Nonpharmacological interventions for 'no-option' refractory angina patients

Refractory angina pectoris (RAP) defined as chronic anginal chest pain because of coronary artery disease (CAD) is a major problem. The increase in the number of patients with RAP in recent years is because of the increasing aging population and improved survival rates among patients with CAD. Management of patients with RAP is often extremely challenging. In this review, we present several interventional approaches for RAP, including device therapies, lifestyle intervention, and cell therapies. Some of these treatments are currently used in the management of RAP, whereas other treatments are under investigation.

Treatment of Scleroderma-Related Microstomia Using Hyaluronic Acid: An Interventional Study

Systemic sclerosis (SSc) or scleroderma is a rare, systemic, autoimmune connective tissue disease. It causes increased collagen synthesis, leading to multi-organ sclerosis, including the skin and joints. Patients' overall health and quality of life are harmed dramatically. Involvement of the face and, especially, the oral opening can limit patients' ability to speak and eat, oral hygiene, and cosmetic appearance. Profhilo® (NAHYCO®) is an over-the-counter product consisting of pure hyaluronic acid. It is used to improve skin quality by increasing collagen production and adipocyte vitality. This interventional study evaluated the results of perioral injections of hyaluronic acid in terms of improved skin quality, elasticity, and increased oral opening. Patients diagnosed with SSc received an injection of one syringe of Profhilo® (2 mL of hyaluronic acid) at each of two clinic visits at one-month intervals. The oral opening was measured between the upper and lower central incisors before and after treatment. Quality of life was assessed using the modified Rodnan Skin Score and Health Assessment Questionnaire-Disability Index. A total of 14 patients received the first treatment, and 11 received the second treatment. The mean oral opening increased from 31.6 mm (range 17-50 mm) prior to therapy to 35.8 mm (range 21-56) 2 months following the second injection. Statistical analysis showed that there was a significant increase in the oral opening as observed one week (36.2 mm, p = 0.011), one month (36.2 mm, p = 0.007), and three months (31.6 mm, p = 0.023) after the second injection, at the 5-month follow-up. Treatment of SSc patients' perioral area with Profhilo® can result in significant improvements in oral opening and quality of life.

Prevalence of anti-synthetase antibodies among systemic sclerosis patients

BACKGROUND

we aimed to estimate the prevalence of Amino acyl-transfer ribonucleic acid synthetase antibodies (Anti-ARS); myositis specific antibodies, among patients with systemic sclerosis (SSc), to evaluate the clinical associations of anti-ARS antibodies in SSc patients and to identify risk factors for development of interstitial lung disease (ILD) in SSc.

METHODS

A prospective study of 71 systemic sclerosis patients in our rheumatology clinic in Israel. Sera were tested for myositis antibodies. Data on patients clinical and serological manifestations and treatment were collected and compared according to anti-ARS antibodies and ILD.

RESULTS

Prevalence of anti-ARS antibodies was 6% (4/71) with anti PL-7, anti- OJ and Jo-1 positivity. Anti Ro-52 was found in 27%, anti-PM/Scl 75, anti-PM/Scl 100 and anti-SRP in 6%, anti-Ku in 3%, anti-Mi-2 beta and anti-Mi-2 alfa in 4%, anti- NXP2 and anti-TIF1gamma in 1%. ILD complication was observed in 42% of patients and was associated with anti RNAP-III, anti Scl-70 and Anti-ARS antibodies. In multiple logistic regression, anti Scl-70 was associated with 6-fold higher risk for ILD.

CONCLUSION

Anti-ARS antibodies were observed in 6% of SSc patients. All of them had ILD. Due to the low prevalence of anti-ARS, this study could not describe clinical associations of anti-ARS antibodies in SSc patients.

Efficacy and Safety of Lenabasum, a Cannabinoid Type 2 Receptor Agonist, in a Phase 3 Randomized Trial in Diffuse Cutaneous Systemic Sclerosis

OBJECTIVE

This phase 3 study was undertaken to investigate the efficacy and safety of lenabasum, a cannabinoid type 2 receptor agonist, in patients with diffuse cutaneous systemic sclerosis (dcSSc).

METHODS

A multinational double-blind study was conducted in 365 dcSSc patients who were randomized and dosed 1:1:1 with lenabasum 20 mg, lenabasum 5 mg, or placebo, each twice daily and added to background treatments, including immunosuppressive therapies (IST).

RESULTS

The primary end point, the American College of Rheumatology combined response index in dcSSc (CRISS) at week 52 for lenabasum 20 mg twice a day versus placebo, was not met, with CRISS score of 0.888 versus 0.887 (P = 0.4972, using mixed models repeated measures [MMRM]). The change in the modified Rodnan skin thickness score (MRSS) at week 52 for lenabasum 20 mg twice a day versus placebo was -6.7 versus -8.1 (P = 0.1183, using MMRM). Prespecified analyses showed higher CRISS scores, greater improvement in MRSS, and lower decline in forced vital capacity in patients on background mycophenolate and those who were taking IST for ≤1 year. No deaths or excess in serious or severe adverse events related to lenabasum were observed.

CONCLUSION

A benefit of lenabasum in dcSSc was not demonstrated. Most patients were treated with background IST, and treatment with mycophenolate mofetil in particular was associated with better outcomes. These findings support the use of IST in the treatment of dcSSc and highlight the challenge of demonstrating a treatment effect when investigational treatment is added to standard of care IST. These findings have relevance to trial design in SSc, as well as to clinical care.

Photo-induced crosslinking uncovers an antiparallel strand orientation in heterodimeric (EIAALEK)3/(KIAALKE)3 and (EIAALEK)3/(RIAALRE)3 coiled-coil systems

We describe for the first time the co-existence of the parallel and antiparallel conformation of the heterodimeric E3/K3 and E3/R3 coiled-coil systems in solution. The introduction of a furanylated amino acid in the (EIAALEK)₃ sequence allowed, upon photo-induced covalent crosslinking, freezing of the respective coiled-coil complexes present in solution. The occurrence of both parallel and antiparallel conformations in solution was supported by computational simulations and further confirmed by fluorescence experiments based on pyrene-pyrene stacking.

Functional IgG Autoantibodies against Autonomic Nervous System Receptors in Symptomatic Women with Silicone Breast Implants

The association between the clinical picture of symptomatic women with silicone breast implants (SBI) and dysregulated immunity was in dispute for decades. In the current study, we describe for the first time the functional activity of purified IgG antibodies derived from symptomatic women with SBIs (suffering from subjective/autonomic-related symptoms), both in vitro and in vivo. We found that IgGs, derived from symptomatic women with SBIs, dysregulate inflammatory cytokines (TNFα, IL-6) in activated human peripheral blood mononuclear cells, compared to healthy-women-derived IgGs. Importantly, behavioral studies conducted following intracerebroventricular injection of IgGs derived from symptomatic women with SBIs (who have dysregulated circulating level of IgG autoantibodies directed against autonomic nervous system receptors) into mice brains demonstrated a specific and transient significant increment (about 60%) in the time spent at the center of the open field arena compared with mice injected with IgG from healthy women (without SBIs). This effect was accompanied with a strong trend of reduction of the locomotor activity of the SBI-IgG treated mice, indicating an overall apathic-like behavior. Our study is the first to show the potential pathogenic activity of IgG autoantibodies in symptomatic women with SBIs, emphasizing the importance of these antibodies in SBI-related illness.

αvβ3 Integrin as a Link between the Development of Fibrosis and Thyroid Hormones in Systemic Sclerosis

Systemic sclerosis (SSc) is an autoimmune disease characterized by fibrosis of the skin and internal organs. Key players mediating fibrosis are myofibroblasts (MF) that, following transforming growth factor β (TGFβ) exposure, produce a collagen-rich extracellular matrix (ECM) that induces myofibroblast differentiation. Myofibroblasts express αvβ3 integrin (a membrane receptor for thyroid hormones) and miRNA-21 that promotes deiodinase-type-3 expression (D3), causing the degradation of triiodothyronine (T3) that attenuates fibrosis. We hypothesized that αvβ3 affects the fibrotic processes through its thyroid hormones (THs) binding site. To test this, dermal fibroblasts (DF) were cultured with/without TGFβ and removed with a base, leaving only normal/fibrotic ECMs in wells. Then, DF were cultured on the ECMs with/without tetrac (αvβ3 ligand, T4 antagonist), and evaluated for pro-fibrotic characteristics, αvβ3, miRNA-21, and D3 levels. Blood free-T3 (fT3), miRNA-21 levels, and the modified Rodnan skin score (MRSS) were evaluated in SSc patients. We found that the "fibrotic-ECM" significantly increased the pro-fibrotic characteristics of DF and the levels of miRNA-21, D3, and αvβ3, compared to the "normal-ECM." Tetrac significantly inhibited the effects of the "fibrotic-ECM" on the cells. In accordance with tetrac's effect on D3/miRNA-21, a negative correlation was found between the patients' fT3 to miRNA-21 levels, and to the development of pulmonary arterial hypertension (PAH). We conclude that occupying the THs binding site of αvβ3 may delay the development of fibrosis.

Enhancement of the spectral broadening efficiency for circular polarization states in the high absorption regime for Gaussian and doughnut-shaped beams in fused silica

We experimentally investigate the spectral broadening in fused silica in the multiphoton absorption regime. Under standard conditions of laser irradiation, linear polarization of laser pulses is more advantageous for supercontinuum generation. However, with high non-linear absorption, we observe more efficient spectral broadening for circular polarizations for both Gaussian and doughnut-shaped beams. The multiphoton absorption in fused silica is studied by measuring the total transmission of laser pulses and by the intensity dependence of the self-trapped exciton luminescence observation. The strong polarization dependence of multiphoton transitions fundamentally affects the broadening of the spectrum in solids.

Catastrophic antiphospholipid syndrome in lupus-associated immune thrombocytopenia treated with eltrombopag A case series and literature review

BACKGROUND

Eltrombopag, a thrombopoietin receptor (TPO-R) agonist, is considered a second-line treatment for patients with refractory immune thrombocytopenia (ITP). Systemic lupus erythematosus (SLE) is frequently associated with ITP. In some cases, thrombocytopenia in SLE patients is attributed to concurrent antiphospholipid antibodies (APLA). Currently, data regarding treatment with TPO-R agonists for ITP in SLE or APLA patients are limited. The incidence of SLE flare or antiphospholipid syndrome while on TPO-R agonists has not been well-studied.

CASES

We report 2 cases of female patients with SLE and concurrent triple positive APLA, without thrombotic events in their medical history, in our rheumatology clinic, who were treated for refractory ITP with eltrombopag. Both developed catastrophic antiphospholipid syndrome a few weeks after beginning treatment with eltrombopag. They were admitted to the intensive care unit and treated with solumedrol, plasmapheresis, anticoagulation and rituximab.

CONCLUSIONS

We describe a severe possible side-effect of eltrombopag as a trigger of catastrophic antiphospholipid syndrome, a rare initial manifestation of antiphospholipid syndrome, in SLE patients with APLA. We suggest that APLA should be tested before initiating eltrombopag in patients with SLE-associated ITP. The safety of this treatment should be considered in these cases.

Myonuclear alterations associated with exercise are independent of age in humans

Age-related decline in skeletal muscle structure and function can be mitigated by regular exercise. However, the precise mechanisms that govern this are not fully understood. The nucleus plays an active role in translating forces into biochemical signals (mechanotransduction), with the nuclear lamina protein lamin A regulating nuclear shape, nuclear mechanics and ultimately gene expression. Defective lamin A expression causes muscle pathologies and premature ageing syndromes, but the roles of nuclear structure and function in physiological ageing and in exercise adaptations remain obscure. Here, we isolated single muscle fibres and carried out detailed morphological and functional analyses on myonuclei from young and older exercise-trained individuals. Strikingly, myonuclei from trained individuals were more spherical, less deformable, and contained a thicker nuclear lamina than those from untrained individuals. Complementary to this, exercise resulted in increased levels of lamin A and increased myonuclear stiffness in mice. We conclude that exercise is associated with myonuclear remodelling, independently of age, which may contribute to the preservative effects of exercise on muscle function throughout the lifespan. KEY POINTS: The nucleus plays an active role in translating forces into biochemical signals. Myonuclear aberrations in a group of muscular dystrophies called laminopathies suggest that the shape and mechanical properties of myonuclei are important for maintaining muscle function. Here, striking differences are presented in myonuclear shape and mechanics associated with exercise, in both young and old humans. Myonuclei from trained individuals were more spherical, less deformable and contained a thicker nuclear lamina than untrained individuals. It is concluded that exercise is associated with age-independent myonuclear remodelling, which may help to maintain muscle function throughout the lifespan.

The Coronary Sinus Reducer Stent for the Treatment of Refractory Angina Pectoris: From the Conception of Innovation to Clinical Application

The Neovasc Coronary Sinus Reducer Stent (CSRS) was developed for the treatment of patients who continue to suffer from disabling symptoms despite optimal medical therapy. This patient population with refractory angina symptoms is expected to grow, since life expectancy of individuals with atherosclerotic coronary artery disease is increasing. In this paper, we discussed the development of a novel device the CSRS and the upside-down strategy to rebuild a retrograde coronary pressure that was attenuated by the atherosclerotic disease.

Micro and nano-scale compartments guide the structural transition of silk protein monomers into silk fibers

Silk is a unique, remarkably strong biomaterial made of simple protein building blocks. To date, no synthetic method has come close to reproducing the properties of natural silk, due to the complexity and insufficient understanding of the mechanism of the silk fiber formation. Here, we use a combination of bulk analytical techniques and nanoscale analytical methods, including nano-infrared spectroscopy coupled with atomic force microscopy, to probe the structural characteristics directly, transitions, and evolution of the associated mechanical properties of silk protein species corresponding to the supramolecular phase states inside the silkworm's silk gland. We found that the key step in silk-fiber production is the formation of nanoscale compartments that guide the structural transition of proteins from their native fold into crystalline β-sheets. Remarkably, this process is reversible. Such reversibility enables the remodeling of the final mechanical characteristics of silk materials. These results open a new route for tailoring silk processing for a wide range of new material formats by controlling the structural transitions and self-assembly of the silk protein's supramolecular phases.

Steroid treatment suppresses the CD4+ T-cell response to the third dose of mRNA COVID-19 vaccine in systemic autoimmune rheumatic disease patients

Prolonged steroid treatment has a suppressive effect on the immune system, however, its effect on the cellular response to mRNA vaccine is unknown. Here we assessed the impact of prolonged steroid treatment on the T-cell and humoral response to the SARS-CoV-2 spike (S) peptide following the third dose of the BNT162b2 vaccine in systemic autoimmune rheumatic disease patients. We found that CD4 T-cell response to the S peptide in patients on high-dose long-term steroid treatment showed significantly less S-peptide specific response, compare to low-dose or untreated patients. Remarkably, these results were not reflected in their humoral response, since almost all patients in the cohort had sufficient antibody levels. Moreover, S-peptide activation failed to induce significant mRNA levels of IFNγ and TNFα in patients receiving high-dose steroids. RNA-sequencing datasets analysis implies that steroid treatments' inhibitory effect of nuclear factor kappa-B signaling may interfere with the activation of S-specific CD4 T-cells. This reveals that high-dose steroid treatment inhibits T-cell response to the mRNA vaccine, despite having sufficient antibody levels. Since T-cell immunity is a crucial factor in the immune response to viruses, our findings highlight the need for enhancing the efficiency of vaccines in immune-suppressive patients, by modulation of the T-cell response.

Immunogenicity and safety of the mRNA-based BNT162b2 vaccine in systemic autoimmune rheumatic diseases patients

BACKGROUND

The COVID-19 outbreak has led to the rapid development and administration of the COVID-19 vaccines worldwide. Data about the immunogenicity and adverse effects of the vaccine on patients with systemic autoimmune rheumatic diseases (SARDs) is emerging.

AIM

To evaluate Pfizer/BioNTech (BNT162b2) mRNA-based vaccine second-dose immunogenicity and safety, and the relation between them, in patients with SARDs.

METHODS

A total of one hundred forty tow adults who received two doses of the BNT162b2 vaccine were included in the study. The SARDs group included Ninety-nine patients and the control group (forty-three participants) comprised a mixture of healthy participants and patients who were seen at the rheumatology clinic for non-SARDs. Anti-SARS-CoV-2 IgG antibodies against the Spike protein were evaluated using a SARS-CoV-2 IgG immunoassay. A level of > 150 AU/mL was considered positive. An adverse effects questionnaire was given to the participants upon their first visit to the clinic after their BNT162b2 vaccination.

RESULTS

Of the 142 participants, 116 were seropositive (81.7%) and 26 (18.3%) were seronegative. Of the seronegative participants, 96.2% were SARDs patients. The proportion of seropositivity in the SARDs patients treated with any immunosuppressant was significantly lower (69.9%) compared to the control group and SARDs patients not receiving immunosuppressants (96.8%). A significant negative correlation between seronegativity and treatment with rituximab, mycophenolate mofetil (MMF), and prednisone was found in the SARDs group (p = 0.004, 0.044, 0.007 respectively). No fever was observed following the BNT162b2 vaccine in seronegative patients, and the frequency of musculoskeletal adverse effects upon the second dose of the BNT162b2 vaccine was significantly higher in seropositive compared to seronegative patients and in the control group compared to the SARDs patients (p = 0.045, p = 0.02 respectively).

CONCLUSION

A decline in the immunogenicity to the second dose of BNT162b2 mRNA is seen in patients with SARDs, especially in patients treated with rituximab, MMF, and prednisone. Adverse effects of the vaccine including fever and musculoskeletal symptoms might be a signal for the acquisition of immunity in those patients.

KEY POINTS

• BNT162b2 mRNA vaccine is less immunogenic in SARDs patients compared to the control group. • Rituximab, prednisone, and mycophenolate mofetil significantly reduced immunogenicity to the vaccine. • There is a correlation between immunogenicity and adverse effects of the vaccine.

Thyroid Disorders in Patients with Systemic Sclerosis: Biochemical and Sonographic Characteristics. A Prospective Cohort Study

BACKGROUND

Patients with systemic sclerosis (SSc) are at increased risk for autoimmune thyroid diseases, but information regarding thyroid nodules and cancer in SSc is scarce. Objectives: To evaluate the thyroid gland in patients with SSc at a single Israeli center.

METHODS

Thyroid workup was conducted in consecutive SSc patients: thyroid-stimulating hormone (TSH), free thyroxine (fT4), anti-thyroid peroxidase, and anti-thyroglobulin antibodies, as well as thyroid ultrasound and fine needle aspiration (FNA) when appropriate.

RESULTS

Fifty patients, mean age 51.3 ± 13.5 years (44 women) were evaluated. Ten were previously diagnosed with thyroid disease. Median TSH level was 2.0 (normal range 0.23-4 mIU/l) and median fT4 level was 1.0 (normal range 0.8-2.0 ng/dL). Among the 40 thyroid disorder-naive patients, 3 had subclinical hypothyroidism and 5 had positive anti-thyroid antibodies; 22 (44%) had 1-6 thyroid nodules, which were ≥ 1 cm in 12 (24%). Accordingly, six patients underwent FNA, and five were diagnosed as colloid nodules and one as papillary carcinoma.

CONCLUSIONS

New cases of clinically significant autoimmune thyroid disease were not detected in our cohort of patients with SSc. Nevertheless, almost half had thyroid nodules. The clinical significance of these findings and their relation to thyroid cancer remains to be determined.

MiRNAs in Systemic Sclerosis Patients with Pulmonary Arterial Hypertension: Markers and Effectors

Background: Pulmonary arterial hypertension (PAH) is a major cause of death in systemic sclerosis (SSc). Early detection may improve patient outcomes. Methods: We searched for circulating miRNAs that would constitute biomarkers in SSc patients with PAH (SSc-PAH). We compared miRNA levels and laboratory parameters while evaluating miRNA levels in white blood cells (WBCs) and myofibroblasts. Results: Our study found: 1) miR-26 and miR-let-7d levels were significantly lower in SSc-PAH (n = 12) versus SSc without PAH (SSc-noPAH) patients (n = 25); 2) a positive correlation between miR-26 and miR-let-7d and complement-C3; 3) GO-annotations of genes that are miR-26/miR-let-7d targets and that are expressed in myofibroblast cells, suggesting that these miRNAs regulate the TGF-β-pathway; 4) reduced levels of both miRNAs accompanied fibroblast differentiation to myofibroblasts, while macitentan (endothelin receptor-antagonist) increased the levels. WBCs of SSc-noPAH and SSc-PAH patients contained equal amounts of miR-26/miR-let-7d. During the study, an echocardiograph that predicted PAH development, showed increased pulmonary artery pressure in three SSc-noPAH patients. At study initiation, those patients and an additional SSc-noPAH patient, who eventually developed PAH, had miR-let-7d/miR-26 levels similar to those of SSc-PAH patients. This implies that reduced miR-let-7d/miR-26 levels might be an early indication of PAH. Conclusions: miR-26 and miR-let-7d may be serological markers for SSc-PAH. The results of our study suggest their involvement in myofibroblast differentiation and complement pathway activation, both of which are active in PAH development.

Low dose naloxone for pruritus in systemic sclerosis: Case series and literature review

RATIONALE

Pruritus is a common symptom in patients with systemic sclerosis and has a tremendous effect on the quality of life. Nevertheless, current therapeutic options are limited. The pathogenesis of pruritus in systemic sclerosis is not completely understood; however, opiate-mediated neurotransmission has been postulated to be involved.

PATIENT CONCERNS AND DIAGNOSIS

We describe 4 female patients with systemic sclerosis suffering from severe pruritus, with an average 5D-itch score of 22.75.

INTERVENTION AND OUTCOMES

Low-dose oral naloxone was initiated, followed by a significant improvement in the level of pruritus, reaching an average 5D-itch score of 7.5, after 6 and 12 months of treatment. None of the patients experienced side effects.

LESSONS

Low-dose naloxone plays an important role in the management of pruritus in systemic sclerosis.

Introducing the concept of cybersecurity footprint

Purpose

This paper aims to introduce the concept of cybersecurity footprint.

Design/methodology/approach

Characteristics of cybersecurity footprint are presented based on documented cases, and the domino effect of cybersecurity is illustrated. Organizational and individual cybersecurity footprints are outlined. Active and passive – digital vs cybersecurity footprints are then reviewed. Taxonomy of aware/unaware vs active/passive cybersecurity footprints are presented, followed by brief discussion of the implications for future research.

Findings

The concept of cybersecurity footprint is defined, and the evidence from prior cyber incidents is shown to emphasize the concept. Smaller organizations may have a large cybersecurity footprint, whereas larger organizations may have smaller one. Cyberattacks are focusing on the individuals or small organizations that are in the supply chain of larger organizations causing the domino effect.

Practical implications

Implications of cybersecurity footprint to individuals, organizations, societies and governments are discussed. The authors present organizations with ways to lower cybersecurity footprint along with recommendations for future research.

Social implications

Cybersecurity has a significant social implication worldwide, as the world is becoming cyber dependent. With the authors’ introduction of the cybersecurity footprint concept and call to further understand how organizations can measure and reduce it, the authors envision it as another perspective of assessing cyber risk and further help mitigate future cyber incidents.

Originality/value

This paper extends the existing information and computer security body of knowledge on the concept of cybersecurity footprint with illustrated cases.

Autonomic Nervous System Indices in Patients with Systemic Sclerosis without Overt Cardiac Disease

BACKGROUND

Systemic sclerosis (SSc) is a connective tissue disease that may affect the heart and the autonomic nervous system (ANS). There is little knowledge regarding the degree of ANS involvement in SSc patients with unknown cardiac disease.

OBJECTIVES

To evaluate cardiac and pupillary autonomic functions in patients before cardiac involvement has emerged.

METHODS

The study comprised 19 patients with SSc and 29 healthy controls. Heart rate variability (HRV) analysis for time and frequency domains, as well as deep breathing test and Ewing maneuvers, were performed in all patients. Automated pupillometry for the evaluation of pupillary diameter and pupillary light reflex was completed in 8 SSc patients and 21 controls.

RESULTS

Both groups had similar characteristics, except for medications that were more commonly or solely prescribed for SSc patients. Compared with control subjects, the SSc patients had significantly lower HRV parameters of NN50 (15.8 ± 24.4 vs. 33.9 ± 33.1, P = 0.03), pNN50 (4.9 ± 7.4% vs.10.8 ± 10.8%, P = 0.03), and triangular index (11.7 ± 3.4 vs. 15.7 ± 5.8, P = 0.02). Abnormal adaptive responses in heart rate changes were recorded during deep breathing tests and Ewing maneuvers. There was no significant difference in any of the pupillometric indices or other HRV parameters within groups.

CONCLUSIONS

SSc patients may manifest cardiac autonomic dysfunction, while their autonomic pupillary function is seemingly spared. The role of certain medications, the significance of differential organ involvement, as well as the prognostic value of our findings should be evaluated in future studies.

Tumor-like Lesions in Patients with Granulomatosis with Polyangiitis: A Case Series

BACKGROUND

Granulomatosis with polyangiitis (GPA) is a rare small vessel vasculitis. It usually involves the respiratory tract and kidney. Rarely, tumor-resembling inflammatory changes ensue.

OBJECTIVES

To report three unique cases of GPA presenting with tumor-like lesions in various organs.

METHODS

We presented three cases of GPA. Case 1 presented with typical upper respiratory symptoms of GPA and a mediastinal mass. Case 2 presented with low back pain, a large retroperitoneal mass, and nodular skin lesions. Case 3 presented with epigastric pain and a paravertebral inflammatory mass.

RESULTS

The patients were treated successfully with rituximab.

CONCLUSIONS

Clinicians should be aware of this presentation of granulomatosis with polyangiitis, which is known as Tumefaction Wegener's granulomatosis.

OP0171 PHASE 3 TRIAL OF LENABASUM, A CB2 AGONIST, FOR THE TREATMENT OF DIFFUSE CUTANEOUS SYSTEMIC SCLEROSIS (DCSSC)

Background:

Lenabasum is an oral CB2 agonist that attenuates inflammation and fibrosis in SSc animal models and showed clinical benefit with acceptable safety in a Phase 2 trial in dcSSc.

Objectives:

Test efficacy and safety of lenabasum in a Phase 3 trial in dcSSc.

Methods:

Subjects ≥18 years old with disease duration ≤ 6 years were randomized 1:1:1 to lenabasum 5 mg, 20 mg, or placebo (PBO), all BID, with stable background immunosuppressant therapy (IST) allowed. The primary efficacy endpoint was ACR CRISS score, and secondary endpoints were ΔmRSS, ΔHAQ-DI, and ΔFVC, all at Week 52 for lenabasum 20 mg vs PBO.

Results:

363 adults were dosed; 37 (10%) stopped study drug early, with only 1 subject (PBO cohort) stopping due to adverse event (AE). Baseline demographics were similar among groups. Disease duration was ≤ 3 years in 60% and 66%, mean mRSS score was 22.0 and 23.3, and background IST was used by 89% and 84% of lenabasum 20 mg and PBO groups, respectively.

Safety results showed serious AEs and severe AEs occurred in 9.2% and 5.8% vs 14.6% and 13.0%, respectively, of lenabasum 20 mg and PBO groups.

Efficacy results (Table) demonstrated:

Table 1.

Primary and secondary efficacy endpoints and post-hoc analyses, Week 52

Group, by IST treatmentCohortNΔmRSS, mean (SD)ΔFVC% mean (SD)ΔFVC, mL mean (SD)ΔHAQ-DI mean (SD)ACR CRISS medianmITT population, MMRM primary analysis methodAllPlacebo123-8.1 (7.72)-1.0 (8.68)-51 (317)-0.13 (0.468)0.887Lenabasum 20 mg120-6.7 (6.59)-1.6 (6.91)-78 (265)-0.13 (0.436)0.888Placebo subjects, per protocol completers, LOCFNo ISTPlacebo16-2.3 (9.4)-2.8 (7.4)-97 (244)0.12 (0.34)0.417All ISTPlacebo97-8.9 (7.07)-1.0 (9.2)-43 (330)-0.17 (0.474)0.936MMF, no other ISTPlacebo29-10.7 (8.1)-0.58 (7.1)-37 (235)-0.12 (0.456)0.935MMF ≤ 2 years, no other ISTPlacebo23-11.7 (8.1)-0.3 (6.0)-41 (197)-0.13 (0.495)0.935Non-MMF ≤ 2 yearsPlacebo24-6.7 (6.2)-1.4 (7.87)-52 (281)-0.15 (0.357)0.931Post-hoc comparisons, per protocol completers, LOCFNo ISTPlacebo16-2.3 (9.4)-2.8 (7.4)-97 (244)0.12 (0.34)0.417Lenabasum 20 mg10-6.3 (6.02)-2.3 (5.58)-99 (209)-0.06 (0.498)0.811Established IST1Placebo26-6.1 (5.35)-4.6 (10.11)-170 (350)-0.17 (0.445)0.619Lenabasum 20 mg38-7.4 (5.08)-0.4 (5.70)2-21 (233)3-0.07 (0.357)0.941Established IST, subjects with ILDPlacebo22-5.9 (5.28)-3.7 (5.43)-133 (206)-0.10 (0.372)0.553Lenabasum 20 mg33-7.2 (5.70)-1.0 (10.5)-47 (365)-0.06 (0.391)0.819

2 P = 0.0386 two-sample t-test; 3 P = 0.0481 two-sample t-test; other comparisons were not significant

• No significant differences were seen in primary and secondary efficacy endpoints. Primary MMRM analyses with treatment-by-time-by-subgroup interactions showed that background mycophenolate (MMF) significantly influenced the outcome

•oSubjects on no IST with disease duration ≤3 years were only 7% of PBO subjects and showed little improvement on PBO, in line with other dcSSc trials in which IST was restricted. Post-hoc subgroup analyses of these subjects on no IST suggested improvement in ΔmRSS and ΔHAQ-DI, for lenabasum 20 mg vs PBO

•uUnexpectedly high improvement occurred in PBO subjects receiving IST, notably those on MMF started within 2 years of baseline

•nPost-hoc analyses of subjects on established IST (MMF or, if no MMF, ≥ 1 non-MMF IST started > 2 years before baseline) suggested improvement in ΔFVC% (nominal P = 0.0386) and ΔFVC mL (nominal P = 0.0481) for lenabasum 20 mg vs PBO. Improvement in FVC was also seen in subjects on established IST who had ILD at baseline, lenabasum 20 mg vs PBO

•mACR CRISS score demonstrated a ceiling effect and correlated most highly with ΔmRSS (r = -0.739) and moderately with MDGA (-0.432), HAQ-DI (-0.362), FVC% (0.366), and PtGA (-0.288)

Conclusion:

Lenabasum was safely used in this study. Unexpectedly high improvement on background IST, especially MMF, has not been previously reported at this level. The primary endpoint was not met. Post-hoc analyses showed greater improvement in lenabasum- vs PBO-treated subjects who were not on background IST and those on established IST, including subjects with ILD.

Disclosure of Interests:

Robert Spiera Consultant of: Abbvie, Roche-Genetech, GSK, CSL Behring, Sanofi, Janssen, Chemocentryx, Formation Biologics, Mitsubishi Tanabe, Grant/research support from: Roche-Genetech, GSK, Boehringer Ingelheim, Chemocentryx, Corbus, Formation Biologics, Sanofi, Inflarx, Astra Zeneca, Kadmon, Masataka Kuwana Speakers bureau: Boehringer-Ingelheim, Chugai, Janssen, Consultant of: Boehringer-Ingelheim, Chugai, Corbus, Grant/research support from: Boehringer-Ingelheim, Chugai, MBL, Ono Pharmaceuticals, Tanabe-Mitsubishi, Dinesh Khanna Shareholder of: Eicos Sciences, Inc (less than 5%). Leadership/Equity position – Chief Medical Officer, CiviBioPharma/Eicos Sciences, Inc, Consultant of: Acceleron, Actelion, Abbvie, Amgen, Bayer, Boehringer Ingelheim, CSL Behring, Corbus, Gilead, Galapagos, Genentech/Roche, GSK, Horizon, Merck, Mitsubishi Tanabe Pharma, Sanofi-Aventis, and United Therapeutics, Grant/research support from: NIH, Immune Tolerance Network, Bayer, BMS, Horizon, Pfizer, Laura Hummers Consultant of: CSL Behring, Boehringer Ingelheim, Grant/research support from: Investigator for study sponsored by Corbus Pharmaceuticals. Corbus, Boehringer Ingelheim, Medpace, Kadmon, Cumberland, CSL Behring, Tracy Frech Grant/research support from: Investigator for study sponsored by Corbus Pharmaceuticals, Wendy Stevens Grant/research support from: Investigator for study sponsored by Corbus Pharmaceuticals, Jessica Gordon Grant/research support from: Investigator for study sponsored by Corbus Pharmaceuticals. Research funding for EICOS Pharmaceuticals and Cumberland Pharmaceuticals., Suzanne Kafaja Grant/research support from: Investigator for study sponsored by Corbus Pharmaceuticals, Marco Matucci-Cerinic Consultant of: Actelion, Janssen, Inventiva, Bayer, Biogen, Boehringer, CSL Behring, Corbus, Galapagos, Mitsubishi, Samsung, Regeneron, Acceleron, MSD, Chemomab, Lilly, Pfizer, Roche, Grant/research support from: Investigator for study sponsored by Corbus Pharmaceuticals, Oliver Distler Consultant of: Consultancy relationship and/or has received research funding in the area of potential treatments for systemic sclerosis and its complications from (last three years): Abbvie, Acceleron Pharma, Amgen, AnaMar, Arxx Therapeutics, Baecon Discovery, Blade Therapeutics, Bayer, Boehringer Ingelheim, ChemomAb, Corbus Pharmaceuticals, CSL Behring, Galapagos NV, Glenmark Pharmaceuticals, GSK, Horizon (Curzion) Pharmaceuticals, Inventiva, iQvia, Italfarmaco, iQone, Kymera Therapeutics, Lilly, Medac, Medscape, Mitsubishi Tanabe Pharma, MSD, Novartis, Pfizer, Roche, Sanofi, Serodapharm, Topadur, Target Bioscience and UCB., Eun Bong Lee Grant/research support from: Investigator for study sponsored by Corbus Pharmaceuticals, Yair Levy Grant/research support from: Investigator for study sponsored by Corbus Pharmaceuticals, Jae-Bum Jun Consultant of: Consultant to Boehringer Ingelheim Korea, Jeil Pharma, Dae Woong Pharma, Kwangdong Pharma, and Sama Pharma., Grant/research support from: Investigator for study sponsored by Corbus Pharmaceuticals, Scott Constantine Employee of: Employee of Corbus Pharmaceuticals, Nancy Dgetluck Employee of: Employee of Corbus Pharmaceuticals, Barbara White Employee of: Employee and stockholder of Corbus Pharmaceuticals, Daniel Furst Consultant of: Corbus, Galapagos, Pfizer, CSL Behring, Mitsubishi Tanabi, Actelion, Amgen, Novartis, Roche/Genentech, Gilead, Talaris, and Boehringer Ingelheim., Grant/research support from: grants from Corbus, Galapagos, GSK, Pfizer, Talaris, CSL Behring, Mitsubishi Tanabi, Christopher Denton Consultant of: Consultancy fees and/or honoraria from Corbus, Actelion, GlaxoSmithKline, Bayer, Sanofi, Galapagos, Inventiva, Boehringer Ingelheim, Roche, CSL Behring, Acceleron, Horizon, Arxx Therapeutics