Acknowledgements:

Medical writing assistance was provided by Helen Taylor, Fishawack Indicia Ltd., UK, part of Fishawack Health, and was funded by GSK.

Disclosure of Interests:

Mirhelen Abreu Grant/research support from: GSK, Amgen, Biogen, Libbs, Odirlei Monticielo Speakers bureau: GSK, AbbVie, UCB, Roche, Novartis, Consultant of: GSK, AbbVie, Janssen, Vander Fernandes Speakers bureau: Janssen, Novartis, Roche, AbbVie, Pfizer, Grant/research support from: Novartis, GSK, Pfizer, Alexandre Cristovão Maiorano: None declared, Fernando dos Santos Beserra: None declared, Flavia Lamarao Employee of: GSK, Nathalie David Shareholder of: GSK, Employee of: GSK, Bruna de Veras Employee of: GSK, Blanca Bica: None declared, Domingos Sávio Nunes de Lima Grant/research support from: GSK, Marta Maria das Chagas Medeiros: None declared

POS0676 SURVIVAL OF THE FIRST COURSE OF BIOLOGIC OR JAK INHIBITOR IN RHEUMATOID ARTHRITIS: ASSOCIATION WITH THE CHOICE OF AGENT AND CONCOMITANT CONVENTIONAL SYNTHETIC DMARDS

Background:

After failure of conventional synthetic disease modifying anti-rheumatic drugs (csDMARDs) in the therapy of rheumatoid arthritis (RA), treatment may be escalated to biologic (bDMARDs) or JAK inhibitors (JAKi) (1). Analysis of drug survival can provide useful information on the effectiveness of these therapeutic schemes.

Objectives:

to evaluate the association of the choice of therapeutic agent with the survival of treatment course in RA patients receiving their first bDMARD or JAKi.

Methods:

BiobadaBrasil is a multicentric registry-based cohort study of Brazilian patients starting their first bDMARD/JAKi (2). This analysis includes RA patients recruited from Jan 2009 to Oct 2019, followed-up over the first course of treatment with a bDMARD/JAKi until censoring (latest date, Nov 19, 2019) or occurrence of the outcome of interest. A treatment course is defined as a period during which the medication scheme does not change, except for dose adjustments. The primary outcome was the interruption of treatment course for any reason (except for pregnancy or disease remission); interruption of treatment due to adverse events (AEs) or death and due to inefficacy served as secondary outcomes. Multivariate Cox proportional hazards models were used for analyses.

Results:

In total, 1177 patients (3800 patient-years [PY]) were enrolled. The overall incidence of treatment interruption was 17.5/100 PY. Adalimumab was the most frequently prescribed agent, followed by infliximab (n= 267). The hazards ratios (HR) of the primary and secondary outcomes are presented in Table 1. Figure 1 compares the survival of treatment curves of different bDMARDs/JAKi.

Table 1.

Hazard ratios (HR) of interruption of therapy course of each therapeutic agent (the reference category for bDMARDs/ JAKi is infliximab). Results are HR, 95% CIs, and P values*.

Agent (number of patients)Interruption for any reason (665 events)Interruption due to adverse events or death (196 events)Interruption due to inefficacy (319 events)Adalimumab (354)0.83 (0.68 to 1.01), P= 0.0620.68 (0.48 to 0.96), P=0.0291.08 (0.80 to 1.44), P=0.621Etanercept (257)0.81 (0.66 to 1.01), P=0.0630.56 (0.37 to 0.83), P=0.0040.93 (0.68 to 1.29), P=0.674Certolizumab (80)0.74 (0.47 to 1.16), P=0.1850.33 (0.13 to 0.86), P=0.0241.32 (0.74 to 2.35), P=0.350Golimumab (53)0.86 (0.53 to 1.38), P=0.5300.46 (0.18 to 1.19), P=0.1111.07 (0.53 to 2.15), P=0.849JAKi (tofacitinib) (59)0.54 (0.30 to 0.99), P=0.0470.19 (0.04 to 0.82), P=0.0260.89 (0.41 to 1.96), P=0.779Rituximab (48)0.87 (0.55 to 1.37), P=0.5400.48 (0.20 to 1.18), P=0.1090.58 (0.26 to 1.34), P=0.205Abatacept (30)0.52 (0.25 to 1.07), P=0.0770.46 (0.14 to 1.56), P=0.2150.46 (0.14 to 1.52), P=0.203Tocilizumab (29)0.29 (0.14 to 0.63), P=0.0020.40 (0.12 to 1.30), P=0.1260.28 (0.09 to 0.90), P=0.033Methotrexate (792)0.95 (0.79 to 1.14), P=0.5610.86 (0.62 to 1.19), P=0.3620.98 (0.75 to 1.28), P=0.860Leflunomide (497)1.17 (0.99 to 1.39), P=0.0611.44 (1.06 to 1.96), P=0.0201.02 (0.80 to 1.30), P=0.856Sulfasalazine (48)1.18 (0.80 to 1.75), P=0.4011.94 (1.07 to 3.54), P=0.0300.85 (0.45 to 1.59), P=0.605Antimalarials (230)0.80 (0.65 to 0.98), P=0.0270.67 (0.45 to 0.99), P=0.0430.67 (0.50 to 0.92), P=0.011

* All tests adjusted for other variables presented in the table and for age, baseline DAS28, disease duration, gender, smoking, seropositivity (RF/anti-CCP), previous malignancy, diabetes, hypertension, hypercholesterolemia, renal failure, ischemic cardiomyopathy, COPD, heart failure, use of corticosteroids, starting year, hypercholesterolemia, osteoporosis, hepatitis B and C.

Conclusion:

In our study, infliximab was related to an overall higher hazard of treatment course interruption than tolicizumab and tofacitinib, and higher hazard of interruption due to AEs than most other anti-TNF agents and tofacitinib. Maintaining antimalarials in patients receiving advanced therapies for RA may reduce interruption of treatment due to inefficacy and AEs.

Disclosure of Interests:

None declared

Can narration and guidance in video-enhanced learning improve performance on E-BLUS exercises?

Introduction

This study aimed to compare trainees’ laparoscopic performance concerning the peg-transfer (PT) and needle-guidance (NG) exercises after watching the original European Basic Laparoscopic Urologic Skills (E-BLUS) video or after watching a video-mentored tutorial (VMT) with ‘tips and tricks’, narration and didactic illustrations.

Material and methods

An experimental, unblinded, parallel, 2-intervention, 2-period randomized trial with an allocation ratio of 1:1 was conducted. Forty-two participants were randomized into 2 groups. Prior to task initiation, Group 1 watched the VMT in both trials and Group 2 watched, firstly, the original E-BLUS examination video and, in the second trial, the VMT. Each participant performed 2 trials for each exercise. Outcome measures were task time and total number of errors.

Results

In the first period, participants who visualized the PT and NG VMT had fewer errors than participants who visualized the E-BLUS video (p = 0.001 and p = 0.014, respectively). In the second period, after watching the VMT, a decrease in the total number of errors in PT and NG exercises was observed in the participants who previously watched the E-BLUS video (p = 0.001 and p = 0.002, respectively). In the second period, a decrease in median task time was observed for Group 1 and 2 after watching the PT VMT (p ≤0.001 and p = 0.003, respectively) and NG VMT (p = 0.005 and p = 0.01, respectively).

Conclusions

The use of VMT can lead to a smaller number of errors and, if coupled with deliberate practice, could lead to a shorter task time in exercise performance among participants with no previous laparoscopic experience.

Are there associations between early emotional trauma and anxiety disorders? Evidence from a systematic literature review and meta-analysis

BACKGROUND

Previous studies indicate a possible association between early emotional trauma (EET) and the development of anxiety disorders (ADs) in adult life. However, no previous studies have compiled the findings of such studies and analyzed their statistical significance. Therefore, the objective of this study was to conduct a systematic literature review and meta-analysis to determine possible associations between EET and three ADs (panic, generalized anxiety, and social anxiety disorders).

METHODS

A systematic search was conducted in PubMed, PsycInfo, and Scielo with no publication date limitations. A total of 2127 studies were found, 32 studies of which were selected for the systematic review and 13 studies of which were selected for the meta-analysis.

RESULTS

High prevalence rates of different EETs were observed among the individuals with ADs (median: 18%-45%). The results of the meta-analysis indicated that individuals with EETs were 1.9- to 3.6-fold more likely to develop ADs compared with a control group of healthy individuals. Emotional traumas were the main risk factor for social anxiety disorder. However, no specific associations were found for the other ADs.

CONCLUSIONS

EET is a risk factor for ADs, underscoring the importance of preventive measures to combat the development of these disorders. Moreover, the identification of EETs among patients with ADs is essential for implementing remedial measures to minimize the impact and damage arising from this association by decreasing the risk and severity of symptoms and to improve the response rate to treatment of ADs.

The effect of levodopa on postural stability evaluated by wearable inertial measurement units for idiopathic and vascular Parkinson's disease

BACKGROUND

Postural stability analysis has shown that postural control is impaired in untreated idiopathic Parkinson's disease (IPD), even in the early stages of the disease. Vascular Parkinson's disease (VPD) lacks consensus clinical criteria or diagnostic tests. Moreover, the levodopa effect on postural balance remains undefined for IPD and even less so for VPD.

OBJECTIVE

To characterize postural stability, using kinematic analysis with wearable inertial measurement units, in IPD and VPD patients without clinical PI, and to subsequently analyze the response to levodopa.

METHODS

Ten patients with akinetic-rigid IPD and five patients with VPD were included. Clinical and postural stability kinematic analysis was performed before and after levodopa challenge, on different standing tasks: normal stance (NS), Romberg eyes open (REO) and Romberg eyes closed.

RESULTS

In the "off state", VPD patients had higher mean distances and higher maximal distance of p ostural sway on NS and REO tasks, respectively. VPD patients maintained a higher range of anterior-posterior (AP) postural sway after levodopa. In the absence of PI and non-significant differences in UPDRS-III, a higher mPIGD score in the VPD patients was mainly due to gait disturbance. Gait disturbance, and not UPDRS-III, influenced the degree of postural sway response to levodopa for VPD patients.

CONCLUSION

Quantitative postural sway evaluation is useful in the investigation of Parkinsonian syndromes. VPD patients have higher AP postural sway that is correlated with their gait disturbance burden and also not responsive to levodopa. These observations corroborate the interconnection of postural control and locomotor networks.

A high pressure x-ray photoelectron spectroscopy study of CO oxidation over Rh(100)

We have studied the oxidation of CO over Rh(100) using high pressure x-ray photoelectron spectroscopy under CO and O2 pressures ranging from 0.01 to 1 mbar. The results show a very low or no conversion for the CO covered surface found at low temperatures, while the activity rises slightly when the temperature is high enough for some CO to desorb, exposing surface sites for dissociative O2 adsorption. As the temperature is increased further, more CO desorbs and oxygen replaces CO as the dominating species at the surface. At the same time we find a sudden increase in the reactivity, such that all CO that reaches the surface is instantly transformed into CO2. We find that the O coverage in the active state is highly dependent on the total pressure and, although we do not detect any presence of a surface oxide as in previous surface x-ray diffraction studies, the highest O coverage indicates that the surface is close to being oxidized.

Postural stability analysis with inertial measurement units in Alzheimer's disease

Background

The cause of frequent falls in patients with Alzheimer's disease (AD) is still not well understood. Nevertheless, balance control and sensory organization are known to be critical for moving safely and adapting to the environment.

Methods

We evaluated postural stability in 20 AD patients (11 fallers and 9 nonfallers) and 16 healthy controls with an inertial measurement unit (triaxial accelerometers and gyroscopes) attached to the center of mass (COM) in different balance conditions (Romberg on flat surface and frontward/backward-inclined surface, with or without visual suppression) in a motor lab.

Results

In AD patients, the group of fallers showed a different kinetic pattern of postural stability characterized by higher vulnerability to visual suppression, higher total/maximal displacement and a mediolateral/anteroposterior range of sway, and a consequent need for more corrections of COM pitch and roll angles.

Conclusion

Further studies are needed to consolidate the normative values of the discriminatory kinetic variables with the potential of inclusion in a multifactorial analysis of the risk of falls. Nevertheless, these results highlight signs of impairment of central postural control in AD, which may require early therapeutic intervention.

Anal canal gastrointestinal stromal tumors: Case report and literature review

Gastrointestinal stromal tumors (GIST) are an uncommon group of tumors of mesenchymal origin. GIST of the anal canal is extremely rare. At present, only 10 cases of c-kit positive anal GIST have been reported in the literature. There is no widely accepted treatment approach for this neoplasia. Literature is sparse on imaging evaluation of anal canal GIST, usually described as a lesion in the intersphincteric space. We describe the case of a 73-year-old man with a mass in the anal canal, and no other symptoms. Endoanal ultrasound and magnetic resonance imaging showed a well circumscribed solid nodule in the intersphincteric space. The patient was treated by local excision. Gross pathological examination showed a 7 cm × 3.5 cm × 3 cm mass, and histological examination showed a proliferation of spindle cells, with prominent nuclear palisading. The mitotic count was of 12 mitoses/50 HPF. The tumor was positive for KIT protein, CD34 and vimentin in the majority of cells, and negative for desmin and S100. A diagnosis of GIST, with high risk aggressive behavior was made. An abdomino-perineal resection was discussed, but refused. The follow-up included clinical evaluation and anal ultrasound. After 5 years the patient is well, with maintained continence and no evidence of local recurrence.

Verbal definitions of familiar objects in blind children reflect their peculiar perceptual experience

BACKGROUND

The aim of the present study was to examine to what extent the verbal definitions of familiar objects produced by blind children reflect their peculiar perceptual experience and, in consequence, differ from those produced by sighted children.

METHODS

Ninety-six visually impaired children, aged between 6 and 14 years, and 32 age-matched sighted children had to define 10 words denoting concrete animate or inanimate familiar objects.

RESULTS

The blind children evoked the tactile and auditory characteristics of objects and expressed personal perceptual experiences in their definitions. The sighted children relied on visual perception, and produced more visually oriented verbalism. In contrast, no differences were observed between children in their propensity to include functional attributes in their verbal definitions.

CONCLUSIONS

The results are discussed in line with embodied views of cognition that postulate mandatory perceptuomotor processing of words during access to their meaning.

Ferromagnetism induced by oxygen and cerium vacancies above the percolation limit in CeO2

We studied the structural, chemical and magnetic properties of non-doped ceria (CeO(2)) thin films electrodeposited on silicon substrates. Experimental results confirm that the observed room temperature ferromagnetism is driven by both cerium and oxygen vacancies. We investigated ceria films presenting vacancy concentrations well above the percolation limit. Irradiation experiments with neon ions were employed to generate highly oxygen defective CeO(2-δ) structures. X-ray photoelectron spectroscopy and x-ray absorption near-edge structure spectroscopy were used to estimate the concentration of Ce(3+) sites in the films, which can reach up to 50% of Ce(3+) replacing Ce(4+), compared to a stoichiometric CeO(2) structure. Despite the increment of structural disorder, we observe that the saturation magnetization continuously increases with Ce(3+) concentration. Our experiments demonstrate that the ferromagnetism observed in ceria thin films, highly disordered and oxygen-deficient, preserving the fluorite-type structure only in a nanometer scale, remains intrinsically stable at room temperature.

Pneumonia eosinofílica aguda com evolução para síndroma de dificuldade respiratória aguda: caso clínico

The Authors present a case of acute eosinophilic pneumonia (AEP) associated with severe acute respiratory distress syndrome in a previously healthy young adult, medicated with nitrofurantoin. AEP must be included in the differential diagnosis of community adquired pneumonia, as well as a cause of acute respiratory distress syndrome; its diagnosis is suggested by the presence of eosinophilic alveolitis in bronchoalveolar lavage fluid. The early diagnosis of AEP and corticosteroid therapy may be lifesaving.

Acute necrotizing esophagitis: a large retrospective case series

BACKGROUND AND STUDY AIMS

Acute necrotizing esophagitis is a rarely described entity. Its incidence has not yet been established, and its multifactorial etiology remains unknown. The aim of the present study was to establish the incidence, clinical presentation, endoscopic course, accompanying factors, and pathogenesis of the condition.

PATIENTS AND METHODS

A retrospective analysis of clinical, laboratory, endoscopic and histological data and the clinical course in 29 patients with acute necrotizing esophagitis was carried out over a 5-year period.

RESULTS

Acute necrotizing esophagitis was observed in 29 of 10 295 upper gastrointestinal endoscopies (0.28 %) carried out during the 5-year period. The average age of the patients was 75.24 years (range 40 - 91), and they were predominantly male. Eighty-three percent of the patients had comorbid conditions. In all cases, acute necrotizing esophagitis became evident with upper gastrointestinal bleeding, without hemodynamic stabilization in the majority of cases (75.9 %). The lesions predominantly affected the lower two-thirds of the esophagus (59 %), and there were coexisting abnormal endoscopic findings in 83 % of cases. Empirical supportive therapy, including oral nutritional rest, omeprazole, sucralfate (15 cases) and broad-spectrum antibiotics (7 cases) was provided. The condition resolved in all patients. Ten patients in the group died of other causes (coexisting illnesses).

CONCLUSIONS

Acute necrotizing esophagitis was more commonly recognized than has previously been reported. It is a serious clinical entity that should be considered in the differential diagnosis of upper gastrointestinal bleeding, particularly in elderly patients. The prognosis depends more on the patient's advanced age and on comorbid illnesses than on the course of the esophageal lesions, which resolved in all patients in this series.

[Drowning: tematic review and casuistic analysis in the Intensive Care Medicine Service of University Hospital of Coimbra (1989-2002)]

Drowning is a major cause of accidental deaths, especially in childrens. In this review (part one) the definition, epidemiology, pathophysiology and treatments (with an enphasis on the ressuscitation) are discussed. From 1989 to 2002 part two) we recorded the clinical course of the 19 patients vitims of submersion admited to our ICU. We conclued that the majority of patients are young (mean = 37,3 years), mortality is high (26%), but the complete recovery is possible (63%). The cardio-respiratory arrest or Glasgow Coma Scale < or = 5 were related with poor prognosis, only with 3 survivors (1 without sequels). Trauma associated lesions were observed only in one patient.

Association between polymorphisms in the fibrinogen alpha- and beta-genes on the post-trauma fibrinogen increase

Fibrinogen is an acute phase reactant, and therefore its plasma levels increase after severe injury. Polymorphisms in the fibrinogen alpha and beta genes have been found to be associated with plasma levels of fibrinogen, and it has also been suggested that they are associated with the fibrinogen increase in acute phase situations. In forty-five consecutive patients admitted to the Intensive Care Unit after acute cranial or thoracic trauma, we investigated the influence of four polymorphisms at the fibrinogen loci (-455G/A and BclI (beta gene), TaqI and T/A312 (alpha gene)) on the post-trauma increase of the fibrinogen levels. At admission, fibrinogen levels were comparable in the patients with the different genotypes for the four polymorphisms studied. However, patients carrying the -455A allele of the -455G/A polymorphism had a significantly wider variation and higher peak levels of fibrinogen, during their stay at the intensive care unit, than did the -455GA homozygotes (5.1 g/l (SD 1.3) and 5.9 g/l (SD 1.0), respectively, p<0.05). Such difference was not found for the other studied polymorphisms. The present study suggests that the increase of fibrinogen level in acute phase situations like severe trauma is associated with the beta-gene -455G/A polymorphism.