Ascending Aortic Length and Its Association With Type A Aortic Dissection

Background

The aim of this study was to determine the role of ascending aortic length and diameter in type A aortic dissection.

Methods and Results

Computed tomography scans from patients with acute type A dissections (n=51), patients with proximal thoracic aortic aneurysms (n=121), and controls with normal aortas (n=200) were analyzed from aortic annulus to the innominate artery using multiplanar reconstruction. In the control group, ascending aortic length correlated with diameter (r²=0.35, P<0.001), age (r²=0.17, P<0.001), and sex (P<0.001). As a result of immediate changes in aortic morphology at the time of acute dissection, predissection lengths and diameters were estimated based on models from published literature. Ascending aortic length was longer in patients immediately following acute dissection (median, 109.7 mm; interquartile range [IQR], 101.0–115.1 mm), patients in the estimated predissection group (median, 104.2 mm; IQR, 96.0–109.3 mm), and patients in the aneurysm group (median, 107.0 mm; IQR, 99.6–118.7 mm) in comparison to controls (median, 83.2 mm; IQR, 74.5–90.7 mm) (P<0.001 all comparisons). The diameter of the ascending aorta was largest in the aneurysm group (median, 52.0 mm; IQR, 45.9–58.0 mm), followed by the dissection group (median, 50.3 mm; IQR, 46.6–57.5 mm), and not significantly different between controls and the estimated predissection group (median, 33.4 mm [IQR, 30.7–36.7 mm] versus 35.2 mm [IQR, 32.6–40.3 mm], P=0.09). After adjustment for diameter, age, and sex, the estimated predissection aortic lengths were 16 mm longer than those in the controls and 12 mm longer than in patients with nondissected thoracic aneurysms.

Conclusions

The length of the ascending aorta, after adjustment for age, sex, and aortic diameter, may be useful in discriminating patients with type A dissection from normal controls and patients with nondissected thoracic aneurysms.

AB0629 ACCURACY OF SYNOVIAL FLUID ANALYSIS FOR THE IDENTIFICATION OF CALCIUM PYROPHOSPHATE CRYSTALS: AN ANCILLARY STUDY OF OMERACT CRITERION VALIDITY STUDY FOR ULTRASOUND IN CPPD

Background:

Synovial fluid analysis (SFA) via compensated polarized light microscopy is still considered the gold standard for the identification and diagnosis of Calcium Pyrophosphate Deposition disease (CPPD)-related arthropathies[1], but very few studies have been published about its diagnostic accuracy.

Objectives:

The aim of this study was to evaluate the accuracy of SFA in the identification of calcium pyrophosphate dihydrate (CPP) crystals compared to microscopic analysis of joint tissues as the reference standard.

Methods:

This is an ancillary study of an international, multicentre cross-sectional study performed by the CPPD subgroup of the OMERACT Ultrasound working group[2]. Consecutive patients with knee osteoarthritis (OA) waiting for total knee replacement surgery were enrolled in the study from 2 participating centres, Mexico and Romania. During surgical procedures synovial fluid (SF), menisci and hyaline cartilage were collected and analysed within 48 hours after surgery under transmitted light microscopy and compensated polarised light microscopy for the presence/absence of CPP crystals. All slides were analysed by expert examiners on site, blinded to other findings. A dichotomic score (absence/presence) was used for scoring both SF and tissues. Microscopic analysis of knee tissues was considered the gold standard. Sensitivity, specificity, accuracy, positive and negative predictive values (PPV and NPV) of SFA in the identification of CPP crystals were calculated.

Results:

15 patients (53% female, mean age 68yo ± 8.4) with OA of grade 3 or 4 according to Kellgren-Lawrence scoring were enrolled. 12 patients (80%) were positive for CPP crystals at SFA and 14 (93%) at tissues microscopic analysis. Among 12 SFA positive patients, all were positive for CPP crystals in either medial or lateral meniscus, and 11 were positive in both; 10 patients were positive at the hyaline cartilage, and all 10 were also positive for at least one meniscus. Regarding the 3 SFA negative patients, only one had no crystals in the examined tissues, while the other 2 patients had CPP crystals in both menisci and hyaline cartilage. The overall diagnostic accuracy of SFA compared to histology analysis for CPPD was 87%, with a sensitivity of 86% and a specificity of 100%, the PPV was 100% and the NPV was 33% (Table 1).

Table 1.

sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and diagnostic accuracy of synovial fluid analysis compared to the reference standard. CI: Confidential Interval. SF: synovial fluid, in parentheses: numerators and denominators for all percentages provided.

SensitivitySpecificityPPVNPVAccuracySF analysis86% (12/14)100% (1/1)100% (12/12)33% (1/3)87% (13/15)(0.65-0.99) CI 95%(0.0-0.25) CI 95%(0.65-0.99) CI 95%(0.0-0.25) CI 95%

Conclusion:

SFA demonstrated to be an accurate test for the identification of CPP crystals in patients with advanced OA. However, is not always feasible and carries some risks for the patient. Considering the availability of validated imaging techniques for the detection of CPPD, such as US, SFA could be used in those patients where imaging and clinical data are not definitely confirmatory of the disease.

References:

[1]W. Zhang et al., ‘European League Against Rheumatism recommendations for calcium pyrophosphate deposition. Part I: terminology and diagnosis’, Ann Rheum Dis, vol. 70, no. 4, pp. 563–570, Apr. 2011, doi: 10.1136/ard.2010.139105.

[2]G. Filippou et al., ‘Criterion validity of ultrasound in the identification of calcium pyrophosphate crystal deposits at the knee: an OMERACT ultrasound study’, Ann Rheum Dis, p. annrheumdis-2020-217998, Sep. 2020, doi: 10.1136/annrheumdis-2020-217998.

Disclosure of Interests:

None declared.

POS1132 DIAGNOSTIC ACCURACY OF CONVENTIONAL RADIOGRAPHY OF THE KNEE FOR CALCIUM PYROPHOSPHATE DEPOSITION DISEASE: AN ANCILLARY STUDY OF THE OMERACT ULTRASOUND – CPPD GROUP

Background:

Conventional Radiography (CR) has been widely used in the assessment of knee chondrocalcinosis (CC) and is still considered one of the most important diagnostic methods for the diagnosis. However, there are very few studies that examine the diagnostic accuracy of CR compared to histology of the knee tissues.

Objectives:

To assess the diagnostic accuracy of CR of the knee in Calcium Pyrophosphate Deposition Disease (CPPD) by using the recently created definitions for CPPD in CR of the ACR/EULAR taskforce for the new classification criteria for CPPD.

Methods:

This is an ancillary study of the Criterion Validity of Ultrasound in CPPD study [1]. Consecutive patients with osteoarthritis (OA) awaiting total knee replacement were enrolled in 4 centres from Romania, Italy, USA and Mexico. All patients underwent CR of the knees taken maximum 6 months before surgery, in posterior-anterior weight baring and lateral projections. DICOM files of the radiographs were anonymised and read independently by two musculoskeletal radiologists with experience in microcrystalline arthropathies. For each patient, a dichotomic score was used (absence/presence of CC) at the level of the menisci and tibiofemoral hyaline cartilage by each reader. The definitions of the ACR/EULAR taskforce for identification of CPPD in CR were used in this study [paper in preparation]. According to these definitions CPPD in CR appears as “linear or punctate opacities in the region of fibro- or hyaline articular cartilage/synovial membrane or joint capsule/within tendons or entheses that are distinct from denser, nummular radio-opaque deposits due to basic calcium phosphate deposition”. In case of disagreement a consensus decision was taken by both radiologists after discussion of the case. Menisci and the hyaline cartilage were analysed using compensated polarized light microscopy as described previously [1], patients were considered positive for CPPD if at least one of their tissue specimens revealed the presence of calcium pyrophosphate crystals. All examiners were blind to each other’s findings.

Results:

We enrolled 33 patients with OA (61% female, mean age 69yo). The accuracy values of CR in the various sites of the knee are indicated in Table 1. CR demonstrated to be a specific exam for identification of CPPD at the knee, but sensitivity remains low in all sites and in the overall evaluation. Identification of CPPD appears challenging and this could be due to the advanced grade of OA in our cohort of patients. Advanced degeneration, dislocation of the menisci and thinning of the hyaline cartilage in these patients is frequent and the eventual presence of calcific deposits in one of these structures could overlap with other anatomical structures making the exact localisation difficult. According to the results of the predictive values, the presence of typical deposition on CR allows a definite confirmation of the diagnosis, but a negative radiography does not exclude CPPD as testified by the low negative predictive value.

Table 1.

Sensitivity, specificity, PPV, NPV, accuracy and AUC of CR for identification of CPPD by using the new ACR/EULAR taskforce definitions.

Medial meniscusLateral meniscusHyaline cartilageOverallSensitivity22%33%31%42%Specificity100%100%85%90%Positive predictive value100%100%67%80%Negative predictive value56%60%55%61%Accuracy61%68%58%66%AUC0.60.70.60.7

Conclusion:

CR has been extensively used for the diagnosis of OA and CPPD and has been tested previously for diagnostic accuracy. The results of our study confirm that the presence of typical CPPD calcifications, as defined by the ACR/EULAR task force, are highly specific but have low sensitivity for disease identification when using CR. Absence of CPPD on CR does not exclude the diagnosis.

References:

[1]Filippou G, et al. Criterion validity of ultrasound in the identification of calcium pyrophosphate crystal deposits at the knee: an OMERACT ultrasound study. Ann Rheum Dis 2020. doi:10.1136/annrheumdis-2020-217998

Disclosure of Interests:

None declared.

POS1133 RELIABILITY OF CONVENTIONAL RADIOGRAPHY OF THE KNEE FOR THE ASSESSMENT OF CHONDROCALCINOSIS: AN ANCILLARY STUDY OF THE OMERACT ULTRASOUND – CPPD GROUP

Background:

Conventional Radiography (CR) has been widely used in the assessment of knee chondrocalcinosis (CC) and is still considered one of the most important diagnostic methods for the diagnosis. However, there are no studies on the reliability of CR for CC.

Objectives:

To assess the reliability of CR of the knee in the assessment of chondrocalcinosis (CC).

Methods:

This is an ancillary study of the Criterion Validity of Ultrasound in Calcium Pyrophosphate Deposition Disease (CPPD) study [1]. Consecutive patients with knee osteoarthritis (OA) that were planned for total knee replacement surgery were enrolled in 4 centres from Romania, Italy, USA and Mexico. All patients underwent CR of the knees taken maximum 6 months before surgery, in posterior-anterior weight baring and lateral projections. DICOM files of the radiographs were retrieved, anonymised and read independently by two musculoskeletal radiologists with experience in microcrystalline arthropathies. Each reader performed a second evaluation 3 weeks after the first one to calculate the inter- and intra-reader agreement. For each patient a dichotomic score was assigned (absence/presence of CC) at the level of the medial and lateral menisci, tibiofemoral hyaline cartilage, quadriceps and patella tendons, synovial membrane/joint capsule. The definitions of the ACR/EULAR taskforce for identification of CPPD in conventional radiography were used in this study [paper in preparation]. According to these definitions CPPD in CR appears as “linear or punctate opacities in the region of fibro- or hyaline articular cartilage/synovial membrane or joint capsule/within tendons or entheses that are distinct from denser, nummular radio-opaque deposits due to basic calcium phosphate deposition”. Cohen’s kappa was used to calculate the agreement between the two readers.

Results:

We enrolled 33 patients with knee OA (60.6% female, mean age 69yo ± 8). The kappa values of the inter-reader and intra-reader agreement in the various sites of the knee are indicated in Table 1. Inter-reader agreement was substantial at the level of both menisci but only moderate or fair at the other sites of assessment. This had a negative impact on the overall evaluation of the knee joint that proved to be unreliable (k of 0.16 – none to slight agreement) if all anatomical structures are included for assessment, and moderately reliable (kappa 0.41) when both menisci and hyaline cartilage are considered. On the other hand, intra-reader kappa values were substantial or higher in all sites (except for synovial membrane/joint capsule for one reader). The striking difference of the intra-reader compared to the inter-reader kappa values, highlight a different interpretation and application of the definitions used for most of the sites with the exception of the menisci.

Table 1.

kappa values for intra- and inter-reader agreement. Values from 0.01–0.20 are considered as none to slight agreement, 0.21–0.40 as fair, 0.41– 0.60 as moderate, 0.61–0.80 as substantial, and 0.81–1.00 as almost perfect agreement.

Medial meniscusLateral meniscusHyaline cartilageQuadriceps tendonPatellar tendonCapsule/ synoviaMenisci + cartilageEntire jointInter-reader0.670.710.340.47NA0.370.400.17Intra-reader 1st assessor0.670.900.840.65NA(insufficient number of categories)0.530.710.76Intra-reader 2nd assessor10.801110.910.860.94

Conclusion:

CR has been extensively used for diagnosis of OA and CPPD. The results of our study raise some concerns on the reliability of CR in identification of CPPD. Assessment of calcium crystals at the menisci level should be used for identification of CC as other sites of the knee seem to present low reliability.

References:

[1]Filippou G et al. Criterion validity of ultrasound in the identification of calcium pyrophosphate crystal deposits at the knee: an OMERACT ultrasound study. Ann Rheum Dis 2020. doi:10.1136/annrheumdis-2020-217998

Disclosure of Interests:

None declared.

POS1124 IDENTIFYING POTENTIAL CLASSIFICATION CRITERIA FOR CALCIUM PYROPHOSPHATE DEPOSITION DISEASE (CPPD): RESULTS FROM THE INITIAL PHASES

Background:

Classification criteria for calcium pyrophosphate deposition disease (CPPD) will facilitate clinical research on this common crystalline arthritis. ACR/EULAR are jointly sponsoring development of CPPD classification criteria using a multi-phase process.

Objectives:

To report preliminary results from the first two phases of a four-phase process for developing CPPD classification criteria.

Methods:

CPPD classification criteria development is overseen by a 12-member Steering Committee. Item generation (Phase I) included a scoping literature review of five literature databases and contributions from a 35-member Combined Expert Committee and two Patient Research Partners. Item reduction and refinement (Phase II) involved a Combined Expert Committee meeting, discussions among Clinical, Imaging, and Laboratory Advisory Groups, and an item rating exercise to assess the influence of individual items toward classification. The Steering Committee reviewed the modal rating score for each item (range -3 [strongly pushes away from CPPD] to +3 [strongly pushes toward CPPD]) to determine items to retain for future phases of criteria development.

Results:

Item generation yielded 420 items (312 from the literature, 108 from experts/patients). The Advisory Groups eliminated items they agreed were unlikely to distinguish between CPPD and other forms of arthritis, yielding 127 items for the item rating exercise. Fifty-six items, most of which had a modal rating of +/- 2 or 3, were retained for future phases (see Table 1). As numerous imaging items were rated +3, the Steering Committee recommended focusing on imaging of the knee, wrist, and one additional affected joint for calcification suggestive of CPP crystal deposition.

Conclusion:

The ACR/EULAR CPPD classification criteria working group has adopted both data- and expert-driven approaches, leading to 56 candidate items broadly categorized as clinical, imaging, and laboratory features. Remaining steps for criteria development include domain establishment, item weighting through a multi-criteria decision analysis exercise, threshold score determination, and criteria validation.

Table 1.

Categories of items retained for future phases of classification criteria development

Age in decade at symptom onsetAcute inflammatory arthritis (e.g. knee, wrist, 1st MTP joint*)Recurrence and pattern of joint involvement (e.g. 1 self-limited episode, >1 self-limited episode)Physical findings (e.g. palpable subcutaneous tophus*, psoriasis*)Co-morbidities and family history (e.g. Gitelman disease, hemochromatosis, familial CPPD)Osteoarthritis location and features (e.g. 2nd or 3rd MCP joint, wrist)Synovial fluid findings (e.g. CPP crystals present, CPP crystals absent on 1 occasion* or 2 occasions*, monosodium urate crystals present*)Laboratory findings (e.g. hypomagnesemia, hyperparathyroidism, rheumatoid factor*, anti-CCP*)Plain radiograph: calcification in regions of fibro- or hyaline cartilage+Plain radiograph: calcification of the synovial membrane/capsule/tendon+Conventional CT: calcification in regions of fibro- or hyaline cartilage+Conventional CT: calcification of the synovial membrane/capsule/tendon+Ultrasound: CPP crystal deposition in fibro- or hyaline cartilage+Ultrasound: CPP crystal deposition in synovial membrane/capsule/tendons+Dual-energy CT: CPP crystal deposition in fibro- or hyaline cartilage+Dual-energy CT: CPP crystal deposition in synovial membrane/capsule/tendon+

*Potential negative predictor +Assessed in the knee, wrist, and/or 1 additional affected joint

Disclosure of Interests:

Sara Tedeschi Consultant of: NGM Biopharmaceuticals, Tristan Pascart: None declared, Augustin Latourte Consultant of: Novartis, Cattleya Godsave: None declared, Burak Kundaki: None declared, Raymond Naden: None declared, William Taylor: None declared, Nicola Dalbeth Speakers bureau: Abbvie and Janssen, Consultant of: AstraZeneca, Dyve, Selecta, Horizon, Arthrosi, and Cello Health, Tuhina Neogi: None declared, Fernando Perez-Ruiz: None declared, Ann Rosenthal: None declared, Fabio Becce Consultant of: Horizon Therapeutics, Grant/research support from: Siemens Healthineers, Eliseo Pascual: None declared, Mariano Andrés: None declared, Thomas Bardin: None declared, Michael Doherty: None declared, Hang Korng Ea: None declared, Georgios Filippou: None declared, John FitzGerald: None declared, Marwin Gutierrez: None declared, Annamaria Iagnocco: None declared, Tim Jansen Speakers bureau: Abbvie, Amgen, BMS, Grunenthal, Olatec, Sanofi Genzyme, Consultant of: Abbvie, Amgen, BMS, Grunenthal, Olatec, Sanofi Genzyme, Minna Kohler Speakers bureau: Lilly, Consultant of: Novartis, Frederic Lioté: None declared, Mark Matza: None declared, Geraldine McCarthy Consultant of: PK Med, Roberta Ramonda: None declared, Anthony Reginato: None declared, Pascal Richette: None declared, Jasvinder Singh Speakers bureau: Simply Speaking, Consultant of: Crealta/Horizon, Medisys, Fidia, UBM LLC, Trio health, Medscape, WebMD, Adept Field Solutions, Clinical Care options, Clearview healthcare partners, Putnam associates, Focus forward, Navigant consulting, Spherix, Practice Point communications, Francisca Sivera: None declared, Alexander So: None declared, Lisa Stamp: None declared, Janeth Yinh: None declared, Chio Yokose: None declared, Robert Terkeltaub Consultant of: Sobi, Horizon Therapeutics, Astra-Zeneca, Selecta, Grant/research support from: Astra-Zeneca, Hyon Choi: None declared, Abhishek Abhishek Consultant of: NGM Biopharmaceuticals.

Safety and efficacy of quavonlimab, a novel anti-CTLA-4 antibody (MK-1308), in combination with pembrolizumab in first-line advanced non-small-cell lung cancer

BACKGROUND

Quavonlimab (MK-1308), a novel anti-CTLA-4 antibody, in combination with pembrolizumab was investigated in a phase I study.

PATIENTS AND METHODS

Dose-escalation (DE) phase: patients with advanced/metastatic solid tumors received an initial flat dose of quavonlimab as monotherapy [25 mg (cohort 1), 75 mg (cohort 2), or 200 mg (cohort 3)] followed by four treatments of the same quavonlimab dose plus pembrolizumab every 3 weeks (Q3W). Dose-confirmation phase (DC): patients with stage IIIB/IV non-small-cell lung cancer (NSCLC) received first-line quavonlimab [25 mg Q3W (arm A), 25 mg Q6W (arm B), 75 mg Q6W (arm C), or 75 mg Q3W (arm E)] plus pembrolizumab. Primary objectives were safety and tolerability and establishment of the recommended phase II dose (RP2D) of quavonlimab when used with pembrolizumab. Objective response rate (ORR) was a secondary endpoint. Efficacy based on PD-L1 expression, tumor mutational burden (TMB), and changes in circulating CD4+/CD8+ cells were exploratory endpoints.

RESULTS

Thirty-nine patients were enrolled in DE [n = 14 (cohort 1); n = 17 (cohort 2); n = 8 (cohort 3)] and 134 in DC [n = 40 (arm A); n = 40 (arm B); n = 40 (arm C); n = 14 (arm E)]. Maximum-tolerated dose was not reached. Grade 3-5 treatment-related adverse events (AEs; graded according to NCI CTCAE v4.03) occurred in 0%, 23.5%, and 75.0% of patients in DE cohorts 1, 2, and 3, respectively, and 35.0%, 30.0%, 35.0%, and 57.1% of patients in DC arms A, B, C, and E, respectively. Efficacy was observed at all dose levels/schedules in patients with NSCLC. ORRs were 40.0% [95% confidence interval (CI), 24.9-56.7; arm A], 37.5% (95% CI, 22.7-54.2; arm B), 27.5% (95% CI, 14.6-43.9; arm C), and 35.7% (95% CI, 12.8-64.9; arm E). PD-L1 expression and total number of circulating CD4+ cells correlated with ORR.

CONCLUSIONS

Quavonlimab 25 mg Q6W plus pembrolizumab demonstrated similar efficacy and a better safety profile among all quavonlimab doses/schedules evaluated; this regimen was the chosen RP2D.

Administration of a soluble ADPase, AZD3366, on top of ticagrelor confers additional cardioprotective benefits to that of ticagrelor alone

Background

Preclinical and pilot human studies suggest platelet-independent cardioprotective effects of ticagrelor most likely due to its ability to block cellular uptake of adenosine. Adenosine is a potent endogenous protective molecule, concentrations of which locally rise as a response to ischemia because of the breakdown of extracellular ATP by an endothelial ADPase (apyrase, CD39) to AMP that is subsequently converted to adenosine by CD73.

Purpose

In the present study we used cardiac magnetic resonance (CMR) imaging in a pig model of myocardial infarction (MI) to examine whether administration of a recombinant soluble form of ADPase, AZD3366 (APT102), confers additional benefits to that of ticagrelor alone in terms of reduced infarct size and improved heart function.

Methods

Pigs (n=20) were administered an oral loading dose of ticagrelor (180mg) and 2h later subjected to MI induction (1.5h closed-chest LAD coronary balloon occlusion). Prior to reperfusion, pigs were randomized to intravenously receive 1) vehicle (n=5); 2) 1mg/kg AZD3366 (n=5); or 3) 3mg/kg AZD3366 (n=5). After reperfusion all pigs were administered ticagrelor (90mg/bid) for 42 days. A non-treated control-MI group (n=5) was run for comparative purposes. Serial-CMR imaging was performed at baseline and 3 and 42 days post-MI for global and regional structural and functional assessments. Light transmittance aggregometry (LTA; challenged by 5, 10 and 20μM ADP) and ear bleeding time were monitored throughout the study.

Results

Ticagrelor significantly reduced edema formation (29.8±1.9 vs. 13.1±0.9%LV) and limited infarct size (17.7±1.5 vs. 8.2±1.2%LV) at 3 days post-MI as compared to control-MI pigs (p&lt;0.05), an effect that persisted up to 42 days. Infusion of 1mg/kg AZD3366 showed a clear signal towards further prevention of myocardial damage that reached significance at doses of 3mg/kg (additional reduction of 35% and 52% in edema and infarct size, respectively, as compared to pigs treated with ticagrelor alone; p&lt;0.05). Left ventricular ejection fraction was higher in all ticagrelor-treated pigs at 3 and 42 days post-MI vs. control (p&lt;0.05). Yet, regional analysis of the jeopardized myocardium revealed that pigs administered 3mg/kg AZD3366 on top of ticagrelor presented minimal dysfunctional segmental contraction as compared to the mild hypokinetic and akinetic disturbances observed in ticagrelor-alone and control-MI pigs (χ2 p&lt;0.05 vs. all). Ticagrelor inhibited ADP-induced platelet aggregation by 30% and addition of AZD3366 acutely abolished (90% inhibition) LTA at all tested ADP doses, an effect remaining significant up to 3 days post-infusion. Ear bleeding time was not affected by AZD3366.

Conclusion

Infusion of a soluble recombinant ADPase (AZD3366) on top of ticagrelor leads to a greater cardioprotection as compared to ticagrelor alone. Co-administration of both drugs in AMI patients undergoing revascularization deserves to be investigated.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Ministerio de Ciencia, Innovaciόn y Universidades / Instituto de Salud Carlos III

Health care providers perspectives about maternal immunization in Latin America

BACKGROUND

Antenatal care providers have a key role in providing appropriate information and immunization recommendations to improve pregnant women's vaccine uptake. The objective of this study is to describe health care providers' perspectives and experience regarding the implementation of maternal immunization programs in Latin America.

METHODS

We conducted 33 in-depth interviews of health care providers from Argentina, Brazil, Honduras, Mexico, and Peru (6-7 per country). Qualitative data analysis was conducted using a combination of both manual techniques and the computer software program NVivo. We identified and coded main themes related to maternal immunization.

RESULTS

The main themes identified in this analysis were practices related to maternal immunization, knowledge and training, resource availability and interactions with pregnant women. Healthcare providers knew that recommendations exists but some did not know their content; they expressed concerns about insufficient training. Providers from all five countries expressed the need for additional human resources and supplies. They also expressed a desire for women to be more proactive and ask more questions during the health visits.

CONCLUSION

This is the first multi-country study assessing the perspectives of health care providers about maternal immunization practices at the facility level in Latin America. Recommendations based on the results from this study include implementing additional trainings around maternal immunization, especially targeting obstetricians and midwives. These trainings should be conducted in coordination with improvements to supply chain and other structural issues.

Pregnant women's perspectives about maternal immunization in Latin America

BACKGROUND

Maternal immunization rates and vaccine uptake in Latin America vary from country to country. This variability stems from factors related to pregnant women, vaccine recommendations from healthcare providers and the health system. The aim of this paper is to describe women's knowledge and attitudes to maternal immunziation, and barriers to access and vaccination related decision-making processes in Latin American countries.

METHODS

We conducted focus group discussions (FGD) with pregnant women in five middle-income countries: Argentina, Brazil, Honduras, Mexico and Peru, between July 2016 and July 2018. The FGDs were conducted by trained qualitative researchers in diverse clinics located in the capital cities of these countries.

RESULTS

A total of 162 pregnant women participated in the FGDs. In general, participants were aware of the recommendation to receive vaccines during pregnancy but lacked knowledge regarding the diseases prevented by these vaccines. Pregnant women expressed a desire for clearer and more detailed communication on maternal vaccines by their healthcare professionals instead of relying on other sources of information such as the internet. Overall, participants had positive attitudes towards maternal immunization and were open to receiving vaccines in pregnancy based on general trust they have in recommendations made by their healthcare providers. The main obstacles pregnant women said they encounter were mainly centered around their clinical experience: long waiting times, vaccine shortages, and impolite behavior of healthcare providers or clinical staff.

CONCLUSION

Important advances have been made in Latin America to promote maternal immunization. Results from this study show that an important aspect that remains to be addressed, and is crucial in improving vaccine uptake in pregnancy, is women's clinical experience. We recommend pregnant women to be treated as a priority population for providing immunization and related healthcare education. It is imperative to train healthcare providers in health communication so they can effectively communicate with pregnant women regarding maternal vaccines and can fill knowledge gaps that otherwise might be covered by unreliable sources dispensing inaccurate information.

ZIGZAG-KM for a comprehension and integrated action as answer to the Emergency Climate Declaration

Background

The headline goal for SDG13 focus specially on strengthening resilience, adaptive capacity to climate-related hazards and natural disasters as well as integrating climate change measures into national policies, strategies and planning. In Colombia, the increase in rainfall and temperature jeopardize the well-being of the population. The Transdisciplinary Seminar on Environmental Health and Climate Change drives the strengthening of multisectoral research on impacts and vulnerability in the territory, promotes the construction of collective adaptation strategies that mitigate the health effects of recent emergency climate declaration.

Objective

ZIGZAG Knowledge Management (ZIGZAG-KM) generate common points from a collective construction on the Climate Change Adaptation Plan from the Environmental Health Component guided by participants. The steps of this methodology lead the stakeholders to develop practical constructions with freedom of adaptation and change, capacity for a new learning culture and an opportunity for collaboration in a team that identifies and balances their interests from a community approach, local resilience and citizen science. After 18 months we concrete a consensus Report on the determination of the contextual vulnerability analysis as a technical outcomes, nowadays, the scientific results are running on and will be included in a Report of collaborative learning about citizen scientists oriented for implement strategies of the adaptation plan with a community approach for Antioquia and the strengthening citizen participation actions to impulse collectively resilience to climate change. This Seminar was structured about multidisciplinary theoretical rules and transdisciplinary practical considerations, which will contribute in the social understanding of adaptation strategies.

Conclusions

In spite of the efforts, the culture of knowledge transformation continues to be limited due to interests that may arise among the participants.

Key messages

ZIGZAG-KM learning guided by experts, decision makers and defenders of health and the environment. Transdisciplinary orientation in thematic dialogues and actions is useful health adaptation on Climate Change and Emergency Climate Declaration.

OP0317 ACCURACY OF THE OMERACT DEFINITIONS FOR IDENTIFICATION OF CALCIUM PYROPHOSPHATE CRYSTALS WITH ULTRASOUND: FINAL RESULTS OF THE OMERACT US IN CPPD SUB-TASK FORCE STUDY

Background:

The OMERACT Ultrasound (US) in calcium pyrophosphate deposition disease (CPPD) sub-task force has been working on the use of US in CPPD since 2014 first creating definitions for CPPD identification and then assessing the reliability[1].

Objectives:

Objective of this study is to assess the diagnostic accuracy (truth) of US in CPPD.

Methods:

Consecutive patients waiting to undergo knee replacement surgery due to osteoarthritis were enrolled in 12 centres from 6 countries. Each patient underwent US examination of the knee, focusing on the menisci and the hyaline cartilage, the day prior to surgery, scoring each site for presence/absence of CPP as defined previously[1]. After surgery, the menisci and the condyles were retrieved and examined microscopically. Six samples were collected, both from the surface and from the internal part of menisci and cartilage trying to cover a large part of it. All slides were observed under transmitted light microscopy and by compensated polarised microscopy. A dichotomous score was given for the presence/absence of CPP. US and microscopic analysis were performed by different operators, blind to each other’s findings. Sensitivity and specificity of US were calculated using microscopic findings as the gold standard.

Results:

101 patients have been enrolled in the study. 33 patients have been excluded due to loss of anatomical pieces at surgery. The mean age of the remaining 68 pts was 71yo (±8), 44 women, 34 were affected by CPPD according to microscopy. Overall and per site diagnostic US accuracy results are presented in table 1

Diagnostic accuracySensitivitySpecificityPositive Predictive valueNegative Predictive valueGlobal0.750.910.590.690.87Medial meniscus0.820.870.770.770.87Lateral meniscus0.750.830.680.680.83Medial cartilage0.860.790.920.880.85Lateral cartilage0.820.710.880.770.84Medial side (combined cartilage and meniscus)0.820.880.760.790.87Lateral side (combined cartilage and meniscus)0.780.880.690.730.86

Conclusion:

Our results demonstrate that US is an accurate exam for identification of CPPD. The best combination of sensitivity and specificity is achieved by examining the medial aspect of the knee.

References:

[1]Filippou G, Scirè CA, Adinolfi A,et al.Identification of calcium pyrophosphate deposition disease (CPPD) by ultrasound: reliability of the OMERACT definitions in an extended set of joints—an international multiobserver study by the OMERACT Calcium Pyrophosphate Deposition Disease Ultrasound Subtask Force.Ann Rheum Dis2018;:annrheumdis-2017-212542. doi:10.1136/annrheumdis-2017-212542

Disclosure of Interests:

Georgios Filippou: None declared, Anna Scanu: None declared, Antonella Adinolfi: None declared, Carmela Toscano: None declared, Dario Gambera: None declared, Raquel Largo: None declared, Esperanza Naredo: None declared, Emilio Calvo: None declared, Gabriel Herrero-Beaumont: None declared, Pascal Zufferey: None declared, Christel Madelaine-Bonjour: None declared, Daryl MacCarter: None declared, Stanley Makman: None declared, Zachary Weber: None declared, Fabiana Figus: None declared, Ingrid Möller: None declared, Marwin Gutierrez: None declared, Carlos Pineda: None declared, Denise Clavijo Cornejo: None declared, Héctor García: None declared, Victor Ilizaliturri: None declared, Jaime Mendoza Torres: None declared, Raul Pichardo: None declared, Luis Carlos Rodriguez Delgado: None declared, Emilio Filippucci Speakers bureau: Dr. Filippucci reports personal fees from AbbVie, personal fees from Bristol-Myers Squibb, personal fees from Celgene, personal fees from Roche, personal fees from Union Chimique Belge Pharma, personal fees from Pfizer, outside the submitted work., Edoardo Cipolletta: None declared, Teodora Serban: None declared, Catalin Cirstoiu: None declared, Florentin Ananu Vreju: None declared, Dun Grecu: None declared, Gael Mouterde: None declared, Marcello Govoni: None declared, Leonardo Punzi: None declared, Nemanja Damjanov Grant/research support from: from AbbVie, Pfizer, and Roche, Consultant of: AbbVie, Gedeon Richter, Merck, Novartis, Pfizer, and Roche, Speakers bureau: AbbVie, Gedeon Richter, Merck, Novartis, Pfizer, and Roche, Lene Terslev Speakers bureau: LT declares speakers fees from Roche, MSD, BMS, Pfizer, AbbVie, Novartis, and Janssen., Carlo Alberto Scirè: None declared, Annamaria Iagnocco Grant/research support from: Abbvie, MSD and Alfasigma, Consultant of: AbbVie, Abiogen, Alfasigma, Biogen, BMS, Celgene, Eli-Lilly, Janssen, MSD, Novartis, Sanofi and Sanofi Genzyme, Speakers bureau: AbbVie, Alfasigma, BMS, Eli-Lilly, Janssen, MSD, Novartis, Sanofi

MON-716 A Novel Human Heterozygous STAT5B Variant Leads to Impaired Growth and Developmental Defects in Zebrafish Embryos

Signal transducer and activator of transcription 5b (STAT5b) has been identified as a key downstream mediator of GH signaling in somatic growth. Autosomic recessive human mutations in STAT5B lead to severe growth retardation associated to immune dysregulation. On the other hand, some heterozygous STAT5B mutations have been associated to a milder form of the disease. We have identified a heterozygous novel STAT5B mutation by Whole Exome Sequencing (WES) in a 2.2-year-old boy who presented proportionate short stature (height -2.77 SDS) with mild immune dysregulation. He also had normal GH response to provocative tests, low IGF-I levels, and a limited response to IGF generation test. This variant is located within the highly conserved SH2 domain responsible for recognizing and interacting with tyrosine-phosphorylated target peptides. The aim of our study was to evaluate the functional consequences of this novel heterozygous human STAT5B variant (K632N), using the zebrafish as a biosensor system, to determine its pathogenicity. To do this, we performed overexpression experiments microinjecting construct-derived mRNA for the wildtype (WT) and mutant variant into zebrafish embryos at the 1-cell stage and assessed the consequences at 72 hours post fertilization (hpf). The missense variant was introduced into the full length STAT5B cDNA clone (Origene) by site-directed mutagenesis. To generate mRNA, WT and mutant forms of STAT5B cDNAs were linearized by digestion with XhoI, purified and subsequently transcribed with Mmessage Mmachine T7 Transcription Kit. Zebrafish embryos microinjected with 100 and 200 pg of mutant mRNA show a dose dependent significant reduction of body length at 72 hpf compared to those microinjected with the same dose of WT mRNA (p&lt;0.001). Body length reduction with 100 pg of mutant mRNA was 4%, while with 200 pg was 12.7% (p&lt;0.001). In addition, a significant number of embryos injected with mutant mRNA show developmental defects including pericardial edema, bent spine, and cyclopia compared to those injected with WT mRNA (p&lt;0.001). In the case of pericardial edema, the number of affected embryos increased significantly with the mutant mRNA dose (p&lt;0.005). In conclusion, our study was able to evidence the pathogenic nature of the STAT5B K632N variant since it leads to growth and developmental defects in zebrafish embryos. The zebrafish, and its conserved GH-IGF-I axis, constitutes an ideal in vivo model for characterizing the functional effect of genetic variants in ortholog human genes.

52 Blocking of embryonic development by nanoparticles derived from endometrial and oviductal cells isolated with an Amicon filter system

The success of development of invitro embryo production needs to mimic culture conditions in the maternal environment. Recently, it has been seen that extracellular vesicles (EVs) secreted by oviducal or endometrial cells may improve development and quality of embryos produced invitro. Extracellular vesicles are a mechanism of cellular communication; they carry molecules that are delivered into the target cells changing gene expression and function. Due to the size range and characteristics of EVs, they require specific methods for purification and characterisation. However, the possible contamination with other nanoparticles and their effect on embryo development have not been considered. Based on that, the goal of this work was to evaluate the effect on invitro bovine embryo development, of the addition to culture medium EVs secreted by oviducal and endometrial cells and isolated by centrifugation and concentrates with Amicon filters. For this purpose, cells were isolated from bovine oviduct and endometrium collected in local abattoir and primary cultures of epithelial and stromal cells were derived. The primary cultures from both sources were exposed or not to progesterone (P4; 15ngmL−1) for 4 days and then cultured for 24h in EV depleted media. The supernatant was harvested and EVs were isolated by serial centrifugations and subsequently concentrated by a 100 kDa Amicon filter system. The isolated EVs were characterised by transmission electron microscopy, nanoparticle tracking analysis, and flow cytometry. Oocytes were obtained from ovaries collected in the abattoir. The cumulus-oocyte complexes were matured invitro for 22h and subsequently fertilised for 18h. Presumptive zygotes were invitro cultured in synthetic oviducal fluid with EVs (1000ngmL−1 of total proteins) or not according to experimental group (1: EVs− (control); 2: EVs−OP4+; 3: EVs−OP4−; 4: EVs−EP4+ and 4: EVs−EP4−). Embryos were cultured for 7 days in 5% CO2, 5% O2, and 90% N2 (25 embryos/well in 4-well plates). At Day 7, embryo development was evaluated considering the blastocyst yield. Transmission electron microscopy showed typical structures and morphology of EVs and they were positive for CD9, CD63, and CD81 markers, and negative for CD40. According to nanoparticle tracking analysis, the mean size of EVs was 160±62nm and concentration of 3.29×1011 particlesmL−1 for oviducal and endometrial cells, respectively. A significant reduction of blastocyst rate was observed when embryos were cultured with cell-derived EVs; control: 152/44 (28.9%) vs. treatments with EVs; OP4+: 74/3 (4.1%), OP4−:76/2 (2.6%), EP4+: 74/6 (8.1%), and EP4−: 73/2 (2.7%) (P ≤ 0.01). Our results indicate that the use of nanoparticles, including EVs, isolated from cells of oviduct or endometrium, has a blocking effect on embryonic development and compromises the performance of blastocysts on Day 7 when used at concentrations of 1000ngmL−1 total protein, independent of the use or not of P4 and the source. These data provide insights regarding the use and protocols of acquiring exosomes for embryo supplementation. This research was supported by FONDECYT, Chile-1170310.

Copper phytoavailability in vineyard topsoils as affected by pyoverdine supply

Pyoverdine (Pvd) is a bacterial siderophore produced by some Pseudomonads species that can bind copper in addition to iron in soil. Pvd is expected to alter the dynamics and the ecotoxicity of Cu in vineyard soils. This study investigated the extent to which the mobility and the phytoavailability of Cu varied among vineyard soils with different pH and how they were affected by a supply of Pvd. Pvd was supplied (or not) to ten vineyard topsoils with pH ranging from 5.9 to 8.6 before metal was extracted with 0.005 M CaCl₂. Cu mobility was assessed through its total concentration and Cu phytoavailability through its free ionic concentration measured in the CaCl₂ extract. Cu mobility varied by a factor of six and Cu phytoavailability by a factor of 5000 among the soil samples. In the CaCl₂ extract, the concentration of Cu²⁺ was not correlated with the concentration of total Cu but was correlated with pH. This revealed that Cu phytoavailability depends to a great extent on Cu complexation in soil pore water, the latter being highly sensitive to pH. Adding Pvd enhanced the mobility of Cu in the soils including in carbonate soils. The Pvd-mobilization factor for Cu varied from 1.4 to 8 among soils, linked to the availability of Fe and Al in the solid phase and to Pvd partitioning between the solid and the liquid phase. Adding Pvd reduced the concentration of Cu²⁺ in CaCl₂ extract, which challenges the idea of using Pvd-producing bacteria to promote Cu phytoextraction.

Evaluation of the GeneQuence® DNA Hybridization Method in Conjunction with 24-Hour Enrichment Protocols for Detection of Salmonella spp. in Select Foods: Collaborative Study

A multilaboratory study was conducted to compare performance of the GeneQuence® DNA hybridization (DNAH) method incorporating new 24 h enrichment protocols and reference culture procedures for detection of Salmonella spp. in select foods. Six food types (raw ground turkey, raw ground beef, dried whole egg, milk chocolate, walnuts, and dry pet food) were tested by the DNAH method and by the culture methods of either the U.S. Department of Agriculture-Food Safety and Inspection Service (USDA-FSIS) or the U.S. Food and Drug Administration's Bacteriological Analytical Manual (FDA/BAM). Fifteen laboratories participated in the study. Four of the foods tested (raw ground turkey, dried whole egg, milk chocolate, and dry pet food), showed no statistically significant differences in performance between the DNAH method and the reference procedure as determined by Chi square analysis. Sensitivity rates for the DNAH method ranged from 92 to 100. The DNAH method, with the specific enrichment protocol evaluated, was found to be ineffective for detection of Salmonella spp. in walnuts. For raw ground beef, results from one trial showed a statistically significant difference in performance, with more positives obtained by the reference method. However, evidence suggests that the difference in the number of positives was likely due to lack of homogeneity of the test samples rather than to DNAH method performance.

2183Intravenous administration of IV-STATIN CARDIOSHIELD during myocardial infarction renders higher cardioprotection than oral atorvastatin given shortly after reperfusion: a translational CMR study

Background

Statins are known to exert rapid cardioprotective effects irrespective of their lipid-lowering properties. Several trials have suggested that high-dose statin treatment may reduce cardiovascular complications in patients undergoing invasive management. However, the ideal timing and administration regime is not clear.

Purpose

We compared the cardioprotective effects derived from IV-STATIN CARDIOSHIELD® administered intravenously during myocardial infarction (MI) with those attained by oral atorvastatin administration shortly after reperfusion. This study was conducted in a preclinical pig model of MI by serial CMR imaging.

Methods

Diet-induced hypercholesterolemic pigs (N=21; cholesterol: 387±74mg/dL) were subjected to 90 minutes of complete coronary occlusion (closed-chest model of MI), then reperfusion was established and animals were kept for 42 days. Within this experimental design animals were distributed in 3 groups (G) (7animals/arm): G1) animals received an intravenous bolus (0.3mg/kg) of IV-STATIN during MI; G2) animals received an intravenous bolus of the vehicle during MI (placebo-control); and G3) animals were administered atorvastatin p.o. initiated within the first 2h post-MI (Atorva-post-MI). G1 and G3 animals remained on atorvastatin p.o. for the following 42 days whereas G2 controls received placebo-pills. We assessed cardiac damage and global and regional functional parameters by CMR at day3 and day42 post-MI. Myocardial samples were processed for molecular studies on cardiac remodeling-related parameters (collagen and AMPK).

Results

CMR analysis at day-3 revealed that G1 pigs showed a marked reduction in infarct size as compared to both G3 and G2 animals (19.1±2.8% LV vs. 29.0±1.8% and 29.3%±3.2%, respectively; p<0.05) with a resultant 50% increase in myocardial salvage (p<0.05 vs. both). At day-42 both G1 and G3 animals showed a significant decrease in the size of the scar vs. G2 animals; however, G1 animals showed a further 24% scar reduction as compared to G3 (14.4±1.1% vs. 18.8±1.0% LV; p<0.05). Functional analyses revealed higher LVESV in G1 animals as compared to G2 (p<0.05) and less wall motion abnormalities in the jeopardized myocardium (p<0.05) vs. both groups at day42 post-MI. Collagen expression and AMPK activation were found to be significantly enhanced in the scar of G1 (p<0.05 vs. both groups). No changes were detected in lipids levels or liver and renal parameters throughout the study in any pig group.

Conclusions

Intravenous IV-STATIN CARDIOSHIELD® treatment during MI limited cardiac damage and improved cardiac function and remodeling to a larger extent than when atorvastatin was administered orally shortly after reperfusion. Our results support this novel regime of intravenous administration of IV-STATIN CARDIOSHIELD® as a routine procedure during MI. Further investigation of the potential benefits of this new therapeutic approach in STEMI patients is warranted.

P3490Intravenous administration of atorvastatin early after cardiac ischemia attenuates adverse left ventricular remodeling, ameliorates cardiac function and limits the deleterious effects of reinfarction

Background

Statins have shown to attenuate reperfusion-induced myocardial injury. However, whether statins directly target ischemia-related cardiac damage attenuating adverse left ventricular (LV) remodeling and post-myocardial infarction (MI) complications remains unknown.

Purpose

We examined the impact of a single intravenous administration of IV-STATIN early after ischemia onset on LV remodeling and reinfarction in a dyslipidemic pig model by serial CMR.

Methods

Diet-induced hypercholesterolemic pigs (N=14; cholesterol: 394±61mg/dL) were subjected to 90min of ischemia (MI-induction by LAD-coronary balloon occlusion) and further reperfusion. One group of pigs received an intravenous bolus of IV-STATIN (a modified preparation of atorvastatin; 0.3mg/kg) at 15min of ischemia (IV-STATIN-ISCH; n=7) whereas the other was orally treated with atorvastatin shortly post-MI (ATORVA-POST-MI; n=7). 40 days thereafter animals underwent a second MI-induction (reinfarction) and were sacrificed at day43. All animals remained post-MI and until sacrifice on p.o. atorvastatin treatment and a high-cholesterol diet. Serial CMR analysis was performed at day3 (early LV remodeling), prior-reinfarction (late LV remodeling; day40) and post-reinfarction (day43) for the assessment of global anatomical and functional parameters and segmental motility. Myocardial tissue was collected for molecular and histological analyses of cell death-, inflammatory-, and angiogenic-related markers.

Results

CMR revealed 3 days post-MI an absolute 6% reduction on infarct size in IV-STATIN-ISCH pigs as compared to ATORVA-POST-MI pigs (18.0±0.8% LV vs. 23.9±1.9% LV; p<0.05) with the resultant 25% increase in myocardial salvage (p<0.05). These infarct size-limiting effects remained up to day40 and lead to 30% smaller scars vs. ATORVA-POST-MI pigs (9.9±0.8% LV vs. 13.9±1.9% LV; respectively; p=0.06). Interestingly, reinfarction did not expand the damage produced by MI in IV-STATIN-ISCH animals whereas it increased by 13% the scar size of ATORVA-POST-MI pigs (p<0.05). These IV-STATIN-ISCH- related benefits detected throughout the study were associated with a significant global improvement in stroke volume and LVEF as well and less regional wall motion abnormalities and dysfunctional segments in the jeopardized region (p<0.05 vs. ATORVA-POST-MI). The scar of reinfarcted IV-STATIN-ISCH pigs showed lower apoptosis execution and MCP-1 expression and higher vessel density vs. ATORVA-POST-MI (p<0.05). Lipids levels and liver/renal parameters remained unchanged in all animals throughout the study.

Conclusions

This is the first study to prove that intravenous administration of IV-STATIN early after MI improves structural and functional cardiac remodeling and limits the worsening effects of reinfarction. The potential cardiac benefits afforded by CardioshieldTM infusion early after MI-diagnosis (i.e., out-of-hospital and/or cath lab setting) deserves to be clinically investigated.

Acknowledgement/Funding

Fundaciό Investigaciό Marato TV3 #20154310; PNS 2015-71653-R and PNS SAF2016-76819-R MINECO, ISCIII; CIBERCV CN16/11/00411