Differential approach to peripheral blood cell ratios in patients with systemic lupus erythematosus and various manifestations

New markers of systemic lupus erythematosus (SLE) activity are under investigation. In recent years, the researchers have been focusing increased attention on the role of haematological indicators in assessing the disease activity. Specifically, neutrophil-, basophil-, eosinophil-, monocyte- and platelet-to-lymphocyte ratios (NLR, BLR, ELR, MLR and PLR) have been considered. The specific objective of this study was to determine the suitability of the haematological markers for the assessment of SLE activity and SLE-related organ damage. This study is a retrospective analysis of 136 patients with SLE (124 women and 12 men) who received chloroquine/hydroxychloroquine (HQ/HCQ) monotherapy or HQ/HCQ therapy combined with low/medium doses of glucocorticoid. All patients were assessed for disease activity using the Systemic Lupus Erythematosus Disease Activity Index 2000 (SLEDAI-2K) scale. In addition, erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) inflammatory parameters were determined in each patient. NLR, BLR, ELR, MLR and PLR were evaluated and correlated with the SLE activity parameters and inflammatory markers. The mean values of the haematological indicators were compared in particular manifestations of SLE-induced organ damage. For numerical variables, descriptive statistics were calculated: median, standard deviation, minimum and maximum values. The Mann–Whitney U test was used for the comparison of continuous variables in the two groups. The Spearman rank correlation test was used to search for any relationships between variables. A p value < 0.05 was considered to be statistically significant. We have found a positive correlation between ELR, MLR and the SLEDAI scale (r = 0.22 and r = 0.27, respectively). NLR, MLR and PLR ratios were significantly correlated with ESR and CRP. Considerably higher NLR values were found in patients with cutaneous and/or mucosal symptoms and with kidney involvement compared to patients without such involvement (4.26 ± 4.2 vs 3.27 ± 2.7; p = 0.05 and 5.45 ± 5.6 vs 3.05 ± 2.0; p < 0.001 respectively). BLR and MLR were significantly higher in patients manifesting symptoms of vasculitis (0.09 ± 0.1 vs 0.02 ± 0.01; p < 0.001 and 3.1 ± 4.2 vs 0.3 ± 0.1; p < 0.001 respectively), arthritis and/or myositis (0.04 ± 0.09 vs 0.02 ± 0.01; p = 0.01 and 1.02 ± 2.6 vs 0.35 ± 0.4; p = 0.01 respectively), whereas elevated ELR ratios were observed in patients with vasculitis (0.4 ± 0.5 vs 0.08 ± 0.06; p < 0.001) compared to patients without such organ involvement. The PLR marker was substantially higher in patients exhibiting haematological disorders in the course of SLE (276.6 ± 226.4 vs 192.6 ± 133.5; p = 0.01). The results indicate that ELR and MLR are effective markers of SLE activity. The haematological indicators may predict SLE-dependent organ damage, particularly cutaneous, mucosal, arthritic, myositic, haematological and kidney involvement.

Peptidyl Arginine Deiminase Type 4 Gene Promoter Hypo-Methylation in Rheumatoid Arthritis

Protein citrullination is carried out by peptidylarginine deiminase type 4 (PAD4) enzyme. As a consequence of this process, post-translationally modified proteins are formed that become antigens for anti-citrullinated protein antibodies (ACPA). The study aimed at identifying whether the PADI4 gene is subject to epigenetic regulation through methylation of its promoter region, whether the degree of methylation differs in healthy individuals vs. rheumatoid arthritis (RA) patients and changes in correlation with ACPA, anti-PAD4 and disease activity. A total of 125 RA patients and 30 healthy controls were enrolled. Quantitative real-time methylation-specific PCR was used to analyze the methylation status. ACPA and anti-PAD4 antibodies were determined in serum by enzyme-linked immunosorbent immunoassay. The differences were observed in the degree of PADI4 gene promoter methylation between RA patients and HC, along with an upward trend for the methylation in RA, which was inversely proportional to the disease activity. A weak or modest negative correlation between the degree of PADI4 gene methylation and anti-PAD4, disease activity score (DAS28) and ACPA level has been found. The elevated methylation is associated with lower disease activity, lower levels of ACPA and aPAD4. The methylation degree in this area is growing up during effective treatment and might play a role in the RA pathophysiology and therefore could be a future therapeutic target.

Hypermethylation of the miR-155 gene in the whole blood and decreased plasma level of miR-155 in rheumatoid arthritis

Objectives

miR-155 plays a critical role in the inflammatory process and in diseases such as rheumatoid arthritis (RA). miR155 gene expression is regulated by its gene promoter region CpG island methylation. Previous studies have shown inconsistent changes in circulating levels of mir-155 in RA patients. The aims of our study were to evaluate miR-155 levels in plasma, to investigate its gene methylation level, and to correlate these levels with RA disease activity.

Methods

One hundred and twenty-five patients with RA, and 30 age and sex-matched healthy controls (HC) were enrolled. Whole blood and plasma samples were collected and stored at -80°C until analysis. DAS28 score at the time of the blood draw was used to assess RA disease activity. The methylation status of miR-155 host gene was determined in whole blood by quantitative real-time methylation-specific PCR (qPCR). miR-155 expression levels were evaluated by quantitative reverse transcription PCR.

Results

We found significantly lower circulating miR155 levels in RA patients compared to HC. Interestingly, the miR-155 gene methylation level was significantly higher in RA patients than in HC. miR-155 levels did not correlate with ACPA or RF positivity or disease activity.

Conclusions

We show here higher miR-155 methylation in whole blood and lower plasma miR155 expression in RA patients in comparison to HC. The evaluation of miR-155 host gene methylation status or miR155 plasma level might be a potentially useful marker in RA determination.

AB0096 FCER1G GENE METHYLATION AND MIR-106/MIR-17 AS A NEW POTENTIAL EPIGENETIC MARKERS IN RHEUMATOID ARTHRITIS

Background:

Rheumatoid arthritis (RA) is a chronic inflammatory disease that leads to joints destruction. One of the most important cytokine responsible for this process is interleukin 6 (IL-6). Fc receptor gamma chain (FcRγ), encoded byFCER1Ggene, is responsible for neutrophils activation, phagocytosis, cell surface signaling pathway as well as IL-4, IL-6, IL-10 and tumor necrosis factor production. Epigenetic factors, including DNA methylation and micro-RNAs (miRs) expression regulate the genes expression on transcriptional and post-transcriptional mechanisms. There are miRs responsible for cytokines production, for example GU rich miRs, miR-106b and miR-155 were reported as associated with IL-6 overproduction.

Objectives:

The aim of our study was to evaluateFCER1Ggene methylation and miR-17 family members as epigenetic markers associated with RA, disease activity and IL-6 expression.

Methods:

Bioinformatics analysis were applied to select the miRs with a possible target sites in a promoter region ofFCER1Ggene. The MiR-17 family members, including miR-17, miR-93 and miR-106b were selected for investigation.

A total of 74 individuals, 50 RA patients, 84% female, aged 53,7±12,3 years (mean±SD) and 24 healthy controls (HC), 87,5% female, aged 53±8,49 years were enrolled. RA patients were selected based on DAS-28 scoring. RA patients with high disease activity (DAS28 >5,1; 58%) and remission (≤2,6; 42%) were included in the analysis. DNA was extracted from a whole blood and miRs were extracted from plasma. Quantitative real-time PCR was use for analyze both methylation and expression levels. In a randomly selected samples (16 from high disease activity group; 9 from remission and 19 from HC) the level of IL-6 in serum was evaluated.

Results:

Patients with RA in comparison to HC have had a lowerFCER1Gmethylation (0.98 [0.73-1.46] vs 1.96 [1.44-3], p<0.00001; median [interquartile range]) and miR-106b (0.79 [0.49-1.68] vs 1.54 [0.88-2.51], p=0.008) and miR-17 (1.26 [0.41-2.04] vs 2.44 [2.09-3.47], p=0.0001) expressions. No difference in methylation between high and remission RA groups was found. MiR-106b and miR-17 expressions were different between RA patients with high disease activity and remission (p=0.009 and p=0.003, respectively), however a high disease activity group was not different to HC (p=0.82 and p=0.12, respectively). Detailed results are presented in Table 1. A strong correlation between IL-6 levels andFCER1Gmethylation (rs= -0.46) was found.

Table 1.

Methylation and expression between patients divided by disease activity in compare to controls.

High disease activity, n=29Remission, n=21HC, n=24FCER1Gmethylation1.11 [0.83-1.52]0.96 [0.61-1.18]1.96 [1.44-3]miR-106b expression1.36 [0.63-1.76]0.54 [0.19-1.19]1.54 [0.88-2.51]miR-93 expression0.63 [0.49-1.21]0.59 [0.15-1.5]1.03 [0.65-1.38]miR-17 expression1.46 [1.05-2.54]0.34 [0.11-1.26]2.44 [2.09-3.47]

Data are given by median [interquartile range]. FCER1G, Fc receptor gamma chain gene; HC, healthy controls; miR, micro-RNA; RA, rheumatoid arthritis patients.

Conclusion:

FCER1Gmethylation was found as a new epigenetic marker of RA, which is independent of disease activity and may be associated with IL-6 production. Plasma miR-17 and miR-106b can be considered as a novel molecular biomarkers of disease severity in RA.

FcRγ may plays a significant role in RA pathogenesis andFCER1Ggene methylation was found as a new, epigenetic and promising marker of RA.

References:

[1]Németh T, Futosi K, Szabó M, Aradi P, Saito T, Mócsai A, Jakus Z. Importance of Fc Receptor γ-Chain ITAM Tyrosines in Neutrophil Activation and in vivo Autoimmune Arthritis. Front Immunol. 2019 Feb 25;10:252.

[2]Cunningham F et al. Ensembl 2019. Nucleic Acids Res. 2019 Jan 8;47(D1):D745-D751.

[3]Salvi V, Gianello V, Tiberio L, Sozzani S, Bosisio D. Cytokine Targeting by miRNAs in Autoimmune Diseases. Front Immunol. 2019 Jan 29;10:15.

Disclosure of Interests:

Marek Ciesla: None declared, Bogdan Kolarz: None declared, Magdalena Dryglewska: None declared, Maria Majdan Consultant of: Roche, Amgen, Speakers bureau: Roche, Amgen

SAT0218 SINGLE NUCLEOTIDE POLYMORPHISMS LOCATED IN REGULATORY REGIONS OF GENES INVOLVED IN SYSTEMIC INFLAMMATION (MAMDC1, ITGAM, AND CRP) CORRELATION WITH THE CLINICAL PICTURE OF DISEASE AND ACTIVITY PARAMETERS IN SYSTEMIC LUPUS ERYTHEMATOSUS

Background:

The exact pathogenesis of systemic lupus erythematosus (SLE) is poorly understood. It is an autoimmune disease that leads to a chronic inflammatory process involving numerous tissues and organs (skin, kidneys, joints, central nervous system, cardiovascular, respiratory, digestive and hematopoietic systems). However, despite the advancement of SLE molecular biology and the wide availability of tests and diagnostic tools, the knowledge about factors predicting the clinical disease activity as well as related changes in the laboratory results is insufficient.

Objectives:

The goal of the study was to assess the relationship between selected single nucleotide polymorphisms (SNPs) and the clinical picture of diseaseand some activity parametersin patients with SLE.

Methods:

We conducted a study of adult patients with SLE diagnosed and treated in the Rheumatology Department of Medical University of Lublin between 2016-2019. We enrolled 80 patients with SLE (71 women, 9 men), with the median (range) age 36 (19-72) and disease duration 6 (1-37) years. To objectively assess disease activity, standardized SLE activity scale - SLEDAI (Systemic Lupus Erythematosus Disease Activity Index) was used. Using the Real-Time PCR method and specific TaqMan probes SNPs of 3 genes:MAMDC1(rs910875; c.-1687G> C),CRP(rs3091244; c.-390C> A), andITGAM(rs7193943; c.-323G> A) were analyzed and then their relationship with specific clinical picture of disease, activity and laboratory results were assessed.

Results:

Carriers of the CC genotype compared to the remaining polymorphic variants (CG and GG) of theMAMDC1gene had an approximately 4-fold higher risk of skin disease compared to other clinical pictures of disease (renal, articular, neuro-psychiatric, hematological) (OR = 4.04; p = 0.0110)). Carriers of this genotype also had a higher risk of hematuria (OR = 4.57; p = 0.0082), sterile leukocyturia (OR = 53.91; p = 0.0071), the presence of anti-Sm / RNP antinuclear antibodies (OR = 4.15, p = 0.0074), reduced values of the C3 complement component (OR = 6.11; p = 0.0071) and the need for oral glucocorticosteroids (OR = 7.01; p = 0.0028). In addition, significantly higher values of SLEDAI disease activity scale were observed in carriers of the CC genotype of theMAMDC1gene (medians: 6 vs 4; p = 0.0220). Moreover, we observed a trend towards a higher risk of hepatomegaly in GG genotype carriers of theITGAMgene (OR=18.50; p=0.0525). In addition, the AA genotype of theCRPgene was associated with a higher risk of proteinuria (OR = 84; p <0.0001), Anti-SSA / Ro autoantibodies (OR = 3.29; p = 0.0484), and aCL IgM (OR = 3.42; p = 0.0332) occurrence. Carriers of AA genotype of the above gene were also at higher risk of earlier occurrence of first disease symptoms as well as disease diagnosis at a younger age (respectively: 24 vs 31 years; p=0.0225, 23 vs 29 years; 0.0442).

Conclusion:

The results suggest the relationship between SNPs in genes involved in systemic inflammation (MAMDC1, ITGAM, CRP) and disease activity as well as the occurrence of some specific clinical pictures of disease in patients with SLE.The genetic dispositions described above may serve as attractive markers in SLE, potentially useful in clinical practice.

Disclosure of Interests:

Aleksandra Majdan: None declared, Radosław Mlak: None declared, Marcin Mazurek: None declared, Dominika Pigon: None declared, Maria Majdan Consultant of: Roche, Amgen, Speakers bureau: Roche, Amgen, Teresa Malecka Massalska: None declared

FRI0223 SUBPHENOTYPES OF ANCA ASSOCIATED VASCULITIS IDENTIFIED BY LATENT CLASS ANALYSIS

Background:

ANCA associated vasculitides (AAV) are a heterogeneous group of rare diseases with unknown etiology and the clinical spectrum ranging from life-threatening systemic disease, through single organ involvement to minor isolated skin changes. Thus there is an unmet need for phenotype identification especially among patients with granulomatosis with polyangiitis GPA, patients with microscopic polyangiitis MPA group seems to be more uniform. Recently, based on previous clustering analysis and clinical, histopathological, serological and prognostic aspects three subcategories of AAV have been proposed and named as: non-severe AAV, severe PR3-AAV and severe MPO-AAV [1].

Objectives:

In line with these attempts to subcategorize AAV we decided to use latent class analysis (LCA) on a large multicenter cohort of polish AAV patients from POLVAS [2] registry to identify potential new subphenotypes or confirm already proposed ones.

Methods:

Latent Class Analysis (LCA) approach was used as a model based clustering method of objects described by dichotomous (e.g., gender; ANCA status – cANCA, pANCA; organ involvement - skin, eye, ENT, respiratory, heart, GI, renal, urinary, CNS, peripheral nerves) and polytomous (number of relapses) variables supported by quantitative covariates (e.g., age at diagnosis, CRP at diagnosis, maximal serum creatinine concentration ever).

Results:

Results of LCA on our AAV group returned four class model of AAV subphenotypes, confirming existence of the previously proposed by Mahr at al. [1] and revealed fourth – previously not described clinically relevant subphenotype. To this fourth class - belong patients only with GPA, diagnosed at young age, with multiorgan involvement, high relapse rate and relatively high risk of death.

Table 1.

AAV subcategorization – summary of clinical characteristics and ANCA specificity

LCA Class 1LCA Class 2LCA Class 3LCA Class 4No of patients13019410297AAV typeMainly GPAMainly GPAmainly MPAOnly GPAAge at diagnosisMiddle ageMiddle ageOldYoungMale/female ratio1:22:11:11:1Main organ involvementENT, respiratory, eyeRenal, respiratory, ENTRenal, respiratory, skinMultiorgan involvementRelapse rateintermediateintermediatelowhighModified class description (based on ref. [1])Non severe AAVSevere PR3 AAVSevere MPO AAVSevere non-renalPR3 AAV

Conclusion:

Based on multiple clinical and serological variables LCA methodology identified 4-class subphenotypes model of AAV. Fourth-class is a new clinically important subphenotype including exclusively PR3-positive young AAV patients with multiorgan involvement, high risk of relapse and distinct mortality.

References:

[1]Mahr A, Specks U, Jayne D. Subclassifying ANCA-associated vasculitis: a unifying view of disease spectrum. Rheumatol Oxf Engl 2019;58:1707–9.https://doi.org/10.1093/rheumatology/kez148.

[2]Wójcik K, Wawrzycka-Adamczyk K, Włudarczyk A, Sznajd J, Zdrojewski Z, Masiak A, i in. Clinical characteristics of Polish patients with ANCA-associated vasculitides—retrospective analysis of POLVAS registry. Clinical Rheumatology. 1 wrzesień 2019;38(9):2553–63.

Disclosure of Interests:

Krzysztof Wójcik: None declared, Adam Ćmiel: None declared, Anna Masiak: None declared, Zbigniew Zdrojewski: None declared, Radoslaw Jeleniewicz: None declared, Maria Majdan Consultant of: Roche, Amgen, Speakers bureau: Roche, Amgen, Iwona Brzosko: None declared, Marek Brzosko: None declared, Piotr Głuszko: None declared, Małgorzata Stasiek: None declared, Małgorzata Wisłowska: None declared, Joanna Kur-Zalewska: None declared, Marta Madej: None declared, Anna Hawrot-Kawecka: None declared, Hanna Storoniak: None declared, Barbara Bułło-Piontecka: None declared, Alicja Dębska-Ślizień: None declared, Eugeniusz Kucharz: None declared, Katarzyna Jakuszko: None declared, Jacek Musiał: None declared

FRI0210 ORBITAL PSEUDOTUMOR AMONG PATIENTS WITH GRANULOMATOSIS WITH POLYANGIITIS – DATA FROM THE POLISH REGISTRY POLVAS

Background:

Orbital inflammatory masses have been described as the common manifestation of granulomatosis with polyangiitis (GPA) occuring in 7- 45% of patients.

Objectives:

Identification and characterization of patients with orbital pseudotumor among Polish patients based on the national vasculitis registry, POLVAS.

Methods:

Clinical presentation and management of all GPA patients fulfilling ACR criteria or Chapel Hill Consensus Conference definition included to the Polish registry POLVAS who developed orbital masses in the course of GPA were evaluated.

Results:

Ocular involvement was found in 114 (27%) of 417 GPA patients registered in POLVAS, 34 (8%) developed orbital masses. Mean patients’ age was 47.8 (range from 19-75) yrs., 23 (67%) were women. Forty four per cent of the patients developed tumor at the beginning of the disease, 56% during relapse. Patients’ characteristics on diagnosis of orbital mass: 24 cANCA, 2 pANCA, and 8 ANCA negative, 9% active smokers and 31% past smokers, 29% had localized disease, 21% early systemic and 50% systemic with organ involvement, 29% had other type of ophthalmological involvement before pseudotumor occurred, 88% had active paranasal sinus involvement, 41% lungs, 15% CNS, 15% skin and 6% heart manifestations. Thirty seven per cent of patients had positive nasal swabs cultures, 50% of which were positive for Staphylococcus aureus. In 65%, tumor occurred during steroid therapy (46% had prednisone more than 5mg/d) and 45% on immunosuppressive treatment (19% when treated with AZA, 16% MTX, 6,5% MMF and 3,5% CYC). Due to orbital mass 86.5% were treated with CYC and 13.5% with RTX. Twenty one per cent had complete remission of the pseudotumor, 76% partial remission and in 3% patients there was no response to the treatment; 43% developed visual impairment, 20% suffered from blindness.

Conclusion:

Orbital inflammatory mass was not common manifestation of GPA among our patients. The mass developed at the beginning or in the course of the disease, even during immunosuppressive treatment. Orbital masses have been resistant to therapeutic interventions and were accompanied by high risk of visual impairment.

Disclosure of Interests:

Anna Masiak: None declared, Marcin Ziętkiewicz: None declared, Krzysztof Wójcik: None declared, Katarzyna Wawrzycka-Adamczyk: None declared, Radoslaw Jeleniewicz: None declared, Marta Madej: None declared, Joanna Kur-Zalewska: None declared, Katarzyna Jakuszko: None declared, Małgorzata Wisłowska: None declared, Hanna Storoniak: None declared, Michał Komorniczak: None declared, Barbara Bułło-Piontecka: None declared, Iwona Brzosko: None declared, Małgorzata Stasiek: None declared, Eugeniusz Kucharz: None declared, Alicja Dębska-Ślizień: None declared, Maria Majdan Consultant of: Roche, Amgen, Speakers bureau: Roche, Amgen, Jacek Musiał: None declared, Zbigniew Zdrojewski: None declared

FRI0080 CLINICAL CHARACTERISTICS OF PATIENTS WITH ELDERLY-ONSET RHEUMATOID ARTHRITIS (EORA)

Background:

The onset of rheumatoid arthritis (RA) occurs usually between 35-50 years of age. Since the general population is ageing, beginning of RA in older age is more common. The termelderly onset of rheumatoid arthritis(EORA) describes the disease with onset at age over 60. The termyounger-onset rheumatoid arthritis(YORA) refers to the disease with typical, earlier onset. Observational studies indicate, that substantial differences do occur between the two RA subtypes (EORA and YORA).

Objectives:

The goal of the study was to analyze the course of disease and treatment in EORA in comparison to YORA patients.

Methods:

The study was conducted in consecutive RA patients, treated in the Department of Rheumatology and Connective Tissue Diseases, Medical University of Lublin, Poland. The study group consisted of 113 patients (93 women, 20 men), with the mean (SD) age 59.4 (19.0), disease duration 12.9 (10.3) years.

The cut off between EORA and YORA was set at 60 years of age. There were 63 (55.8%) EORA and 50 (44.2%) YORA patients. Demographic and clinical information was obtained through structured interview, review of medical records and laboratory tests. Disease activity was assessed based on joint counts and Disease Activity Score of 28 joints (DAS28).

Results:

In patients with EORA vs YORA, the mean (SD) age was 73.64 (6,6) vs 41.5 (13.7) (p<0.001), the age of RA diagnosis 65.0 (4.2) vs 23.3 (4.8) (p<0.001), RA duration 8.6 (5.4) vs 18.3 (12.3) years (p<0.001).

The group of patients with EORA compared with YORA, was characterized by: significantly higher number of men [respectively 16 (25.4%) vs 4 (8.0%)], unfavorable metabolic parameters [higher body mass index (BMI): 26.0 (5.8) vs 23.4 (4.1) kg/m2(p=0.04); serum uric acid: 5.7 (1.5) vs 4.4 (1.6) mg/dl (p=0.001)], as well as unfavorable parameters of RA activity [higher DAS28: 4.4 (1.5) vs 3.2 (1.6) (p<0.001); higher tender joints count (TJC): 6.1 (6.2) vs 3.2 (3.7) (p=0.01); higher erythrocyte sedimentation rate (ESR) 45.9 (30.3) vs 24.1 (25.6) (p<0.001) and white blood cell count (WBC): 8.3 (2.7) vs 7.0 (2.4)x103/ml (p=0.01)]. At the time of assessment, remission or low disease activity was achieved in significantly fewer EORA vs YORA patients [15 (23.8%) vs 25 (50%) (p=0.007)].

In EORA patients methotrexate was used as the first disease modifying drug (DMARD) more often [54 (85.7%) vs 26 (52%) (p<0.001)], the use of biological DMARDs was less common [5 (7.9%) vs 23 (46.0%) (p<0.001)], as well as glucocorticoids (GC) [49 (77.8%) vs 47 (94.0%) (p=0.04)]. Significantly more patients with EORA than YORA, were affected by concomitant diseases [62 (98.4%) vs 41 (82%) (p=0.007)].

The prevalence of joint erosions, extra-articular manifestations and antibodies typical for RA (rheumatoid factor, RF-IgM and/or anti-citrullinated peptide, ACPA) did not differ significantly between the groups.

Conclusion:

In our study group, EORA patients were characterized by higher proportion of men, higher inflammatory parameters and higher disease activity, in comparison with YORA. In patients with EORA we also found unfavorable metabolic parameters and higher incidence of concomitant diseases, which could affect the method of treatment (less common use of GC and biological DMARDs).

Disclosure of Interests:

Bozena Targonska-Stepniak Consultant of: Berlin-Chemie Mennarini, Sandoz, Speakers bureau: KRKA, Sandoz, Krzysztof Grzechnik: None declared, Katarzyna Kolarz: None declared, Danuta Gagol: None declared, Maria Majdan Consultant of: Roche, Amgen, Speakers bureau: Roche, Amgen

Clinical and serological parameters of progression and prognosis in patients with systemic sclerosis - a state of the art review

OBJECTIVE

Systemic sclerosis (SSc) is a multi-organ connective tissue disease that leads to the dysfunction and the impaired morphology of blood vessels due to non-specific inflammation and progressive fibrosis. Due to the diversity of SSc and even though the factors predisposing to the severe course of SSc are known, it is not always possible to predict the disease progression and to determine the prognosis. Ideally, the group of patients with faster progression of organ lesions and a worse course of the disease should be identified and the early intensive treatment should be instituted. The aim of the article, is an attempt to identify the factors that worsen the prognosis in the course of SSc. The analysis of numerous studies demonstrated that patients with short-lasting SSc, with the presence of anti-RNA polymerase III antibodies, with a generalized type of SSc with quickly progressing skin lesions and males should be most strictly monitored. Moreover, vascular complications, tendon ruptures and fast capillaries loss observed in nailfold capillaroscopy are the factors deteriorating the prognosis in SSc.

CONCLUSION

In conclusion, despite the known, the factors that worsen the prognosis, it is difficult to predict the course of systemic sclerosis. Due to its incompletely elucidated etiopathology as well as the diverse and unpredictable nature of the disease, reliable markers to determine the prognosis in SSc have not been found.

Seasonal patterns of traumatic brain injury deaths due to traffic-related incidents in the Slovak Republic

Objective: Traumatic Brain Injuries (TBIs) are an important type of injury in terms of both morbidity and mortality. Road Traffic Incidents are one of the most frequent causes of TBI. This analysis seeks to quantify the number of such injuries occurring in the Slovak Republic, and examine patterns of TBI according to mode of transport and seasonality.Methods: Data concerning total numbers of TBIs occurring from the years 1996-2015 were obtained from the Statistical Office of the Slovak Republic. The events caused by road incidents were examined separately according the external cause stated on death certification. Events were classified into seasons according to the month of death. Summary statistics were produced concerning numbers of deaths according to sex, mode of transport and season. Analyses were performed to examine trends in TBI by season and type of road user.Results: During a period of 20 years from 1996, there were 17,047 recorded deaths involving TBI in the Slovak Republic. Of these, 5,370 were caused by road traffic incidents (RTIs). Age standardized rates tended to decrease from 8.3/100,000/year (1996) to 2.5/100,000/year (2015). Males made up approximately 79% of road traffic-caused TBIs. Summer and autumn showed significantly more events than any other season, with motorcyclists and cyclists in particular being more frequently injured at this time of year.Conclusions: The results show that Slovakia, like many countries, suffers a considerable burden of TBI and that RTIs are a major contributor to this, especially among young adults. Rates of TBI vary by season in Slovakia, and users of different modes of transport appear more or less likely to suffer such injury during different seasons. Considerable variability in rates of injury exists between road users and times of year. Improved understanding of the timing and sufferers of injuries may allow better planning of response and care services. Further research into transport modes and policies aimed at safer driving should be explored.

Factors associated with quality of life in systemic sclerosis: a cross-sectional study

INTRODUCTION

Systemic sclerosis (SSc) is a connective tissue disease characterized by progressive fibrosis of the skin and internal organs, leading to their failure and disturbances in the morphology and function of blood vessels. The disease affects people in different ways, and identifying how the difficulties and limitations are related to quality of life may contribute to designing helpful interventions. The aim of this study was to identify factors associated with quality of life in people with SSc.

METHODS

This was a cross-sectional study conducted in 11 rheumatic centres in Poland. Patients diagnosed with SSc were included. Quality of life was measured using the SSc Quality of Life Questionnaire (SScQoL). The following candidate factors were entered in preliminary multivariable analysis: age, place of residence, marital status, occupational status, disease type, disease duration, pain, fatigue, intestinal problems, breathing problems, Raynaud's symptoms, finger ulcerations, disease severity, functional disability, anxiety and depression. Factors that achieved statistical significance at the 10% level were then entered into a final multivariable model. Factors achieving statistical significance at the 5% level in the final model were considered to be associated with quality of life in SSc.

RESULTS

In total, 231 participants were included. Mean age (SD) was 55.82 (12.55) years, disease duration 8.39 (8.18) years and 198 (85.7%) were women. Factors associated with quality of life in SSc were functional disability (β = 2.854, p < 0.001) and anxiety (β = 0.404, p < 0.001). This model with two factors (functional disability and anxiety) explained 56.7% of the variance in patients with diffuse SSc and 73.2% in those with localized SSc.

CONCLUSIONS

Functional disability and anxiety are significantly associated with quality of life in SSc. Interventions aimed at improving either of these factors may contribute towards improving the quality of life of people with SSc.

Monitoring the activity of anca-associated vasculitis: some questionnaires and laboratory parameters

Systemic vasculitis is a group of diseases manifested by symptoms from many organs. ANCA-associated vasculitis (AAV) require chronic and often aggressive immunosuppressive treatment. This treatment should be adapted to the disease activity. Assessment of AAV is based on various disease activity questionnaires which contain clinical symptoms of the disease and lab results. The most useful questionnaire is BVAS version 3 (Birmingham Vasculitis Activity Score). In every patients, distinction between activity of AAV and irreversible damage is needed. ANCA antibodies are a predictor of poor prognosis in some patients. Using of these antibodies in monitoring of AAV activity has got minor importance.

Urticarial rash, fever, and arthritis: A case of refractory Adult-onset Still's disease with good response to tocilizumab

Adult-onset Still's disease (AOSD) is a rare, systemic inflammatory disorder of not completely understood etiology. Aberrant activation of the innate immune system and overproduction of several pro-inflammatory mediators are considered a critical component in disease pathogenesis. AOSD still poses a challenge due to the broad range of differential diagnoses and no specific biomarkers. Four cardinal symptoms are quotidian spiking fever, joint involvement, evanescent salmon pink-rash rash, and leukocytosis with neutrophilia. We present a case of a 61-year-old female with a recurrent urticarial rash accompanied by attacks of high fever, tender joints, sore throat, enlarged liver, elevated inflammatory reactants, and hyperferritinemia. After an extensive workup, the patient fulfilled the criteria of AOSD. She was refractory to the glucocorticosteroids and disease-modifying anti-rheumatic drugs (DMARDs). Finally, after several unsuccessful attempts to achieve disease control with traditional DMAR's administration of Tocilizumab (TCZ), a humanized anti-IL-6 receptor antagonist resulted in substantial disease improvement. Since skin manifestations are a common feature of AOSD, it should be among differential diagnoses in patients with skin lesions and constitutional symptoms. Biologic agents represent a significant therapeutic advance in patients with AOSD refractory to conventional therapy.

IRF5 promoter methylation as a new potential marker of rheumatoid arthritis

Introduction: The interferon regulatory factor 5 (IRF5) gene is implicated in the toll‑like receptor signaling pathway and has proinflammatory and chemotactic effects, but its role in the pathogenesis of rheumatoid arthritis (RA) remains unclear. Since the pathobiology of RA shares some similarities with other autoimmune diseases, we tested the hypothesis that RA may be associated with IRF5‑related pathways, as has been reported for systemic lupus erythematosus and Sjögren syndrome. Objectives: The aim of the study was to investigate the association between the presence of methylation in the IRF5 promoter and the morbidity and severity of RA as well as with levels of inflammatory markers. Patients and methods: A total of 146 unrelated individuals, 122 patients with RA and 24 healthy controls, were enrolled in the study. All RA patients were genotyped with regard to the following polymorphisms in the IRF5 gene: rs10488631, T>C and rs4728142 G>A. The methylation analysis included 52 patients with RA and 24 healthy controls. A quantitative real‑time methylation‑specific polymerase chain reaction was used to evaluate methylation status. Results: We found differences between patients with RA and healthy controls in the methylation pattern of the promoter region. The methylation level was 43.6% lower in RA patients than in controls (median [interquartile range], 0.79 [0.6-1.13] vs 1.4 [1.16-1.66]; P = 0.0001). Variant rs4728142 G>A was more common in seronegative patients with RA. Conclusions: The methylation profile of the IRF5 promoter may be used as a new potential marker of RA, which is independent of current criteria of disease activity.

Head trauma in sports - clinical characteristics, epidemiology and biomarkers

Traumatic brain injury (TBI) is clinically divided into a spectrum of severities, with mild TBI being the least severe form and a frequent occurrence in contact sports, such as ice hockey, American football, rugby, horse riding and boxing. Mild TBI is caused by blunt nonpenetrating head trauma that causes movement of the brain and stretching and tearing of axons, with diffuse axonal injury being a central pathogenic mechanism. Mild TBI is in principle synonymous with concussion; both have similar criteria in which the most important elements are acute alteration or loss of consciousness and/or post-traumatic amnesia following head trauma and no apparent brain changes on standard neuroimaging. Symptoms in mild TBI are highly variable and there are no validated imaging or fluid biomarkers to determine whether or not a patient with a normal computerized tomography scan of the brain has neuronal damage. Mild TBI typically resolves within a few weeks but 10-15% of concussion patients develop postconcussive syndrome. Repetitive mild TBI, which is frequent in contact sports, is a risk factor for a complicated recovery process. This overview paper discusses the relationships between repetitive head impacts in contact sports, mild TBI and chronic neurological symptoms. What are these conditions, how common are they, how are they linked and can they be objectified using imaging or fluid-based biomarkers? It gives an update on the current state of research on these questions with a specific focus on clinical characteristics, epidemiology and biomarkers.

[Late-onset sjögren's syndrom]

Sjögren's syndrome is a systemic autoimmune disease characterized by exocrine glands damage, resulting in the development of dry eyes and dry mouth, as well as extraglandular manifestation. It usually starts between the ages of 30 and 50. Late-onset Sjögren's syndrome should be considered as a disease that appears after age 65, but the literature also reports of the age 50, 60, or even 70. The prevalence of late-onset Sjögren's syndrome is estimated about 20%. The course of late-onset Sjögren's syndrome may differ when compared with patients with a younger onset. Lack of sicca symptoms and marker antibodies may be associated with a delay in Sjögren's syndrome diagnosis. Particularly in the elderly, the occurrence of sicca symptoms may be considered as age-related and medication-related.

[Uwarunkowania opóźnienia rozpoznań osiowych spondyloartropatii zapalnych]

OBJECTIVE

Wstęp: Prawdopodobieństwo rozwoju osiowej postaci spondyloartropatii zapalnej (axSpA) wynosi ponad 90% u chorych z przewlekłym bólem kręgosłupa, obecnym antygenem HLA B27 i dodatnim wywiadem rodzinnym w kierunku zesztywniającego zapalenia stawów kręgosłupa (ZZSK), łuszczycy, reaktywnego zapalenia stawów, chorób zapalnych jelit lub zapalenia błony naczyniowej oka. Aktywność choroby w postaci nieradiologicznej axSpA i ZZSK podobnie wpływa na jakość życia a z praktycznego punktu widzenia podejście do leczenia jest jednakowe. Cel pracy: Próba identyfikacji przyczyn spóźnionych rozpoznań ZZSK wśród chorych hospitalizowanych w Klinice Reumatologii i Układowych Chorób Tkanki Łącznej w Lublinie oraz sugestie dotyczące poprawy ścieżki diagnostycznej, zwłaszcza wśród lekarzy innych specjalności niż reumatolodzy.

PATIENTS AND METHODS

Materiał i metody: Retrospektywnej analizie poddano historie chorób 82 pacjentów z ustalonym rozpoznaniem ZZSK hospitalizowanych w Klinice Reumatologii i Układowych Chorób Tkanki Łącznej w Lublinie w latach 2000-2019, którzy ukończyli 45. rok życia.

RESULTS

Wyniki: Spośród 82 chorych (28 kobiet i 54 mężczyzn) rozpoznanie ZZSK po 45. roku życia postawiono u 25 chorych (10 kobiet i 15 mężczyzn) - grupa t (30,4%), u pozostałych 57 chorych (grupa n) rozpoznanie ustalono przed 45. rokiem życia. Średni wiek w chwili rozpoznania w całej grupie (t+n) wynosił 40,7±10,2 (18-76) roku, wiek, w którym pojawił się zapalny ból kręgosłupa (wiek objawów osiowych) wynosił 30,9±8,5 (13-51) roku a opóźnienie rozpoznania (okres od pojawienia się objawów osiowych do ustalenia rozpoznania) 9,7±9,5 (0-46) roku. Nie stwierdzono istotnych statystycznie zależności między płcią a wiekiem w chwili rozpoznania, wiekiem pojawienia się objawów osiowych i opóźnieniem rozpoznania. Nie zaobserwowano istotnych zależności między częstością występowania zapalenia przyczepów ścięgnistych, błony naczyniowej oka, stawów obwodowych, chorób z kręgu spondyloartropatii zapalnych w rodzinie oraz stężenia CRP między grupą t i n. Antygen HLA B27 częściej obecny był w grupie t.

CONCLUSION

Wnioski: Mimo postępu w diagnostyce i większego upowszechniania wiedzy na temat spondyloartropatii zapalnych, opóźnienia w rozpoznaniu tych chorób są wieloletnie, ponieważ pacjenci bardzo często poszukują pomocy u innych specjalistów, którzy mogą być niezaznajomieni z kryteriami bólu zapalnego kręgosłupa. W chwili obecnej jedynymi biomarkerami wykorzystywanymi w diagnostyce i monitorowaniu aktywności spondyloartropatii zapalnych jest odpowiednio obecność antygenu HLA B27 i stężenie CRP a jedynym "biomarkerem obrazowym" jest rezonans magnetyczny. Występowanie objawów pozaosiowych nie poprawia czułości diagnostycznej.

Reasons for diagnostic delays of axial spondyloarthritis

OBJECTIVE

Introduction: The probability of development of axial spondyloarthritis (axSpA) is estimated to be above 90% among patients with chronic back pain, presence of HLA B27 antigen and positive family history of ankylosing spondylitis (AS), psoriasis, reactive arthritis, inflammatory bowel disease or uveitis. The nonradiographic axSpA and ankylosing spondylitis diseases' activity has a comparable impact on the patients' quality of life and from the practical point of view the approach to treatment of each of them is the same. The aim: The attempt to identify the reasons of diagnostic delays of AS among patients hospitalized in the Rheumatology and Connective Tissue Diseases Department in Lublin and to suggest the ways of improving the accuracy of diagnostic track among other healthcare providers than rheumatologists.

PATIENTS AND METHODS

Material and methods: We performed a retrospective analysis of the records of 82 patients' with the established diagnosis of AS, hospitalized in the Rheumatology and Connective Tissue Diseases Department in Lublin in 2000-2019, and of 45 years of age and older.

RESULTS

Results: From among 82 patients (28 women and 54 men) the diagnosis of AS after 45 years of age was established in 25 patients (10 women and 15 men) - group t, and in the other 57 patients (group n) the diagnosis was established before 45 years of age. On average the age at the time of diagnosis in the whole group (t+n) was 40,7±10,2 (18-76) years, the age at the beginning of inflammatory back pain (age of axial symptoms) was 30,9±8,5 (13-51) years and the diagnostic delay (period between first axial symptoms and diagnosis establishment) was 9,75±9,5 (0-46) years. We did not find any statistically significant associations between sex and age at the moment of diagnosis, age of the beginning of axial symptoms and the time of diagnostic delay. There was no significant difference of incidence of enthesitis, uveitis, arthritis, prevalence of family history of spondyloarthritis and CRP level between group t and n. Antigen HLA B27 was more frequently present in group t.

CONCLUSION

Conclusions: Instead of the recognition progress and worldwide popularization of knowledge about axSpA, the diagnostic delays in this field are still estimated to last many years, the patients are looking for other specialists' help, and they can be not knowledgeable of the inflammatory back pain criteria. Currently, HLA B27 antigen and C-reactive protein are the two most commonly used biomarkers for diagnostic and disease activity monitoring purposes of axSpA and magnetic resonance is the only "imaging biomarker". The presence of extra-axial symptoms does not improve the diagnostic sensitivity.

Diastolic dysfunction in rheumatoid arthritis patients with low disease activity

INTRODUCTION/OBJECTIVES

Patients with rheumatoid arthritis (RA) are at increased risk for congestive heart failure (CHF) and left ventricular diastolic dysfunction (LVDD), as compared to the general population. High disease activity is to be associated with higher incidence of cardiovascular disease (CVD), CHF, and mortality in RA patients. LVDD is not anticipated in RA patients without CVD symptoms and may be underdiagnosed especially in those with low disease activity.

METHOD

The study group consisted of 70 RA patients (54 women, 16 men) with no CVD and 33 healthy controls, of comparable age. All RA patients had low disease activity (DAS28 ≤ 3.2) from 2 to 7 years. Laboratory and imaging assessments included metabolic, RA-related, and cardiovascular parameters. Echocardiographic and Doppler studies were conducted in patients and controls with assessment of ejection fraction (EF) and diastolic dysfunction (assessed as E/A ratio).

RESULTS

The mean E/A ratio did not differ significantly between RA patients and healthy controls (1.08 (0.28) vs 0.99 (0.21), NS); comparable numbers of patients and controls had abnormal E/A (< 1.0) (26 (37.1%) vs 10 (30.3%), NS). Patients with decreased E/A were significantly older and had higher disease duration, activity, and presence of bone erosions than their RA counterparts with normal E/A. The mean EF was not significantly different in patients and controls.

CONCLUSIONS

The prevalence of DD as expressed by E/A ratio in RA patients with continued low disease activity was not different from that of controls. Higher disease duration and severity may predispose to DD occurrence in patients with preserved EF.

Anti-CCP antibodies and rheumatoid factor in systemic sclerosis: Prevalence and relationships with joint manifestations

BACKGROUND

It is known that anti-citrullinated protein (a-CCP) antibodies and rheumatoid factor (RF) can be present in systemic sclerosis (SSc) patients, particularly with joint involvement.

OBJECTIVES

The aim of the study was to assess the prevalence of a-CCP antibodies and immunoglobulin M class (IgM) RF, and the relationships between their presence and joint manifestations in patients with SSc.

MATERIAL AND METHODS

The study included 100 European Caucasian SSc patients hospitalized consecutively in the Department of Rheumatology and Connective Tissue Diseases (Lublin, Poland). Anti-citrullinated protein antibodies and IgM RF were determined using a commercial enzyme-linked immunosorbent assay (ELISA) test.

RESULTS

Anti-citrullinated protein antibodies were found in 10 out of 100 (10%) SSc patients and IgM RF in 71 out of 100 (71%) SSc patients. In the study, 90/100 (90%) SSc patients had joint manifestations (arthralgia or arthritis), 34/100 (34%) had arthritis and 6/100 (6%) had a systemic sclerosis-rheumatoid arthritis (SSc-RA) overlap syndrome. Significantly higher a-CCP antibody levels (p = 0.012), erythrocyte sedimentation rate (ESR) (p = 0.029) and C-reactive protein (CRP) levels (p = 0.020) were observed in the SSc group with arthritis. A significant correlation was found between the group with arthritis and the presence of a-CCP antibodies, and between the arthralgia group and the presence of IgM RF.

CONCLUSIONS

The prevalence of RF and a-CCP antibodies is relatively high in SSc, and joint involvement occurs frequently. There was a significantly higher prevalence of IgM RF in the group with joint manifestations. About 1/3 of SSc patients had symptoms of arthritis. Arthritis is connected with the presence of a-CCP antibodies, while arthralgia is connected with the presence of IgM RF.

Tofacitinib in the treatment of patients with rheumatoid arthritis: position statement of experts of the Polish Society for Rheumatology

Tofacitinib is a newly approved small-molecule targeted synthetic disease-modifying antirheumatic drug. The drug was designed as a selective and specific inhibitor of pro-inflammatory receptor signalling. Tofacitinib inhibits the process of intracellular signalling from the receptor to the cellular nucleus and inhibits the inflammation process via a new pathway (inhibition of the Janus kinases), which is unavailable to biological medicines. Tofacitinib has been approved for use in the treatment of patients with moderate to severe active RA. The drug may be used in combination with methotrexate or another conventional synthetic disease-modifying antirheumatic drug or in monotherapy. The efficacy of tofacitinib has been confirmed in several clinical trials. The drug inhibits radiographic progression of the disease. The innovative mechanism of action of tofacitinib is a noteworthy feature because it offers hope of effective treatment for patients who fail to respond to other drugs. The presented article discusses the mechanism of action and the clinical application of tofacitinib. Tofacitinib represents a new group of disease-modifying antirheumatic drugs that can be placed on an equal footing with biological drugs already available.