OP0283 DOES TNF-INHIBITION DECREASE THE RISK OF SEVERE COVID-19 IN RMD-PATIENTS?

Background:

Patients with rheumatic and musculoskeletal diseases (RMD) might have an increased risk for infection due to their immunomodulatory treatment, secondary to their disease and comorbidities. Recent studies suggest a decreased risk of severe COVID-19 in RMD-patients treated with biologics.

Objectives:

The aim of this study was to assess courses of RMD patients treated with TNF-inhibitors (TNF-I) included in the German COVID-19 registry.

Methods:

In the German physician-reported COVID-19-RMD registry, patients with an RMD and confirmed SARS-CoV-2-infection were documented (data entered between March 30, 2020 and January 30, 2021). We analysed TNF-I treated patients, their course and outcome of the infection. Data were compared to RMD-patients treated with other immunomodulatory drugs (OID) than TNF-I.

Results:

A total of 269 patients were treated with a TNF-I (57% female) compared to 874 patients who were treated with OID (68% female). Median age was 52 years (range: 19-87) in the TNF-I-group versus 58 years (range: 18-91) in the OID-group. Rheumatoid arthritis was the most common diagnosis (38% in TNF-I-group vs. 52% in the OID-group), followed by ankylosing spondylitis (32% vs. 6%), psoriatic arthritis (22% vs. 11%) and other RMD (9% vs. 31%). Adalimumab (35%) and etanercept (35%) were the most frequently used TNF-I (tab. 1). Glucocorticoids (GC) were used in 22% of TNF-I-treated patients and in 42% of the OID-group.

Under TNF-I, stable disease was reported prior to the SARS-CoV-2-infection in 53% of the patients (OID-group: 47%), followed by low disease activity in 35% (OID: 34%), moderate disease activity in 6% (OID: 12%) and high disease activity in 4% (OID: 3%). Most frequent comorbidities were arterial hypertension (29% under TNF-I vs. 35% under OID), diabetes (8% vs. 11%) and cardiovascular diseases (7% vs. 12%).

The most common reported COVID-19 symptoms were dry cough (57% vs. 55%), fever (53% vs. 61%) and fatigue (50% vs. 49%). Hospitalization due to SARS-CoV infection was required in only 12% of the TNF-I-treated cases vs. in 29% in the OID-group. Oxygen treatment was necessary in 5% of the patients under TNF-I compared to 22% under OID and invasive ventilation in 2% in the TNF-I-group compared to 6% under OID. Most notably, no fatal courses of COVID-19 were reported among the 269 RMD-patients treated with TNF-I versus 49 deaths in the 874 cases (5.6%) treated with OID. Focussing on the hospitalizated TNF-I patients, the rate of concomitant GC use (p<0.001) and higher disease activity (p=0.005) was significant higher (tab.1).

Conclusion:

High or moderate RMD-disease activity is an important factor associated with severity of COVID-19 including mortality. In this large cohort RMD patients treated with TNF-I show a low hospitalisation rate and no fatal course. This is reassuring for patients and treating rheumatologists to use TNF-I to control RMD disease activity. The use of glucocorticoids and high disease activity seem to counteract possible protective effects of TNF-I.

Table 1.TNF inhibition (269)Other immunomodulation (874)Total patientsRate (%)Total patientsRate (%)Disease activitystable1415340847low933529934Moderate15610812High104293Comorbiditiescardiovascular diseases18710412arterial hypertension772930335bronchial asthma124657COPD/interstitial lung disease1148610chronic renal failure93779Osteoporosis135678Diabetes2289211COVID-19 related symptomsFever1425347855dry cough1525753061Expectoration3112839muscular pain973628032Fatigue1355042449Headache1013823727shortness of breath491824528no symptoms239566COVID-19 outcomeOutpatients2378861971Inpatients321225529need of oxygen treatment18718922invasive ventilation52496fatal course00496TNF inhibitorsAdalimumab9535Infliximab239Certolizumab3312Golimumab249Etanercept9435GC and disease activity in TNF-I treated patientsTNF-I inpatients treated with GC18/3256p< 0.001TNF-I outpatients treated with GC42/23718TNF-I inpatients with high disease activity4/3213TNF-I outpatients with high disease activity6/2376p= 0.005

Acknowledgements:

The authors would like to thank all physicians and personnel involved in the documentation of the cases in our registry.

Disclosure of Interests:

None declared

POS1261 DISEASE ACTIVITY AND PAIN LEVELS ARE NOT INFLUENCED BY THE CURRENT COVID19 PANDEMIC IN PATIENTS WITH RHEUMATIC DISEASES IN GERMANY – DATA FROM THE GERMAN COVID-19 PATIENT SURVEY

Background:

The current pandemic constitutes an entirely new situation for patients as well as physicians. The insecurity of the early phase, shutdowns, increasing infection rate and appearing SARS-CoV2 mutations have created a situation that makes live difficult especially for chronic diseases i.e. patients with rheumatic and musculoskeletal diseases (RMD) and their treating physicians. The psychosocial burden that is created by this special situation is completely unknown and is estimated to be higher in patients than in the general population.

Objectives:

In order to measure the impact on our patients, the German COVID19-Rheuma patient survey was set up in April 2020, during Germany’s first shut down.

Methods:

The German COVID19-Rheuma patient survey is a patient reported longitudinal online survey where patients with RMD who registered between April and July 2020 are asked on a monthly base using an online survey on social, personal, medical factors, whether a COVID19 infection occurred, isolation measures were changed and scores regarding stress and anxiety are recorded. Between April and July 2020, 637 patients registered and completed a first survey. Up to January 2021, about 400 patients are still enrolled.

Here we present an interim analysis of the first 6 months regarding patients that were enrolled in April and May during the first shut-down. This first analysis compares the situation in the first lockdown to July, a phase with very low infection numbers in Germany, and to November, the beginning of the second lockdown.

Results:

150 patients (87% female) were enrolled in April/early May 2020. Mean age was 48 years (range 11-89). The majority of patients suffered from rheumatoid arthritis (51%), followed by psoriatic arthritis (17%), other spondyloarthropathies (10%) and connective tissue diseases (10%).

The majority of patients received antirheumatic therapies: 32% glucocorticoids (GC), 31% cDMARDs, 21% TNF inhibitors, 7% Jak inhibitors, and 9% other biologicals. Of the patients treated with GC, 25% were on GC monotherapy.

In the first lockdown, 26% of patients were working remotely and 24% were self-isolating (doubles included). Additionally, 48% were using masks that were not mandatory at that time and 41% were using disinfection in a regular manner. The rates for remote work and self-isolation did not change significantly over time while the mask use increased to 98% with the official obligation to do so. The use of disinfectants increased to 88% in November.

Regarding disease activity, no change in patient global assessment could be observed over time (4.3 ± 2.5 vs. 4.0 ±2.6 and 4.0 ± 2.5). Self-reported pain was also stable over time as were sleep disturbances. While 48.2% of patients who were receiving physiotherapy paused in April, only 10 and 14% did so in July and November, respectively. 11% of the patients paused their medication in the first lockdown, whereas only 2.75% did so in July and 3.4% in November. Contact with the treating rheumatologist was maintained over time in the majority of cases.

Conclusion:

While in the beginning of the pandemic the insecurity was considerable and the concern that the fear for infection would lead to inadequately treated patients with RMDs, we here show for the first time that on the one hand our patients were timely in taking adequate measures to keep themselves safe (e.g. self-isolating, mask use) and adapted to the clinical situation in not pausing their medication. Altogether, in this alert cohort, the pandemic did not lead to an increase of patient-reported disease activity in the first six months.

Acknowledgements:

Thanks goes to all patients who participated in the study.

Disclosure of Interests:

None declared

Cranial findings detected by second-trimester ultrasound in fetuses with myelomeningocele: a systematic review

Background

Abnormal intracranial findings are often detected at mid‐trimester ultrasound (US) in fetuses with myelomeningocele (MMC). It is unclear whether these findings constitute a spectrum of the disease or are an independent finding, which should contraindicate fetal surgery.

Objective

To ascertain the spectrum and frequency of US‐detected cranial findings in fetuses with MMC.

Search strategy

MEDLINE, Embase, Web of Science and CENTRAL were searched from January 2000 to June 2020.

Selection criteria

Study reporting incidence of cranial US findings in consecutive cases of second‐trimester fetuses with MMC.

Data collection and analysis

Publication quality was assessed by Newcastle–Ottawa Scale (NOS) and modified NOS. Meta‐analysis could not be performed as a result of high clinical diversity and study heterogeneity.

Main results

Fourteen cranial US findings were reported in 15 studies. Findings in classic Chiari II malformation (CIIM) spectrum included posterior fossa funnelling (96%), small transcerebellar diameter (82–96%), ‘banana’ sign (50–100%), beaked tectum (65%) and ‘lemon’ sign (53–100%). Additional cranial findings were small biparietal diameter (BPD) and head circumference (HC) (<5th centile; 53 and 71%, respectively), ventriculomegaly (45–89%), abnormal pointed shape of the occipital horn (77–78%), thinning of the posterior cerebrum, perinodular heterotopia (11%), abnormal gyration (3%), corpus callosum disorders (60%) and midline interhemispheric cyst (42%).

Conclusions

We identified 14 cranial findings by second‐trimester US in fetuses with MMC. The relatively high incidence of these findings and their unclear prognostic significance might not contraindicate fetal surgery in the case of normal fetal genetic testing. Some cranial findings may independently affect postnatal outcome, however. Long‐term detailed follow‐up is required to investigate this.

Tweetable abstract

A high rate of cranial abnormalities found on second‐trimester ultrasound in fetuses with myelomeningocele.

A high rate of cranial abnormalities found on second‐trimester ultrasound in fetuses with myelomeningocele.

Midterm Results after Implant-Free Patellar Fixation Technique for Medial Patellofemoral Ligament Reconstruction

Problems and complications concerning the patellar fixation in medial patellofemoral ligament reconstruction (MPFLR) have been reported. The purpose of this retrospective study was to systematically analyze the surgical technique for MPFLR with a V: -shaped patellar bonetunnel for implant-free fixation of an autologous gracilis tendon, allowing early functional rehabilitation, regarding restoration of the patellofemoral stability, patient satisfaction, return to sports, and technique-specific complications. In 2010, 128 cases of consecutive isolated MPFLR were performed. All these cases were included. After a minimum follow-up of 3 years, 104 cases were retrospectively analyzed (follow-up: 81.3%) with regard to redislocation, subjective functional outcome (Tegner's score and sports level compared with preoperative level), patient satisfaction, revision surgery, and technique-specific complications. After a follow-up of 45.7 ± 3.2 months, 101 of 104 cases (97.1%) showed no redislocation. Mean Tegner's score was 5.1 ± 1.8 (range, 2-9). A total of 61.5% patients reported about a higher sports level compared with their preoperative level. The patient satisfaction was high with 94.2%. In two cases (1.9%), technique-specific problems occurred as the bone bridge of the V: -shaped tunnel was insufficient due to a malpositioning of the aiming device. No further technique-specific problems occurred and no revision surgery was necessary during the observational period. The presented surgical technique is safe and it reliably restores the patellofemoral stability, with a low rate of redislocations, an excellent subjective functional outcome, and a high-patient-reported satisfaction. No major technique-specific complications occurred.

A European multicentre evaluation of detection and typing methods for human enteroviruses and parechoviruses using RNA transcripts

Polymerase chain reaction (PCR) detection has become the gold standard for diagnosis and typing of enterovirus (EV) and human parechovirus (HPeV) infections. Its effectiveness depends critically on using the appropriate sample types and high assay sensitivity as viral loads in cerebrospinal fluid samples from meningitis and sepsis clinical presentation can be extremely low. This study evaluated the sensitivity and specificity of currently used commercial and in-house diagnostic and typing assays. Accurately quantified RNA transcript controls were distributed to 27 diagnostic and 12 reference laboratories in 17 European countries for blinded testing. Transcripts represented the four human EV species (EV-A71, echovirus 30, coxsackie A virus 21, and EV-D68), HPeV3, and specificity controls. Reported results from 48 in-house and 15 commercial assays showed 98% detection frequencies of high copy (1000 RNA copies/5 µL) transcripts. In-house assays showed significantly greater detection frequencies of the low copy (10 copies/5 µL) EV and HPeV transcripts (81% and 86%, respectively) compared with commercial assays (56%, 50%; P = 7 × 10-5 ). EV-specific PCRs showed low cross-reactivity with human rhinovirus C (3 of 42 tests) and infrequent positivity in the negative control (2 of 63 tests). Most or all high copy EV and HPeV controls were successfully typed (88%, 100%) by reference laboratories, but showed reduced effectiveness for low copy controls (41%, 67%). Stabilized RNA transcripts provide an effective, logistically simple and inexpensive reagent for evaluation of diagnostic assay performance. The study provides reassurance of the performance of the many in-house assay formats used across Europe. However, it identified often substantially reduced sensitivities of commercial assays often used as point-of-care tests.

Fetal cerebral Doppler changes and outcome in late preterm fetal growth restriction: prospective cohort study

OBJECTIVES

To explore the association between fetal umbilical and middle cerebral artery (MCA) Doppler abnormalities and outcome in late preterm pregnancies at risk of fetal growth restriction.

METHODS

This was a prospective cohort study of singleton pregnancies at risk of fetal growth restriction at 32 + 0 to 36 + 6 weeks of gestation, enrolled in 33 European centers between 2017 and 2018, in which umbilical and fetal MCA Doppler velocimetry was performed. Pregnancies were considered at risk of fetal growth restriction if they had estimated fetal weight and/or abdominal circumference (AC) < 10^th percentile, abnormal arterial Doppler and/or a fall in AC growth velocity of more than 40 percentile points from the 20-week scan. Composite adverse outcome comprised both immediate adverse birth outcome and major neonatal morbidity. Using a range of cut-off values, the association of MCA pulsatility index and umbilicocerebral ratio (UCR) with composite adverse outcome was explored.

RESULTS

The study population comprised 856 women. There were two (0.2%) intrauterine deaths. Median gestational age at delivery was 38 (interquartile range (IQR), 37-39) weeks and birth weight was 2478 (IQR, 2140-2790) g. Compared with infants with normal outcome, those with composite adverse outcome (n = 93; 11%) were delivered at an earlier gestational age (36 vs 38 weeks) and had a lower birth weight (1900 vs 2540 g). The first Doppler observation of MCA pulsatility index < 5^th percentile and UCR Z-score above gestational-age-specific thresholds (1.5 at 32-33 weeks and 1.0 at 34-36 weeks) had the highest relative risks (RR) for composite adverse outcome (RR 2.2 (95% CI, 1.5-3.2) and RR 2.0 (95% CI, 1.4-3.0), respectively). After adjustment for confounders, the association between UCR Z-score and composite adverse outcome remained significant, although gestational age at delivery and birth-weight Z-score had a stronger association.

CONCLUSION

In this prospective multicenter study, signs of cerebral blood flow redistribution were found to be associated with adverse outcome in late preterm singleton pregnancies at risk of fetal growth restriction. Whether cerebral redistribution is a marker describing the severity of fetal growth restriction or an independent risk factor for adverse outcome remains unclear, and whether it is useful for clinical management can be answered only in a randomized trial. © 2020 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology.

Posterior cruciate ligament lesions are mainly present as combined lesions even in sports injuries

PURPOSE

To analyse 1000 consecutive patients, treated with isolated or combined posterior cruciate ligament (PCL) reconstruction in a single centre according to the epidemiological factors and differences in injury patterns depending on the activity during trauma.

METHODS

Between 2004 and 2019, one thousand isolated and combined PCL reconstructions were performed. The medical charts and surgical reports of all patients were analysed regarding epidemiological factors. The PCL lesions were divided into isolated and combined lesions with at least one additional ligamentous injury. The influence of activity during accident and additional injury on the presence of isolated or combined lesions and injury patterns was calculated.

RESULTS

In 388 patients (38.8%), sporting activity was the main activity in PCL lesions, followed by traffic accidents in 350 patients (35.0%). Combined injuries were present in 227 patients (58.5%) with sports injuries and 251 patients (71.7%) with traffic accidents. Only during handball, an isolated PCL lesion (69.1%) was more common than a combined lesion. Highest rate of combined lesions was present in car accidents (91.7%). In all activities except skiing and biking, the most common additional peripheral injury was a tear of the posterolateral corner. In skiing and biking accidents, the most common additional peripheral lesion was a lesion of the medial collateral ligament. In patients with PCL lesion and additional fracture of the same lower extremity, a combined lesion was more common than an isolated lesion (p = 0.001).

CONCLUSION

Combined PCL lesions are more common than isolated lesions, even in sports injuries (except handball). Incidence and injury pattern vary depending on activity during trauma. Main additional peripheral lesion is a lesion of the posterolateral corner, except biking and skiing accidents where a medial lesion is more common.

LEVEL OF EVIDENCE

Level III.

FRI0174 THE LONGER THE DELAY IN DIAGNOSIS, THE WORSE THE OUTCOME IN SLE – CROSS SECTIONAL ANALYSIS OF A GERMAN LONG-TERM STUDY (LULA COHORT)

Background:

Patients with systemic lupus erythematosus (SLE), even compared to those with other rheumatic diseases, are thought to often experience a long delay from the onset of symptoms to diagnosis.

Objectives:

Our aim was to study the association of this delay to the long-term outcome of the disease.

Methods:

Information on demographics, onset of first symptoms, first physicians visit, time of diagnosis and organ involvement was assessed by self-reported questionnaires among SLE patients in Germany in 2011 (LuLa cohort, n=585). Disease related damage (Brief Index of Lupus Damage; BILD), disease activity (Systemic Lupus Activity Questionnaire; SLAQ) and health related quality of life (SF-12) were chosen as proxies for outcome. The association to the outcome of the disease was analyzed by linear regression analysis, adjusted for age, disease duration, organ involvement and sex.

Results:

In our cohort, the mean reported duration between the onset of symptoms and the diagnosis of SLE was 46 months (SD 73), which includes 13 months (SD 41) between the onset of symptoms and the first physicians visit. The participating patients were diagnosed between 1960 and 2004.

Linear regression analysis revealed that longer time to diagnosis was associated with (i) higher disease activity (SLAQ, p<0.0001, β=0.199), (ii) higher disease-related damage (BILD, p=0.002, β=0.137) and (iii) lower health-related quality of life (SF-12 physical p=0.004, β=-0.136, SF-12 mental p=0.004, β=-0.143) in the year 2011. The organ involvement at the time of diagnosis did not alter these results.

Conclusion:

A delay in diagnosis was associated with a worse outcome in SLE (disease activity, disease-related damage and health-related quality of life). Therefore, an early diagnosis seems to be important to improve the long-term outcome of the disease. It will be interesting to see whether adopting the new EULAR/ACR 2019 classification criteria can contribute to a faster diagnosis and a better outcome in consequence.

The LuLa study is supported by unrestricted grants from GlaxoSmithKline and UCB Pharma.

Disclosure of Interests:

Anna Kernder Grant/research support from: Grant/research support from: GlaxoSmithKline and UCB Pharma for performing the LuLa-study., Jutta Richter Grant/research support from: Grant/research support from: GlaxoSmithKline and UCB Pharma for performing the LuLa-study., Rebecca Fischer-Betz Consultant of: UCB, Speakers bureau: Abbvie, Amgen, Biogen, BMS, Celgene, Chugai, GSK, Janssen, Lilly, Medac, MSD, Novartis, Roche, UCB, Pfizer., Borgi Winkler-Rohlfing: None declared, Martin Aringer Consultant of: Boehringer Ingelheim, Roche, Speakers bureau: Boehringer Ingelheim, Roche, Matthias Schneider Grant/research support from: GSK, UCB, Abbvie, Consultant of: Abbvie, Alexion, Astra Zeneca, BMS, Boehringer Ingelheim, Gilead, Lilly, Sanofi, UCB, Speakers bureau: Abbvie, Astra Zeneca, BMS, Chugai, GSK, Lilly, Pfizer, Sanofi, Gamal Chehab Grant/research support from: Grant/research support from: GlaxoSmithKline and UCB Pharma for performing the LuLa-study.

CO0004 OLDER AGE, CARDIOVASCULAR COMORBIDITY AND GLUCOCORTICOSTEROIDS ARE RISK FACTORS FOR COVID-19 HOSPITALISATION IN PATIENTS WITH INFLAMMATORY RHEUMATIC DISEASES: FIRST RESULTS OF THE GERMAN COVID-19-IRD REGISTRY

Background:

Patients with inflammatory rheumatic diseases (IRD) and infection with SARS-CoV-2 may be at risk to develop a severe course of COVID-19. To gather knowledge about SARS-CoV-2 infections in IRD patients, a national registry was established to elucidate IRD specific profiles of COVID-19.

Objectives:

To identify risk factors for hospitalisation.

Methods:

Patients from the German registry on SARS-CoV-2 infection in IRD were analysed. Patients are enrolled with a pre-existing IRD and a positive lab-result for a SARS-CoV-2 infection. The main outcome parameter was hospitalisation versus non-hospitalisation. Multivariable logistic regression was used to estimate odds ratios (OR) and 95% confidence intervals (CI). Covariates included in the model were age group, gender, key comorbidities (cardiovascular, lung diseases, chronic renal insufficiency), prior and/or current use of glucocorticosteroids (GC) or NSAIDs and remission.

Results:

Until May 17th, 2020, data from 192 IRD patients with SARS-CoV-2 infection were reported (67 males; 124 females; 1 diverse). 64 patients were hospitalised, 21 patients were ventilated non-invasively/invasively and 15 patients died.

Baseline characteristics are shown in table 1, stratified into the patient groups non-hospitalisation, hospitalisation without ventilation, and hospitalisation with ventilation. Non-hospitalised patients were younger, had less comorbidities and were less often treated with GC. In the group of hospitalised patients compared to non-hospitalised patients more patients were male (42% vs 32% male) with an even higher proportion in the ventilated patient group (57% male).

In the multivariable logistic regression model, age>65 years (OR 5.1; 95%CI 2.3-11.4), cardiovascular comorbidity (OR 2.3; 95%CI 1.0-5.0), and prior and/or current treatment with GC (OR 2.6; 95%CI 1.2-5.4) were independently associated with hospitalisation.

Parameter, N (%)Non-hospitalisation128 (66.7)Hosp. without ventilation42 (22.4)Hosp. with ventilation21 (10.9)Age [years], mean (SD)53.8 (13.4)65.2 (15.5)69.7 (9.9)Female87 (68.5)28 (65.1)9 (42.9)RA60 (46.9)24 (55.8)12 (57.1)Psoriasis23 (18)3 (7)3 (14.3)Axial spondyloarthritis14 (10.9)2 (4.7)0Lupus7 (5.5)1 (2.3)0Remission of IRD67 (52.3)23 (53.5)4 (19)Number of comorbidities, mean (SD)1 (1.2)1.8 (1.4)2.4 (1.5)Cardiovascular disease42 (32.8)25 (58.1)16 (76.2)Pulmonary disease16 (12.5)8 (18.6)8 (38.1)Chronic renal insufficiency5 (3.9)7 (16.3)4 (19)Cancer2 (1.6)4 (9.3)2 (9.5)Obesity (BMI>30)23 (18)5 (11.6)3 (14.3)Diabetes3 (2.3)7 (16.3)4 (19)Other comorbidities20 (15.6)9 (20.9)6 (28.6)csDMARD (without HCQ)59 (46.1)25 (58.1)8 (38.1)HCQ13 (10.2)1 (2.3)2 (9.5)bDMARD48 (37.5)15 (34.9)8 (38.1)tsDMARD5 (3.9)1 (2.3)1 (4.8)Glucocorticosteroids47 (37)29 (67.4)13 (61.9)NSAIDs21 (16.4)5 (11.6)1 (4.8)

Conclusion:

As has been described for COVID-19 in general, also in IRD male gender may be associated with a more severe course of the infection as the descriptive analysis of data shows. Risk factors for SARS-CoV-2 infection-dependent hospitalisation in IRD patients include age (>65 years), cardiovascular comorbidities, and prior and/or current treatment with GC.

Disclosure of Interests:

Anne Regierer Speakers bureau: Novartis, Celgene, Janssen-Cilag, Rebecca Hasseli Grant/research support from: Pfizer, Consultant of: Pfizer, Gilead, Novartis, Celgene, Abbvie, Medac, Bimba Hoyer: None declared, Andreas Krause: None declared, Hanns-Martin Lorenz Grant/research support from: Consultancy and/or speaker fees and/or travel reimbursements: Abbvie, MSD, BMS, Pfizer, Celgene, Medac, GSK, Roche, Chugai, Novartis, UCB, Janssen-Cilag, Astra-Zeneca, Lilly. Scientific support and/or educational seminars and/or clinical studies: Abbvie, MSD, BMS, Pfizer, Celgene, Medac, GSK, Roche, Chugai, Novartis, UCB, Janssen-Cilag, Astra-Zeneca, Lilly, Baxter, SOBI, Biogen, Actelion, Bayer Vital, Shire, Octapharm, Sanofi, Hexal, Mundipharm, Thermo Fisher., Consultant of: see above, Alexander Pfeil Grant/research support from: This study Investigator Initiated Study “Automatic assessment of joint space narrowing in rheumatoid arthritis based on the Post-hoc analysis” (number: IIS-2016-110818) is a part of the of the Investigator Initiated Study “The quantification of inflammatory related periarticular bone loss in certolizumab pegol treated patients with rheumatoid arthritis” (number: IIS-2014-101458) which is supported by UCB Pharma GmbH, Monheim, Germany., Jutta Richter Grant/research support from: Grant/research support from: GlaxoSmithKline and UCB Pharma for performing the LuLa-study., Tim Schmeiser Speakers bureau: Actelion, UCB, Pfizer, Christof Specker Consultant of: Abbvie, Boehringer Ingelheim, Chugai, Lilly, Novartis, Sobi, UCB, Celgene, Janssen-Cilag, MSD, Pfizer, Roche, UCB, Toshiba, Anja Strangfeld Speakers bureau: AbbVie, BMS, Pfizer, Roche, Sanofi-Aventis, Reinhard Voll: None declared, Hendrik Schulze-Koops: None declared, Ulf Müller-Ladner Speakers bureau: Biogen

European LeukemiaNet 2020 recommendations for treating chronic myeloid leukemia

The therapeutic landscape of chronic myeloid leukemia (CML) has profoundly changed over the past 7 years. Most patients with chronic phase (CP) now have a normal life expectancy. Another goal is achieving a stable deep molecular response (DMR) and discontinuing medication for treatment-free remission (TFR). The European LeukemiaNet convened an expert panel to critically evaluate and update the evidence to achieve these goals since its previous recommendations. First-line treatment is a tyrosine kinase inhibitor (TKI; imatinib brand or generic, dasatinib, nilotinib, and bosutinib are available first-line). Generic imatinib is the cost-effective initial treatment in CP. Various contraindications and side-effects of all TKIs should be considered. Patient risk status at diagnosis should be assessed with the new EUTOS long-term survival (ELTS)-score. Monitoring of response should be done by quantitative polymerase chain reaction whenever possible. A change of treatment is recommended when intolerance cannot be ameliorated or when molecular milestones are not reached. Greater than 10% BCR-ABL1 at 3 months indicates treatment failure when confirmed. Allogeneic transplantation continues to be a therapeutic option particularly for advanced phase CML. TKI treatment should be withheld during pregnancy. Treatment discontinuation may be considered in patients with durable DMR with the goal of achieving TFR.

[Technique of all arthroscopic autologous chondrocyte implantation (ACI) for the treatment of cartilage defects in the knee]

OBJECTIVE

All arthroscopic treatment of deep cartilage defects in the knee for reconstruction of the articular surface.

INDICATIONS

Focal cartilage defects of the knee (ICRS ≥ grade 3) from a size of 2.5 cm² and more.

CONTRAINDICATIONS

Osteoarthritis (Kellgren-Lawrence > grade 2), osseus defect situation, cartilage lesion of the opposing articular surfaces (ICRS > grade 2), instability, malalignment (>3-4°), inflammatory joint diseases.

SURGICAL TECHNIQUE

First procedure (cell harvesting): Treatment of additional pathologies, preparation of the cartilage defect, harvesting of osteochondral cylinders for cell culture. Second procedure (cell implantation): Dry arthroscopy, cleaning and drying of the already prepared defect, implantation of the in situ crosslinking cartilage cell suspension.

POSTOPERATIVE MANAGEMENT

First procedure (cell harvesting): Early functional treatment with weight bearing as tolerated. Second procedure (cell implantation): No drains, extension brace for 4 days, then free range of motion, partial weight bearing for 4 weeks in patellofemoral implantation and for 8 weeks in tibiofemoral implantation, continuous passive motion beginning in postoperative week 2, cycling from postoperative week 9.

RESULTS

In the literature, results for ACI in the knee are reported to be good, especially for larger cartilage defects. Arthroscopic techniques should lead to a decrease of complications and perioperative morbidity. No technique-specific complications occurred in our cohort. From 2012-2015, 98 patients were treated using the above mentioned technique, whereby 62 patients were retrospectively evaluated after 31.0 ± 14.8 (12.5-61.4) months. In 15 patients (28%) additional procedures were performed (7 anterior cruciate ligament reconstructions, 3 correction osteotomies and 5 medial patellofemoral ligament reconstructions). Average cartilage defect size was 4.7 ± 2.8 cm², in 18 patients (29%) more than one cartilage defect was treated. The subjective IKDC and total KOOS scores resulted in 66 ± 10 and 73 ± 19 points.

Gene replacement therapy after neuropathy onset provides therapeutic benefit in a model of CMT1X

X-linked Charcot-Marie-Tooth disease (CMT1X), one of the commonest forms of inherited demyelinating neuropathy, results from GJB1 gene mutations causing loss of function of the gap junction protein connexin32 (Cx32). The aim of this study was to examine whether delayed gene replacement therapy after the onset of peripheral neuropathy can provide a therapeutic benefit in the Gjb1-null/Cx32 knockout model of CMT1X. After delivery of the LV-Mpz.GJB1 lentiviral vector by a single lumbar intrathecal injection into 6-month-old Gjb1-null mice, we confirmed expression of Cx32 in lumbar roots and sciatic nerves correctly localized at the paranodal myelin areas. Gjb1-null mice treated with LV-Mpz.GJB1 compared with LV-Mpz.Egfp (mock) vector at the age of 6 months showed improved motor performance at 8 and 10 months. Furthermore, treated mice showed increased sciatic nerve conduction velocities, improvement of myelination and reduced inflammation in lumbar roots and peripheral nerves at 10 months of age, along with enhanced quadriceps muscle innervation. Plasma neurofilament light (NEFL) levels, a clinically relevant biomarker, were also ameliorated in fully treated mice. Intrathecal gene delivery after the onset of peripheral neuropathy offers a significant therapeutic benefit in this disease model, providing a proof of principle for treating patients with CMT1X at different ages.

The 2018 ISDE achalasia guidelines

Achalasia is a relatively rare primary motor esophageal disorder, characterized by absence of relaxations of the lower esophageal sphincter and of peristalsis along the esophageal body. As a result, patients typically present with dysphagia, regurgitation and occasionally chest pain, pulmonary complication and malnutrition. New diagnostic methodologies and therapeutic techniques have been recently added to the armamentarium for treating achalasia. With the aim to offer clinicians and patients an up-to-date framework for making informed decisions on the management of this disease, the International Society for Diseases of the Esophagus Guidelines proposed and endorsed the Esophageal Achalasia Guidelines (I-GOAL). The guidelines were prepared according the Appraisal of Guidelines for Research and Evaluation (AGREE-REX) tool, accredited for guideline production by NICE UK. A systematic literature search was performed and the quality of evidence and the strength of recommendations were graded according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE). Given the relative rarity of this disease and the paucity of high-level evidence in the literature, this process was integrated with a three-step process of anonymous voting on each statement (DELPHI). Only statements with an approval rate >80% were accepted in the guidelines. Fifty-one experts from 11 countries and 3 representatives from patient support associations participated to the preparations of the guidelines. These guidelines deal specifically with the following achalasia issues: Diagnostic workup, Definition of the disease, Severity of presentation, Medical treatment, Botulinum Toxin injection, Pneumatic dilatation, POEM, Other endoscopic treatments, Laparoscopic myotomy, Definition of recurrence, Follow up and risk of cancer, Management of end stage achalasia, Treatment options for failure, Achalasia in children, Achalasia secondary to Chagas' disease.

The influence of tibial slope on the graft in combined high tibial osteotomy and anterior cruciate ligament reconstruction

BACKGROUND

Young patients with severe medial osteoarthritis, varus malalignment and insufficiency of the anterior cruciate ligament (ACL) are difficult to treat. The tibial slope has gained attention with regard to osteotomies and ligamentous instability. The purpose was to evaluate the outcome of combined high tibial osteotomy (HTO), ACL reconstruction and chondral resurfacing (CR, abrasion plus microfracture), and to analyse graft failure rates with regard to the tibial slope.

METHODS

Fifty cases (48.9 ± 5.4 years) of combined HTO, ACLR and CR were retrospectively analysed with regard to survival, functional outcome (subjective International Knee Documentation Committee (IKDC) examination form) and subjective satisfaction. The tibial slope was determined on lateral radiographs and analysed with regard to its influence on graft functionality at the time of hardware removal.

RESULTS

Follow-up rate was 100% after 5.6 ± 1.6 years. No arthroplasties were performed. Subjective IKDC score was 70 ± 18, and 94% were satisfied with the result. The graft was intact in 39 cases (78%), and non-functional in 11 cases (22%). No significant changes were present in pre- and postoperative tibial slope (P = 0.811). Graft insufficiency was strongly dependent on tibial slope, with a failure rate of seven percent in cases of postoperative tibial slope <7.5°, 24% in cases of 7.5-12.5°, and 36% in cases of >12.5°.

CONCLUSION

Combined HTO, ACLR and CR is an effective treatment in these cases. The graft failure rate increases with an increase in tibial slope, in particular when exceeding 12.5°.

LEVEL OF EVIDENCE

Case series, Level 4.

Molecular signatures that can be transferred across different omics platforms

Motivation

Molecular signatures for treatment recommendations are well researched. Still it is challenging to apply them to data generated by different protocols or technical platforms.

Results

We analyzed paired data for the same tumors (Burkitt lymphoma, diffuse large B-cell lymphoma) and features that had been generated by different experimental protocols and analytical platforms including the nanoString nCounter and Affymetrix Gene Chip transcriptomics as well as the SWATH and SRM proteomics platforms. A statistical model that assumes independent sample and feature effects accounted for 69–94% of technical variability. We analyzed how variability is propagated through linear signatures possibly affecting predictions and treatment recommendations. Linear signatures with feature weights adding to zero were substantially more robust than unbalanced signatures. They yielded consistent predictions across data from different platforms, both for transcriptomics and proteomics data. Similarly stable were their predictions across data from fresh frozen and matching formalin-fixed paraffin-embedded human tumor tissue.

Availability and Implementation

The R-package ‘zeroSum’ can be downloaded at https://github.com/rehbergT/zeroSum. Complete data and R codes necessary to reproduce all our results can be received from the authors upon request.