POS1252 COVID-19 IN PATIENTS WITH RHEUMATIC DISEASES ON CHRONIC USE OF HYDROXYCHLOROQUINE IN A LARGE BRAZILIAN COHORT – A 24-WEEK PROSPECTIVE STUDY

Background:

The role of chronic use of hydroxychloroquine (HCQ) in rheumatic disease (RD) patients during the SARS-CoV-2 pandemic is still subject of discussion.

Objectives:

To compare the occurrence of COVID-19 and its outcomes between RD patients on HCQ use with individuals from the same household not taking the drug during community viral transmission in an observational prospective multicenter study in Brazil.

Methods:

Participants were enrolled and monitored through 24-week (From March 29th to Sep 30th, 2020) regularly scheduled phone calls performed by trained medical professionals. Epidemiological and demographic data, as well as RD disease activity status and current treatment data, specific information about COVID-19, hospitalization, need for intensive care, and death was recorded in both groups and stored in the Research Electronic Data Capture (REDCap) database. COVID-19 was defined according to the Brazilian Ministry of Health (BMH) criteria. The statistical analysis was performed using IBM-SPSS v.20.0 software. Group comparisons were made using the Man-Whitney, Chi-Square and Fisher Exact Test, as well as multivariate regression models adjusted to confounders. Survival curves were performed using Kaplan-Meier analysis.

Results:

A total of 10,427 participants mean age (SD) of 44.04 (14.98) years were enrolled, including 6004 (57.6%) rheumatic disease patients, of whom 70.8% had systemic lupus erythematosus (SLE), 6.7% rheumatoid arthritis (RA), 4% primary Sjögren’s syndrome (pSS), 1.8% mixed connective tissue disease (DMTC), 1% systemic sclerosis (SSc) and others (15.9), including overlap syndromes. In total, 1,132 (10.8%) participants fulfilled criteria for COVID-19, being 6.7% RD patients and 4.1% controls (p=0.002). A recent influenza vaccination had a protective role (p<0.001). Moderate and severe COVID-19 included the need for hospitalization, intensive care, mechanical ventilation or death. Infection severity was not different between groups (p=0.391) (Table 1). After adjustments for multiple confounders, the main risk factors significantly associated with COVID-19 were higher education level (OR=1.29 95%CI 1.05-1.59), being healthcare professionals (OR=1.91; 95%CI 1.45-2.53), presence of two comorbidities (OR=1.31; 95%CI 1.01-1.66) and three or more comorbidities associated (OR=1.69; 95%CI 1.23-2.32). Interestingly, age >=65 years (OR=0.20; 95%CI 0.11-0.34) was negatively associated. Regarding RD, the risk factors associated with COVID-19 diagnosys were SLE (OR= 2.37; 95%CI 1.92-293), SSc (OR=2.25; 95%CI 1.05-4.83) and rituximab use (OR=1.92; 95%CI 1.13-3.26). In addition, age >=65 years (OR=5.47; 95%CI 1.7-19.4) and heart disease (OR=2.60; 95%CI 1.06-6.38) were associated with hospitalization. Seven female RD patients died, six with SLE and one with pSS, and the presence of two or more comorbidities were associated with higher mortality rate.

Conclusion:

Chronic HCQ use did not prevent COVID-19 in RD compared to their household cohabitants. Health care profession, presence of comorbidities LES, SSc and rituximab were identified as main risk factors for COVID-19 and aging and heart disease as higher risk for hospitalization. Our data suggest these outcomes could be considered to manage them in clinical practice.

Table 1.

Frequency and severity of COVID-19 in patients with rheumatic diseases on chronic use of hydroxychloroquine compared to their household controls

COVID-19 outcomesTotal(%)GroupsPPatients(%)Controls (%)DiagnosisNo9256 (89.1)5300 (88.3)3956 (90.2)0.002Yes1132 (10.9)704 (11.7)428 (9.8)SeverityMild1059 (93.6)662 (94.0)397 (92.8)0.391Moderate52 (4.6)32 (4.5)20 (4.7)Severe21 (1.9)10 (1.4)11 (2.6)

HCQ: hydroxychloroquine.

Moderate and severe COVID-19 included the need for any of the following: hospitalization, intensive care, mechanical ventilation or death.

Acknowledgements:

To the Brazilian Society of Rheumatology for technical support and rapid nationwide mobilization.

To all the 395 interviewers (medical students and physicians) who collaborated in the study and the participants

To CNPq (Number 403442/2020-6)

Disclosure of Interests:

None declared

NISAR-F SCORE: a simple risk stratification tool for patients implanted with cardiac resynchronization therapy

Funding Acknowledgements

Type of funding sources: None.

Introduction

Individualized estimation of prognosis after cardiac resynchronization therapy (CRT) remains challenging. Outcomes in this group of patients are influenced by multiple factors and a comprehensive and customized approach to estimate prognosis after CRT is lacking

Aims

To develop and validate a simple prognostic score for patients implanted with CRT (NISAR-F score), based on readily available clinical and echocardiographic variables to predict the combined endpoints of death or hospitalization in 24 months.

Methods

A single-centre retrospective study was conducted with inclusion of all consecutive patients who underwent CRT implantation between 2012 and 2019. Follow-up started after CRT implantation and ended upon death, hospitalization or 24 months after study entry. Survival analysis was performed using a multivariate Cox regression model, in order to analyze the effect on survival /hospitalization in 24 months of the following factors: age, gender, NYHA Class III-IV, ischemic heart failure, type 2 diabetes, arterial hypertension, dyslipidemia and ejection fraction &lt; 21%. According to the analysis, points were attributed to each factor. Afterwards, the NISAR-F score was calculated for each patient, summing the points of each variable. The authors finally created ROC curves for the NISAR-F score to predict the occurrence of the combined endpoint in 2 groups of patients: CRT responders (ejection fraction increase of at least 10% after CRT implantation) and CRT non-responders. The statistical analysis was performed in SPSS.

Results

102 patients were included in the study (75.4% male, mean age 68 ± 10.46 years). 10(9.8%) of the patients were re-hospitalized and 8 (7.8%) died during the 24-month follow-up.  After calculating NISAR-F score for each patient, area under ROC curves were obtained. The analysis of the ROC curves allows us to confirm the good performance of the score created [responders group (AUC 0.812) vs non-responders (AUC 0.721)].

Conclusion The NISAR-F score is a useful tool to predict the combined endpoint (mortality and hospitalization in 24 months) after CRT implantation, in both responders and non-responders, revealing good performance of this new and simple score based only on clinical and echocardiographic variables.

500 Consecutive Liver Transplants: The Outcomes of a New Transplantation Program in the Middle West of Brazil

INTRODUCTION

Liver transplantation is the standard treatment for end-stage liver disease. Brazil holds the third highest number of liver transplants performed per year, but center maldistribution results in high discrepancies in accessing this treatment. In 2012, an interstate partnership successfully implemented a new liver transplantation program in the middle west of Brazil. Here, we report the results of the first 500 liver transplants performed in this new program and discuss the impacts of a new transplant center in regional transplantation dynamics.

METHODS

We reviewed data from the first 500 consecutive deceased donor liver transplants performed in the new program during an 8-year period. We analyzed data on patients' clinical and demographic profiles, postoperative outcomes, and graft and recipient survival rates. Univariate survival analysis was conducted using log-rank tests to compare the groups.

RESULTS

Almost half (48%) of the procured organs and 40% of the recipients transplanted in our center were from outside our state. Recipient 30-day mortality was 9%. Overall recipient survival at 1 year and 5 years was 85% and 80%, respectively. Mortality was significantly associated with higher Model for End-Stage Liver Disease (P < .001) but not with the presence of hepatocellular carcinoma (P = .795).

DISCUSSION

The new transplantation program treated patients from different regions of Brazil and became the reference center in liver transplantation for the middle west region. Despite the recent implementation, our outcomes are comparable to experienced centers around the world. This model can inspire the creation of new transplantation programs aiming to democratize access to liver transplantation nationwide.

Identification of Streptococcus pneumoniae in hospital-acquired pneumonia in adults

Hospital-acquired pneumonia (HAP) is often more severe and life-threatening than community-acquired pneumonia (CAP). The role of Streptococcus pneumoniae in CAP is well-understood, but its role in HAP is unclear. The objective of this study was to summarize the available literature on the prevalence of S. pneumoniae in HAP episodes. We searched MEDLINE for peer-reviewed articles on the microbiology of HAP in individuals aged ≥18 years, published between 2008 and 2018. We calculated pooled estimates of the prevalence of S. pneumoniae in episodes of HAP using a random-effects, inverse-variance-weighted meta-analysis. Forty-seven of 1908 articles met the inclusion criteria. Bacterial specimen isolation techniques for microbiologically defined HAP episodes included bronchoalveolar lavage, protective specimen brush, tracheobronchial aspirate and sputum, as well as blood culture. Culture was performed in all studies; five studies also used urine antigen detection (5/47; 10.6%). S. pneumoniae was identified in 5.1% (95% confidence interval (CI): 3.8-6.6%) of microbiologically defined HAP episodes (N = 20), with 5.4% (95% CI: 4.3-6.7%, N = 29) in ventilator-associated HAP and 6.0% (95% CI: 4.1-8.8%, N = 6) in non-ventilator-associated HAP. S. pneumoniae was identified in 5.3% (95% CI: 4.5-6.3%) of HAP occurring in the intensive care unit (ICU, N = 41) and in 5.6% (95% CI: 3.3-9.5%, N = 5) outside the ICU. A higher proportion of early-onset HAP (10.3%; 95% CI: 8.3-12.8%, N = 16) identified S. pneumoniae as compared with late-onset HAP (3.3%; 95% CI: 2.5-4.4%, N = 16). In conclusion, S. pneumoniae was identified by culture in 5.1% of microbiologically defined HAP episodes. The importance of HAP as part of the disease burden caused by S. pneumoniae merits further research.

Impact of Donor Positive Blood Culture in Deceased Donor Liver Transplantation

INTRODUCTION

In the era of shortage of organs for donation, transplantation from suboptimal donors is an expanding alternative to minimize waitlist mortality. In that sense, the safety of using organs from bacteremic donors has been a recurrent matter of discussion. We aimed to evaluate the influence of donor positive blood culture in the recipient and graft outcomes after liver transplantation from deceased donors.

MATERIAL AND METHODS

Blood culture results from 255 deceased liver donors were retrospectively reviewed. Patients were categorized into 2 groups based on the recipients who obtained a graft from a donor with negative or positive blood culture. Graft and recipient outcomes were compared between the 2 groups using univariate survival analysis and multivariate regression models. Transmission of bloodstream infection from donor to recipient was assessed by reviewing recipients' microbiologic status when there was evidence of infection.

RESULTS

Positive blood culture in donors was not associated with negative outcomes after transplantation. Death within 30 days after transplantation and overall recipient and graft survival did not differ between the 2 groups. Only Child-Pugh score ≥10 and retransplantation status were considered independent predictors of recipient death and graft failure. We identified 1 potential case of bacteremia transmission from donor to recipient.

CONCLUSION

Donor positive blood culture was not associated with negative outcomes after liver transplantation. Transmission of infection from donor to recipient is possible, but rare. The results support the usage of bacteremic donors as a safe alternative to the scarcity of optimal donors.

Interrater Reliability of the Pediatric Neuromuscular Recovery Scale in Children with Spina Bifida

Purpose: The purpose of this study was to examine the interrater reliability of the Pediatric Neuromuscular Recovery Scale (Peds NRS) to classify motor capacity in children with myelomeningocele (MMC) form of spina bifida.Methods: Twenty-one children with MMC (1.5-10 years of age) were each scored on the Peds NRS three times: two live testing sessions and one video recorded session. Every child was scored by two physical therapists and one occupational therapist. Interrater reliability was analyzed using intraclass correlation coefficients (ICC) for individual items and the summary score.Results: Strong interrater reliability was determined for the overall Peds NRS score (ICC = 0.89; 95% CI, .80-.95). Eleven of 16 individual items exhibited good to excellent reliability (ICC ≥ 0.80). Pediatric clinicians were able to reliably administer and score the Peds NRS on children with MMC, representing a wide range of ages and functional levels.

Short communication: Production performance and nutrient digestibility of lactating dairy cows fed diets with and without addition of a live-yeast supplement

The objective of this study was to evaluate the use of a live-yeast product when feeding relatively high-forage diets to high-producing cows in mid lactation. Eight primiparous [607 ± 43 kg of body weight (BW) and 130 ± 16 d in milk (DIM) at the beginning of the experiment] and 16 multiparous (706 ± 63 kg of BW and 137 ± 22 DIM at the beginning of the experiment) Holstein cows were blocked by parity and DIM, and randomly assigned to 1 of 2 diets (control vs. yeast) for a 12-wk period according to a randomized complete block design. The formulated diets contained 50.4% corn silage, 10.4% alfalfa hay, and 39.2% concentrate. The yeast diet was formulated to provide approximately 5.4 × 10¹¹ cfu/d of Saccharomyces cerevisiae (BeneSacc; Global Nutritech Biotechnology LLC, Richmond, VA). Total-tract nutrient digestibility was estimated using 240-h undigested neutral detergent fiber (NDF) as an internal marker. Supplementing live yeast to lactating dairy cows did not affect dry matter intake (25.0 kg/d), milk yield (38.6 kg/d), milk fat concentration (4.78%), milk fat yield (1.83 kg/d), milk protein concentration (3.09%), milk protein yield (1.18 kg/d), milk lactose concentration (4.79%), milk lactose yield (1.84 kg/d), BW gain (-0.05 kg/d), or body condition score gain (0.16 units). The digestibility of dry matter was greater for the control treatment than for the yeast treatment (69.3 and 67.1%, respectively), but the digestibilities of crude protein (61.5%), NDF (40.5%), and starch (98.6%) were not affected by treatment. In conclusion, supplementation of live yeast did not affect production performance or nutrient digestibility of high-producing cows in mid lactation. The reasons for the lack of effect are not clear, but an evaluation of interactions between yeast and rumen buffer supplementation is warranted.

Efeito da abundância dos adultos sobre as ninfas de Gerromorpha (Heteroptera) em riachos de Cerrado no estado de Goiás

Entender como as espécies interagem entre si e como o ambiente afeta as espécies é um dos objetivos que os ecólogos ainda buscam responder. Diante disso os nossos objetivos foram avaliar o efeito (i) da abundância de adultos de Gerromorpha, (ii) da integridade de habitat e (iii) das condições morfológicas (largura, profundidade e declividade) do riacho sobre a abundância de ninfas de Heteroptera semiaquáticos (Gerromorpha). As coletas foram realizadas em 21 córregos na região de Barro Alto e Niquelândia, no estado de Goiás. A abundância de adultos de Gerromorpha exerce efeito positivo sobre a abundância de ninfas. A integridade de habitat, as variáveis morfológicas do canal (largura, profundidade e a declividade) não exerceram efeito sobre a abundância de ninfas e de adultos de Gerromorpha. Em ambientes tropicais, adultos e ninfas de Gerromorpha coexistem sem prejuízos, e as variáveis ambientais não exercem efeito sobre a abundância de ninfas de Gerromorpha. A proteção das ninfas é importante do ponto de vista populacional, pois garante a manutenção e o crescimento das populações presentes na comunidade e, consequentemente, evita extinções locais de espécies.

Production performance and nutrient digestibility of lactating dairy cows fed low-forage diets with and without the addition of a live-yeast supplement

We aimed to evaluate the use of a live-yeast product as a means to attenuate plausible nutritional disturbances when feeding relatively low-forage diets containing rapidly fermentable carbohydrates (i.e., wheat) to high-producing cows in early to mid lactation. Eight primiparous [mean ± SD; 569 ± 35 kg of body weight (BW) and 80 ± 29 d in milk (DIM) at the beginning of the experiment] and 16 multiparous (665 ± 67 kg of BW and 64 ± 10 DIM at the beginning of the experiment) Holstein cows were blocked by parity and DIM, and randomly assigned to 1 of 2 diets (control vs. yeast) for a 12-wk-long period according to randomized complete block design. The formulated diets contained 36.7% corn silage, 8.3% alfalfa hay, and 55% concentrate. The yeast diet was formulated to provide approximately 5.4 × 10¹¹ cfu/d of Saccharomyces cerevisiae (BeneSacc; Global Nutritech Biotechnology LLC, Richmond, VA). Total-tract nutrient digestibility was estimated using 240-h undigested neutral detergent fiber (NDF) as an internal marker. Dry matter intake, milk yield, and milk component concentrations and yields were analyzed using repeated measures. The statistical model for these variables included the effects of block, treatment, the block by treatment interaction, week, the treatment by week interaction, and the random residual error. The statistical model for analyzing BW gain, body condition score gain, and dry matter and nutrient digestibilities included the effects of block, treatment, and the random residual error. Supplementing live yeast to lactating dairy cows did not affect dry matter intake (26.0 kg/d), milk yield (48.1 kg/d), milk fat concentration (3.61%), milk fat yield (1.72 kg/d), milk protein concentration (2.96%), milk protein yield (1.43 kg/d), milk lactose concentration (4.84%), milk lactose yield (2.35 kg/d), milk urea nitrogen (7.99 mg/dL), body weight gain (0.62 kg/d), and body condition score gain (0.02 units; all averages of the 2 treatments). The digestibilities of dry matter (70.2%), crude protein (71.4%), NDF (36.4%), and starch (99.8%) were not affected by treatments. In conclusion, the supplementation of the live yeast did not affect production performance and nutrient digestibility of high-producing dairy cows. A potential interaction between live-yeast supplementation and NDF passage rate, which may have hindered the beneficial effects of live-yeast supplementation on production performance and nutrient utilization, deserves further research.

Peptide receptor radionuclide therapy with 177Lu-DOTA-TATE as a promising treatment of malignant insulinoma: a series of case reports and literature review

INTRODUCTION

Insulinomas are a rare type of pancreatic neuroendocrine tumours characterized by insulin hypersecretion. They are considered malignant when metastases are present. Traditional therapies often promote only temporarily symptomatic relief and may be associated with severe adverse effects. There is scarce experience in treating malignant insulinomas with peptide receptors radionuclide therapy (PRRNT).

PATIENTS AND METHODS

We describe PRRNT results in four patients with inoperable malignant insulinomas with poorly controllable hypoglycaemia. All patients received therapy with ¹⁷⁷Lu-DOTA-TATE after conventional therapies failed in controlling disease progression and symptoms. The activity administered per cycle was 4.8-7.4 GBq. The interval between cycles was 10-16 weeks. Haematology, liver and kidney function tests were performed before treatment initiation and 5 and 10 weeks after each cycle.

RESULTS

Patient 1 presented significant clinical benefit for 13 months after PRRNT, with imaging improvement. Patient 2 obtained reduction of the number and severity of hypoglycaemic episodes during 15 months after therapy. Patient 3 is asymptomatic since PRRNT first cycle performed 23 months ago and revealed significant imaging improvement. Patient 4 had resolution of hypoglycaemia only 3 days after PRRNT first cycle and today, 16 months after therapy, the disease seems to be in remission and the patient maintains euglycaemic state. PRRNT was well tolerated, with only hematologic grade 2 toxicity in patient 1 and mild kidney toxicity in patient 3.

CONCLUSIONS

After the start of ¹⁷⁷Lu-DOTA-TATE all patients achieved hypoglycaemia symptomatic control and had evident improvement of their quality of life. Three patients showed imagiological improvement suggesting reduced tumour load.

Production performance, nutrient digestibility, and milk fatty acid profile of lactating dairy cows fed corn silage- or sorghum silage-based diets with and without xylanase supplementation

The objective of this study was to evaluate the effects of supplementing xylanase on production performance, nutrient digestibility, and milk fatty acid profile in high-producing dairy cows consuming corn silage- or sorghum silage-based diets. Conventional corn (80,000 seeds/ha) and brown midrib forage sorghum (250,000 seeds/ha) were planted, harvested [34 and 32% of dry matter (DM), respectively], and ensiled for more than 10 mo. Four primiparous and 20 multiparous Holstein cows were randomly assigned to 1 of 4 diets in a replicated 4 × 4 Latin square design with a 2 × 2 factorial arrangement of treatments and 19-d periods. Treatment diets consisted of (1) corn silage-based diet without xylanase, (2) corn silage-based diet with xylanase, (3) sorghum silage-based diet without xylanase, and (4) sorghum silage-based diet with xylanase. The xylanase product was supplemented at a rate of 1.5 g of product/kg of total DM. Corn silage had higher concentrations of starch (31.2 vs. 29.2%), slightly higher concentrations of crude protein (7.1 vs. 6.8%) and fat (3.7 vs. 3.2%), and lower concentrations of neutral detergent fiber (36.4 vs. 49.0%) and lignin (2.1 vs. 5.7%) than sorghum silage. Xylanase supplementation did not affect DM intake, milk yield, milk fat percentage and yield, milk protein percentage and yield, lactose percentage and yield, and 3.5% fat-corrected milk yield. Cows consuming corn silage-based diets consumed 13% more DM (28.8 vs. 25.5 kg/d) and produced 5% more milk (51.6 vs. 48.9 kg/d) than cows consuming sorghum silage-based diets. Milk from cows consuming sorghum silage-based diets had 16% greater fat concentrations (3.84 and 3.30%) than milk from cows consuming corn silage-based diets. This resulted in 8% greater fat yields (1.81 vs. 1.68 kg/d). Silage type did not affect milk protein and lactose concentrations. Xylanase supplementation did not affect nutrient digestibility. Cows consuming corn silage-based diets showed greater DM (77.3 vs. 73.5%), crude protein (78.0 vs. 72.4), and starch (99.2 vs. 96.5%) digestibilities than cows consuming sorghum silage-based diets. In conclusion, xylanase supplementation did not improve production performance when high-producing dairy cows were fed corn silage- or sorghum silage-based diets. In addition, production performance can be sustained by feeding sorghum silage in replacement of corn silage.

Short communication: Effect of corn planting population on phosphorus concentration and uptake in corn silage

Greater utilization of nutrients reduces the potential runoff of nutrients to bodies of water. The objective of this study was to determine the concentration of P in corn biomass to estimate the removal of P from the soil when planting corn at different population levels. Whole-plant corn samples were collected during an on-farm research project conducted previously. The study included 7 different growing and harvesting conditions. In each cornfield, corn was planted in plots at a theoretical seeding rate of 55,000, 70,000, 85,000, and 100,000 seeds/ha. Each seeding rate had 4 replicates within each field. At harvesting time, 5 consecutive plants from the 2 center rows and at 2 randomly selected spots within each plot were cut by hand at 15 cm above ground. Whole plants were weighed and chopped. After mixing thoroughly, a sample of the chopped material was placed in a bag, immediately placed in a cooler with dry ice, and transferred to the laboratory for storage. After thawing and drying, samples were ground and analyzed for P concentration. Single plant biomass and the number of standing plants at harvesting were used to determine dry matter yield. Total extraction of P was estimated as the product between plant biomass and P concentration. All variables were analyzed using a statistical model that included the effects of field, planting population, planting population nested within field, and random residual error. The concentration of P in the corn plant was greatest for 55,000 and 70,000 plants/ha (0.250% dry matter) and least for 85,000 and 100,000 plants/ha (0.235% dry matter), whereas the uptake of P through the harvested biomass increased when corn planting population increased. In conclusion, increasing the planting population of corn for silage can increase P uptake from the soil, therefore reducing the potential runoff of P to bodies of water.