Social determinants of health influence disease activity and functional disability in Polyarticular Juvenile Idiopathic Arthritis

BACKGROUND

Social determinants of health (SDH) greatly influence outcomes during the first year of treatment in rheumatoid arthritis, a disease similar to polyarticular juvenile idiopathic arthritis (pJIA). We investigated the correlation of community poverty level and other SDH with the persistence of moderate to severe disease activity and functional disability over the first year of treatment in pJIA patients enrolled in the Childhood Arthritis and Rheumatology Research Alliance Registry.

METHODS

In this cohort study, unadjusted and adjusted generalized linear mixed effects models analyzed the effect of community poverty and other SDH on disease activity, using the clinical Juvenile Arthritis Disease Activity Score-10, and disability, using the Child Health Assessment Questionnaire, measured at baseline, 6, and 12 months.

RESULTS

One thousand six hundred eighty-four patients were identified. High community poverty (≥20% living below the federal poverty level) was associated with increased odds of functional disability (OR 1.82, 95% CI 1.28-2.60) but was not statistically significant after adjustment (aOR 1.23, 95% CI 0.81-1.86) and was not associated with increased disease activity. Non-white race/ethnicity was associated with higher disease activity (aOR 2.48, 95% CI: 1.41-4.36). Lower self-reported household income was associated with higher disease activity and persistent functional disability. Public insurance (aOR 1.56, 95% CI 1.06-2.29) and low family education (aOR 1.89, 95% CI 1.14-3.12) was associated with persistent functional disability.

CONCLUSION

High community poverty level was associated with persistent functional disability in unadjusted analysis but not with persistent moderate to high disease activity. Race/ethnicity and other SDH were associated with persistent disease activity and functional disability.

Development of nanoporous textile sludge based adsorbent for the dye removal from industrial textile effluent

The development of a novel textile sludge based activated carbon (TSBAC) adsorbent and its performance for the treatment of textile dyeing effluent, have been explained in this paper. TSBAC was prepared by the thermal treatment of textile effluent treatment sludge followed by the chemical activation using phosphoric acid. Characterization of TSBAC resulted in enhanced specific surface area (123.65 m²/g) along with the presence of active surface functional groups including -OH, -COOH, -CO. TSBAC showed superior adsorption capacity for methylene blue (123.6 mg/g), reactive red 198 (101.4 mg/g), and reactive yellow 145 (96.8 mg/g) individually, and from the synthetic textile effluent (106 mg/g). The pseudo-second order model and Langmuir isotherm model were found to be fitted well with batch experimental data. The results of the continuous column studies showed that adsorption capacity for methylene blue, reactive red 198, reactive yellow 145 are 101.8 mg/g, 76.6 mg/g, and 75.1 mg/g respectively, and the synthetic textile effluent resulted in an adsorption capacity value of 79.1 mg/g. The reuse potential of TSBAC was proved by effective dye removal up to six reuse cycles. The leachability studies proved that the used adsorbent could be safely disposed of without any harmful effect to the environment.

COVID-19 and tobacco cessation: lessons from India

OBJECTIVES

The Government of India prohibited the sale of tobacco products during the COVID-19 lockdown to prevent the spread of the SARS-CoV-2 virus. This study assessed the tobacco cessation behaviour and its predictors among adult tobacco users during the initial COVID-19 lockdown period in India.

METHODS

A cross-sectional study was conducted with 801 adult tobacco users (both smoking and smokeless tobacco) in two urban metropolitan cities of India over a 2-month period (July to August 2020). The study assessed complete tobacco cessation and quit attempts during the lockdown period. Logistic and negative binomial regression models were used to study the correlates of tobacco cessation and quit attempts, respectively.

RESULTS

In total, 90 (11.3%) tobacco users reported that they had quit using tobacco after the COVID-19 lockdown period. Overall, a median of two quit attempts (interquartile range 0-6) was made by tobacco users. Participants with good knowledge on the harmful effects of tobacco use and COVID-19 were significantly more likely to quit tobacco use (odds ratio [OR] 2.2; 95% confidence interval [CI] 1.2-4.0) and reported more quit attempts (incidence risk ratio 5.7; 95% CI 2.8-11.8) compared to those with poor knowledge. Participants who had access to tobacco products were less likely to quit tobacco use compared to those who had no access (OR 0.3; 95% CI 0.2-0.5].

CONCLUSIONS

Access restrictions and correct knowledge on the harmful effects of tobacco use and COVID-19 can play an important role in creating a conducive environment for tobacco cessation among users.

Treatment of triclosan through enhanced microbial biodegradation

Triclosan (TCS) is extensively used in healthcare and personal care products as an antibacterial agent. Due to the persistent and toxic nature of TCS, it is not completely degraded in the biological wastewater treatment process. In this research work, identification of TCS degrading bacteria from municipal wastewater sludge and applying the same as bioaugmentation treatment for wastewater have been reported. Based on the 16S rRNA analysis of wastewater sludge, it was found that Providencia rettgeri MB-IIT strain was active and able to grow in higher TCS concentration. The identified bacterial strain was able to use TCS as carbon and energy source for its growth. The biodegradation experiment was optimized for the operational parameters viz. pH (5-10), inoculum size (1-5% (v/v)) and different initial concentration (2, 5, and 10 mg/L) of TCS. During the TCS degradation process, manganese peroxidase (MnP) and laccase (LAC) enzyme activity and specific growth rate of P. rettgeri strain were maximum at pH=7% and 2% (v/v) inoculum size, resulting in 98% of TCS removal efficiency. A total of six intermediate products were identified from the Liquid chromatography-high-resolution mass spectrometry (LC-HRMS) analysis, and the two mechanisms responsible for the degradation of TCS have been elucidated. The study highlights that P. rettgeri MB-IIT strain could be advantageously used to degrade triclosan present in the wastewater.

Diabetic ketoacidosis and mortality in COVID-19 infection

Aim

- Patients with diabetes have increased morbidity and mortality from COVID-19. Case reports describe patients with simultaneous COVID-19 and diabetic acidosis (DKA), however there is limited data on the prevalence, predictors and outcomes of DKA in these patients.

Methods

- Patients with COVID-19 were identified from the electronic medical record. DKA was defined by standardized criteria. Proportional hazard regression models were used to determine risk factors for, and mortality from DKA in COVID-19.

Results

- Of 2366 patients admitted for COVID-19, 157 (6.6%) patients developed DKA, 94% of whom had antecedent type 2 diabetes, 0.6% had antecedent type 1 diabetes, and 5.7% patients had no prior diagnosis of diabetes. Patients with DKA had increased hospital length of stay and in-patient mortality. Higher HbA1c predicted increased risk of incident DKA (HR 1.47 per 1% increase, 95% CI 1.40–1.54). Risk factors for mortality included older age (HR 1.07 per 5 years, 95% CI 1.06–1.08) and need for pressors (HR 2.33, 95% CI 1.82–2.98). Glucocorticoid use was protective in patients with and without DKA.

Conclusion

- The combination of DKA and COVID-19 is associated with greater mortality, driven by older age and COVID-19 severity.

Spectral analysis, in vitro cytotoxicity and antibacterial studies of bioactive principles from the leaves of Conocarpus lancifolius, a common tree of Jazan, Saudi Arabia

The objective of the present study was to analyse the bioactive compounds of the leaves of Conocarpus lancifolius (C. lancifolius). The GC-MS analysis of the hot methanolic extract of the leaves (HMEL) of C. lancifolius exhibited the bioactive compounds such as 1-(3-Methoxy-2-nitrobenzyl) iso quinoline, morphin-4-ol-6,7-dione, 1-bromo-N-methyl-, phytol, hexadecanoic acid, 2,3-dihydroxypropyl ester, 2,2':4',2"-terthiophene, ethyl iso-allocholate, caryophyllene oxide, campesterol, epiglobulol, cholestan-3-ol, 2-methylene-, (3á,5à)-, dasycarpidan-1-methanol, acetate (ester) and oleic acid, eicosyl ester. The FT-IR analysis of HMEL of C. lancifolius showed a unique peak at 3184, 2413, 1657 cm-1 representing coumaric acid, chlorogenic acid and ferulic acid. The HMEL of C. lancifolius was actively inhibiting the proliferation of breast cancer cells MCF-7 ATCC at the concentration of 72.66 ± 8.21 µg/ml as IC50 value. The HMEL of C. lancifolius also revealed a good spectrum of activity against Gram-positive and Gram-negative bacterial cultures screened in this work. The activity observed has shown more or less similar effects against screened bacteria. However, the magnitude of potentiality was significantly lesser compared to standard ciprofloxacin disc at p< 0.001 level (99% confidence intervals). Furthermore, the study demonstrating the bioactive compounds can be isolated from the leaves of C. lancifolius.

Formulation and design optimization of nano-transferosomes using pioglitazone and eprosartan mesylate for concomitant therapy against diabetes and hypertension

Hypertension, a form of cardiovascular diseases, is considered a major risk factor associated with deaths in type 2 diabetes patients. The current medication systems for treating such chronic coexisting diseases are limited and challenging due to the difficulties in overcoming the side effects from complex therapeutic and treatment regimen. The objective of the present study is to design and optimize pioglitazone (PIO) and eprosartan mesylate (EM)-loaded nano-transferosomes (NTs) using Design-Expert software, aiming its transdermal delivery as a novel combination therapy for concomitant treatment of hypertensive diabetic patients. The developed formulations were characterized for various parameters, including in-vitro skin permeation, skin irritation, in-vivo antidiabetic, and antihypertensive activities. NTs were prepared using PIO and EM as the two model drugs and optimized using Box-Behnken design by considering phospholipid (X1), surfactant (X2), ratio of solvents (X3), and sonication time (X4), as independent variables, each at three levels. Entrapment efficiency (Y1 and Y2) and flux (Y3 and Y4) of PIO and EM, respectively, were selected as dependent variables. Among all the prepared formulations, one optimized formulation was chosen by the point prediction method and evaluated for drug-polymer compatibility, particle size, and surface charge analysis, followed by skin permeation and pharmacodynamic studies. The optimized nano-transferosomal gel (ONTF) showed all responses which confirm with the values predicted by the design. Pharmacodynamic studies showed improved and prolonged management of diabetes and hypertension in Wistar rats after the ONTF was applied, compared to oral and drug-loaded NT formulations. Results of the current study suggest that the development of such combinational delivery system can result in a rational therapeutic regimen for effective treatment of concomitant disease conditions of diabetic hypertensive patients.

POS0799 THE EFFICACY AND SAFETY OF TOCILIZUMAB IN PATIENTS WITH GIANT CELL ARTERITIS: A SYSTEMATIC REVIEW AND META-ANALYSIS

Background:

Tocilizumab (TCZ) has been proven to be safe and effective for the treatment of giant cell arteritis (GCA) in 2 randomized controlled trials; however, data from additional types of studies provide valuable information related to the treatment of GCA with TCZ.

Objectives:

To review and analyze efficacy and safety data for TCZ in GCA based on peer-reviewed publications to date.

Methods:

A systematic literature review was conducted according to the PRISMA guidelines. Publications were retrieved from the MEDLINE, Embase, Cochrane, Scopus and Web of Science databases. Publications of clinical trials and retrospective or prospective observational studies (April 11, 2005-October 8, 2019) including patients with GCA (classified based on ACR criteria and/or positive biopsy vs imaging) treated with TCZ and reporting a measure of efficacy were eligible for inclusion. Extracted data included year of publication, year(s) when the study was conducted, number of patients with GCA, method of GCA diagnosis, age and sex, TCZ treatment details (dose, route of administration, frequency, duration), clinical outcome (remission, relapse), serious adverse events (SAEs) following treatment with TCZ, corticosteroid dose before and following TCZ initiation and imaging data following TCZ treatment. Results are presented for the studies (unweighted) and as the weighted population mean. Unweighted mean proportions were calculated as the average of the proportions reported from each study; unweighted means were calculated by computing the mean of individual reported study means. The weighted population proportion was estimated by calculating the total number of patients achieving an outcome and dividing by the total number of patients in all of the studies. The weighted population mean was equivalent to the sum of the individual patient’s outcome values divided by the total number of patients in all of the studies.

Results:

The search retrieved 664 references; 55 full-text articles were reviewed for eligibility, and 36 studies were included in the meta-analysis (Figure 1); the once-weekly and every-2-weeks subcutaneous (SC) TCZ arms of the GiACTA trial were counted as separate studies. A total of 519 patients were included. The median (IQR) duration of treatment with intravenous and SC TCZ was 26.0 (20.0-37.3) and 52.0 (26.0-52.0) weeks, respectively, across all studies in the unweighted analysis and 25.8 (20.8-41.9) and 38.9 (32.4-45.5) weeks in the weighted analysis. The mean (SE) proportion of patients achieving investigator-defined remission at the end of the study was 86.3% (4.3%) and 79.3% (6.0%) in the unweighted and weighted analyses, respectively (Table 1). The mean (SE) proportion of patients who relapsed while receiving TCZ was 2.6% (1.3%) and 12.0% (4.5%) in the unweighted and weighted analyses, respectively. The median prednisone dose at the end of the study was < 5 mg/day, and the mean proportion of patients with SAEs after TCZ initiation was ≈ 14.0%.

Conclusion:

A high proportion of patients with GCA treated with TCZ were in investigator-defined remission at the end of the study across all studies analyzed. These meta-analysis findings add to the evidence of the efficacy and safety of TCZ in GCA.

Table 1.

Summary of Remission, Relapse and Adverse Events

Mean (SE) [95% CI]Across GCA Studies; Unweighted(n = 36 studies)Weighted Population Mean(n = 519 patients)Percentage of patients in investigator-defined remission at the end of the studyn=35n=41186.3 (4.3)79.3 (6.0)[77.6 to 94.9][67.2 to 91.4]Percentage of patients who relapsed while receiving TCZn=31n=392.6 (1.3)12.0 (4.5)[−0.18 to 5.3][2.8 to 21.2]Percentage of patients who relapsed after TCZ discontinuationn=20n=4126.4 (7.8)14.8 (5.8)[10.1 to 42.7][2.7 to 26.9]Percentage of patients receiving no steroids at the end of follow-upn=31n=17041.8 (6.8)49.4 (8.1)[27.8 to 55.8][32.8 to 66.0)Percentage of patients with SAEs after TCZ initiationn=35n=7214.0 (4.1)14.3 (1.3)[5.5 to 22.4][11.7 to 17.0]

Acknowledgements:

This study was sponsored by Genentech, Inc. Support for third-party writing assistance, furnished by Health Interactions, Inc., was provided by Genentech, Inc.

Disclosure of Interests:

Matthew Koster: None declared, Kenneth J Warrington Grant/research support from: Lilly and Kiniksa.(clinical trial support), Jian Han Shareholder of: Genentech, Inc., Employee of: Genentech, Inc., Shalini Mohan Shareholder of: Genentech, Inc., Employee of: Genentech, Inc.

POS0808 CHARACTERISTICS OF GIANT CELL ARTERITIS FLARES AFTER SUCCESSFUL TREATMENT WITH TOCILIZUMAB: RESULTS FROM THE LONG-TERM EXTENSION OF A RANDOMIZED CONTROLLED PHASE 3 TRIAL

Background:

GiACTA investigated tocilizumab (TCZ) for the treatment of giant cell arteritis (GCA).

Objectives:

To investigate disease flare characteristics after successful treatment with TCZ in GiACTA.

Methods:

We report a post hoc analysis from part 2 of GiACTA. Part 1 was a 52-week, double-blind, randomized controlled period and part 2 was a 2-year open-label follow-up. In part 1, patients received TCZ 162 mg subcutaneously every week or every other week with a 26-week prednisone taper or placebo plus a 26- or 52-week prednisone taper. Patients who were in remission at week 52 were to enter part 2 on no TCZ treatment. Part 2 treatment was at the investigator’s discretion. We report characteristics of first disease flare in patients assigned to TCZ in part 1 who were in sustained remission at week 52 and experienced flare in part 2. Flare was defined as reappearance of cranial symptoms (headaches, jaw claudication, visual manifestations, scalp tenderness) or polymyalgia rheumatica (PMR) symptoms or elevation of erythrocyte sedimentation rate (ESR) ≥30 mm/h attributable to GCA that required treatment.

Results:

Of 149 patients assigned to TCZ in part 1, 81 (54%) were in sustained remission on entering part 2. Of these 81 patients, 37 (46%) experienced at least one flare in part 2, including 17 with new-onset GCA and 20 with relapsing GCA at baseline. Median time to flare was 26.6 weeks. In patients with new-onset GCA, flares included cranial (53%) more often than PMR symptoms (18%). Cranial and PMR symptoms were balanced (both 60%) at the time of flare in patients with relapsing GCA. Visual manifestations occurred in two patients (5%) (Table 1). ESR and CRP were elevated in 65% and 36% of patients, respectively, at the time of flare. Three (8%) flares occurred with elevated ESR without clinical symptoms.

Table 1.

Clinical manifestations during flare in part 2

Part 1 TreatmentaTCZ QW+PredTCZ Q2W+PredAll TCZNew-onset diseasePatients, n281442Patients with ≥1 flare, n (%)b9 (32.1)8 (57.1)17 (40.5)Patients with ESR ≥30 mm/h during flare, n (%)b6 (66.7)6 (75.0)12 (70.6)Patients with CRP ≥10 mg/L during flare, n (%)b4 (44.4)2 (25.0)6 (35.3)Patients with GCA signs or symptoms during flare, n (%)c7 (77.8)7 (87.5)14 (82.4)PMR symptoms1 (11.1)2 (25.0)3 (17.6)Cranial symptomsd4 (44.4)5 (62.5)9 (52.9) Amaurosis fugax000 Blurred vision1 (11.1)01 (5.9) Diplopia000 Blindness000 Ischemic optic neuropathy000Fever1 (11.1)01 (5.9)Othere3 (33.3)2 (25.0)5 (29.4)Relapsing diseasePatients, n281139Patients with ≥1 flare, n (%)b14 (50.0)6 (54.5)20 (51.3)Patients with ESR ≥30 mm/h during flare, n (%)b8 (57.1)4 (66.7)12 (60.0)Patients with CRP ≥10 mg/L during flare, n (%)b5 (35.7)3 (50.0)8 (40.0)Patients with GCA signs or symptoms during flare, n (%)c14 (100)6 (100)20 (100)PMR symptoms8 (57.1)4 (66.7)12 (60.0)Cranial symptomsd8 (57.1)4 (66.7)12 (60.0)Amaurosis fugax1 (7.1)01 (5.0)Blurred vision000Diplopia000Blindness000Ischemic optic neuropathy1 (7.1)01 (5.0)Fever000Othere6 (4.3)1 (16.7)7 (35.0)

aPatients from part 1 TCZ+Pred groups who were in sustained remission at week 52 entered part 2 on no treatment.

bPercentage based on N in disease-onset group.

cPercentage based on number of flare patients in disease-onset group. Individual signs or symptoms are shown as number of patients with each symptom; patients could have ≥1 sign or symptom at the time of flare.

dNew-onset localized headache, scalp tenderness, temporal artery tenderness or decreased pulsation, ischemia-related vision loss, or jaw pain claudication.

eIncludes fatigue, malaise, subjective weakness, and night sweats.

Conclusion:

Overall, 46% of GCA patients successfully treated with TCZ for 1 year experienced disease flare within the next 2 years. Flares in patients with new-onset disease occurred more often with cranial than PMR symptoms. Visual manifestations were rare, and no blindness occurred. ESR and CRP were normal in a sizable percentage of patients experiencing flare.

Disclosure of Interests:

Sebastian Unizony Consultant of: Sanofi and Kiniksa Pharmaceuticals, Grant/research support from: Genentech, Inc., Shalini Mohan Shareholder of: Genentech, Inc., Employee of: Genentech, Inc., Jian Han Shareholder of: Genentech, Inc., Employee of: Genentech, Inc., John H. Stone Consultant of: Roche/Genentech and Sanofi

Transferring Occlusal Anatomy from Worn Temporary Crowns to Zirconium Oxide Crowns

Purpose/Aim: To evaluate the accuracy of transferring the occlusal anatomy of provisional crowns to monolithic zirconium oxide crowns. Materials and Methods: From a prepared typodont-tooth (#36), ten CAD/CAM provisional polymethylethacrylate crowns were fabricated with the E4D system. Each provisional crown had its occlusion adjusted. They were scanned (E4D) and the .stl files of the crown preparations were merged with the files from the adjusted crowns (3 shape software) to produce ten polished monolithic zirconium oxide crowns. For comparison, provisional and monolithic zirconium oxide crowns were scanned (True-Definition scanner), the .stl files aligned, converted into a normalized 76x76-matrix, analyzed with ANOVA with repeated measures and Tukey's test. To generate deviation distribution tables and difference plots, .stl files (provisional crowns and monolithic zirconium oxide crowns) were merged with Geomagic software. Results: There were significant differences between provisional crowns and monolithic zirconium oxide crowns. The differences were manly in the fissure area. 86% of the calculated deviations were between + 0.06mm and - 0.04mm, 42.4% of all data points were within ± 0.022mm with a SD of 0.005mm. The main differences were in the fissures, requiring clinically none or only minimal occlusal adjustments for these zirconium oxide crowns.

Am I Ready to Be an Independent Neuroradiologist? Objective Trends in Neuroradiology Fellows' Performance during the Fellowship Year

BACKGROUND AND PURPOSE

Aside from basic Accreditation Council for Graduate Medical Education guidelines, few metrics are in place to monitor fellows' progress. The purpose of this study was to determine objective trends in neuroradiology fellowship training on-call performance during an academic year.

MATERIALS AND METHODS

We retrospectively reviewed the number of cross-sectional neuroimaging studies dictated with complete reports by neuroradiology fellows during independent call. Monthly trends in total call cases, report turnaround times, relationships between volume and report turnaround times, and words addended to preliminary reports by attending neuroradiologists were evaluated with regression models. Monthly variation in frequencies of call-discrepancy macros were assessed via χ² tests. Changes in frequencies of specific macro use between fellowship semesters were assessed via serial 2-sample tests of proportions.

RESULTS

From 2012 to 2017, for 29 fellows, monthly median report turnaround times significantly decreased during the academic year: July (first month) = 79 minutes (95% CI, 71-86 minutes) and June (12th month) = 55 minutes (95% CI, 52-60 minutes; P value = .023). Monthly report turnaround times were inversely correlated with total volumes for CT (r = -0.70, F = 9.639, P value = .011) but not MR imaging. Words addended to preliminary reports, a surrogate measurement of report clarity, slightly improved and discrepancy rates decreased during the last 6 months of fellowship. A nadir for report turnaround times, discrepancy errors, and words addended to reports was seen in December and January.

CONCLUSIONS

Progress through fellowship correlates with a decline in report turnaround times and discrepancy rates for cross-sectional neuroimaging call studies and slight improvement in indirect quantitative measurement of report clarity. These metrics can be tracked throughout the academic year, and the midyear would be a logical time point for programs to assess objective progress of fellows and address any deficiencies.

A Double-Edged Sword: Neurologic Complications and Mortality in Extracorporeal Membrane Oxygenation Therapy for COVID-19-Related Severe Acute Respiratory Distress Syndrome at a Tertiary Care Center

In this clinical case series, we report our experience to date with neurologic complications of extracorporeal membrane oxygenation therapy for COVID-19 Acute Respiratory Distress Syndrome. We have found an unexpectedly increased rate of complications as demonstrated by neuroimaging compared with meta-analysis data in extracorporeal membrane oxygenation therapy for all Acute Respiratory Distress Syndrome etiologies over the past few decades and compared with the most recent baseline data describing the incidence of neurologic complication in all patients with COVID-19. For our 12-patient cohort, there was a rate of intracranial hemorrhage of 41.7%. Representative cases and images of devastating intracranial hemorrhage are presented. We hypothesize that the interplay between hematologic changes inherent to extracorporeal membrane oxygenation and inflammatory and coagulopathic changes that have begun to be elucidated as part of the COVID-19 disease process are responsible. Continued analysis of extracorporeal membrane oxygenation therapy in this disease paradigm is warranted.

Retrospective, dual-centre review of imaging findings in neurosarcoidosis at presentation: prevalence and imaging sub-types

AIM

To assess the prevalence of various imaging manifestations in neurosarcoidosis (NS) patients at presentation and to explore if specific imaging findings may cluster in different sub-groups.

MATERIALS AND METHODS

A retrospective, dual-institution, systematic imaging review was undertaken of the magnetic resonance imaging (MRI) findings in 100 consecutive NS patients who presented over a 15-year period. Clustering analysis (k-mode) was performed to evaluate co-occurrence of imaging findings.

RESULTS

Non-enhancing white matter (NEWM) lesions were the most common imaging abnormality (56%), followed by leptomeningeal (47%) and pachymeningeal (32%) involvement. Other common manifestations included cranial nerve involvement (30%), parenchymal granulomas (27%), hypothalamic-pituitary-adrenal axis involvement (26%), and hydrocephalus (14%). Additionally, a higher prevalence of perivascular enhancement (23%), cerebrovascular events (including ischaemic and haemorrhagic events; 17%), and ependymal involvement (20%) were noted than recognised previously. Additional k-mode analysis was performed to explore underlying disease sub-clusters. This was evaluated for clusters varying between two though five (k=2-5). For k=4, the analysis revealed that the imaging findings may possibly be divided into disease sub-sets of four groups, each with varying distribution of imaging manifestations and clinical manifestations.

CONCLUSION

Overall, NEWM lesions and meningeal involvement are the most common imaging manifestations of NS. The prevalence of perivascular enhancement, cerebrovascular events, and ependymal involvement is likely higher than reported previously. Additionally, different imaging findings in NS may cluster together and imaging subtypes in NS possibly exist.

FRI0220 EFFICACY OF ADJUNCTIVE METHOTREXATE IN PATIENTS WITH GIANT CELL ARTERITIS TREATED WITH TOCILIZUMAB PLUS PREDNISONE TAPERING: SUBANALYSIS OF THE GIACTA TRIAL

Background:

There is conflicting evidence regarding the efficacy of methotrexate (MTX) in giant cell arteritis (GCA).1,2The benefit of adjunctive treatment with MTX remains to be determined in these patients. Data are presented from a subanalysis of the 52-week, double-blind, randomized controlled GiACTA trial in a subgroup of patients with GCA who received MTX in addition to tocilizumab (TCZ) or placebo (PBO) in combination with prednisone tapering.

Objectives:

Assess the efficacy of adjunctive MTX in patients with GCA.

Methods:

In part 1 of GiACTA, patients were randomly assigned to TCZ administered subcutaneously every week (QW) or every other week (Q2W) plus 26-week prednisone tapering or PBO plus 26-week (PBO+26) or 52-week (PBO+52) prednisone tapering.3MTX could be initiated at a stable dose during screening, continued during the double-blind period, and reduced or discontinued at the investigator’s discretion according to disease status. Efficacy was determined as the achievement of sustained remission (absence of GCA flare and C-reactive protein <1 mg/dL from weeks 12 to 52 and adherence to the prednisone taper).3

Results:

During part 1 of GiACTA, 28 of 250 (11%) treated patients received adjunctive MTX for a median duration of 52.1 weeks: 14 of 149 (9%) TCZ-treated patients received MTX for a median of 52.1 weeks, and 14 of 101 (14%) PBO-treated patients received MTX for a median of 51.9 weeks. Baseline characteristics (Table 1) were balanced between patients who received and did not receive MTX, except for longer disease duration and a higher proportion of patients with relapsing GCA among those who received MTX. The MTX-treated patients tended to have lower prednisone doses at baseline. The median cumulative glucocorticoid dose received over 52 weeks was similar between PBO-treated patients who received MTX and those who did not (3033 mg and 3672 mg, respectively) and between TCZ-treated patients who received MTX and those who did not (1339 mg and 1862 mg, respectively). Sustained remission was achieved by 6 of 14 (43%) patients treated with TCZ + MTX and by 76 of 135 (56%) patients treated with TCZ without MTX (Figure 1). None of the 14 PBO + MTX-treated patients achieved sustained remission, whereas 16 of 87 (18%) patients who received PBO without MTX achieved sustained remission (among all patients in the primary analysis,382 of 149 [55%] in the TCZ groups and 16 of 101 [16%] in the PBO groups achieved sustained remission). The mean annualized relapse rate at 52 weeks was not different between the MTX-treated and MTX-untreated groups for the TCZ (0.76 with MTX vs 0.47 without MTX;p= 0.2549) or PBO (1.89 vs 1.46;p= 0.4611) groups (pvalues based onttests). Rates of adverse events per 100 patient-years were numerically higher in MTX-treated than MTX-untreated patients: 1267 and 858, respectively, in the TCZ groups and 1331 and 952, respectively, in the PBO groups.

Conclusion:

Preliminary data from a small subgroup of patients suggest that adjunctive MTX does not increase the likelihood of sustained remission, reduce disease relapse rate, or improve steroid sparing in patients with GCA. Response rates in TCZ-treated patients appear to be independent of treatment with MTX. The results from this post hoc analysis in a small sample of GCA patients treated with MTX should be confirmed in larger studies.

References:

[1]Hoffman GS et al.Arthritis Rheum2002;46:1309-18. 2. Mahr AD et al.Arthritis Rheum2007;56:2789-97. 3. Stone JH et al.N Engl J Med2017;377:317-28.

Baseline Demographics and Disease CharacteristicsPBO+PredTCZ+PredMTXn=14No MTXn=87MTXn=14No MTXn=135Age, y, median71.568.063.071.0Female, %93717176White, %1009810096Body mass index, kg/m2, median27.524.825.625.5GCA duration, days, median303.042.0306.542.0Relapsing GCA, %93487948Pred dose ≤30 mg/day, %71498647CRP, mg/L, median5.83.43.74.1ESR, mm/h, median16.020.015.517.5Pred, prednisone.

Disclosure of Interests:

Shalini Mohan Shareholder of: Genentech, Inc., Employee of: Genentech, Inc., Jian Han Shareholder of: Genentech, Inc., Employee of: Genentech, Inc., John H. Stone Grant/research support from: Roche, Consultant of: Roche

SAT0121 PAIN AND OTHER PATIENT-REPORTED OUTCOMES IN PATIENTS WITH RHEUMATOID ARTHRITIS WHO DID OR DID NOT ACHIEVE TREATMENT RESPONSE BASED ON IMPROVEMENT IN SWOLLEN JOINTS IN TOCILIZUMAB CLINICAL TRIALS

Background:

Significant improvements in pain and other patient-reported outcomes (PROs) have been shown in large clinical trials in patients with rheumatoid arthritis (RA) who receive tocilizumab (TCZ) compared with placebo (PBO). Recent data suggest that pain in RA may be noninflammatory as well as inflammatory, and improvement in pain scores and other PROs may be seen in patients who do not respond to treatment based on disease activity measures that evaluate inflammation.

Objectives:

To assess changes in pain scores and other PROs in patients with RA who did or did not achieve ≥ 20% improvement in SJC in TCZ clinical trials.

Methods:

Data from patients with active RA who received intravenous TCZ 8 mg/kg + MTX or PBO + MTX in 3 Phase III studies (OPTION [NCT00106548], TOWARD [NCT00106574] and LITHE [NCT00109408]) were included. All patients had moderate to severe RA with an inadequate response or intolerance of MTX (OPTION, LITHE) or conventional synthetic disease-modifying antirheumatic drugs (csDMARDs; TOWARD). Changes in pain (visual analog scale [VAS], 0-100 mm), Health Assessment Questionnaire Disability Index (HAQ-DI, 0-3), 36-Item Short Form Survey (SF-36) physical component score (PCS) and mental component score (MCS; 0-50) and Functional Assessment of Chronic Illness Therapy (FACIT)-Fatigue score (0-52) from baseline to Week 24 were evaluated. Results were compared between patients receiving TCZ + MTX and those receiving PBO + MTX in both patients who achieved ≥ 20% improvement in SJC (responders) and those who did not (nonresponders). The changes from baseline were analyzed using a mixed model with repeated measures, including the following covariates and interactions: treatment, visit, baseline of endpoint, region, baseline DAS28 and interactions of visit with treatment and baseline of endpoint.

Results:

Data from 1254 responders (TCZ + MTX, n = 831; PBO + MTX, n = 423) and 620 nonresponders (TCZ + MTX, n = 225; PBO + MTX, n = 395) were included. Patients receiving TCZ + MTX had significantly greater improvement in pain scores and HAQ-DI compared with PBO + MTX in the responder group (–27.19 vs –16.77 and –0.55 vs –0.34, respectively;P< 0.0001 for both) and nonresponder group (–9.59 vs 2.53 and –0.20 vs 0.01;P< 0.0001 for both) at Week 24 (Figure 1). Similar results were seen at Week 16 in the nonresponder group (–11.06 vs –2.38 and –0.23 vs –0.04;P< 0.0001 for both) prior to initiation of rescue treatment. At Week 24 in the responder group, patients receiving TCZ + MTX had significantly greater improvements compared with PBO + MTX in SF-36 PCS and MCS (9.16 vs 5.71 and 6.55 vs 3.79, respectively;P< 0.0001 for both) (Figure 2) and FACIT-Fatigue (8.39 vs 5.11;P< 0.0001). In the nonresponder group, patients receiving TCZ + MTX had significantly greater improvements compared with PBO + MTX in SF-36 PCS at Week 16 (3.81 vs 1.65;P= 0.0006) and Week 24 (4.42 vs 1.01;P< 0.0001) (Figure 2) and FACIT-Fatigue at Week 16 (3.82 vs 1.32;P= 0.0039) and Week 24 (3.90 vs 1.40;P= 0.0111).

Conclusion:

Patients with RA who received TCZ + MTX had significantly greater improvements in pain score and other PROs than those who received PBO + MTX regardless of whether they achieved ≥ 20% improvement in SJC. Clinical outcome at Week 24 correlated well with PROs, with a relatively larger improvement in pain score and other PROs in the responder group than in the nonresponder group; relative to PBO + MTX, these improvements appear numerically similar in the responder and nonresponder groups with consistently smaller difference between the groups in TCZ-treated arms. The consistent effect of TCZ on PROs in both responder and nonresponder groups warrants further study on the impact of TCZ on sources of pain independent of that caused by joint inflammation.

Figure:

Acknowledgments:

This study was sponsored by Genentech, Inc. Support for third-party writing assistance, furnished by Health Interactions, Inc, was provided by Genentech, Inc.

Disclosure of Interests:

Anthony Sebba Consultant of: Genentech, Gilead, Lilly, Regeneron Pharmaceuticals Inc., Sanofi, Speakers bureau: Lilly, Roche, Sanofi, Jian Han Shareholder of: Genentech, Inc., Employee of: Genentech, Inc., Shalini Mohan Shareholder of: Genentech, Inc., Employee of: Genentech, Inc.

Intracranial vessel wall imaging: applications, interpretation, and pitfalls

Vessel wall imaging (VWI) is being increasingly used as a non-invasive diagnostic method to evaluate the intra- and extracranial vascular bed. Whereas conventional vascular imaging primarily assesses the vessel lumen, VWI changes the focus of analysis toward the vessel wall. As the technical challenges of high spatial resolution, signal-to-noise ratio, and contrast-to-noise ratio and long scans times are addressed, interest in the clinical applications of this technique has steadily increased over the years. In this review, the authors will discuss the various applications of VWI as well as principles of interpretation and common imaging findings, focusing on intracranial atherosclerosis, vascular dissection, vasculitides (such as primary angiitis of the central nervous system (PACNS) and neurosarcoidosis), vasculopathies (such as reversible cerebral vasoconstriction syndrome (RCVS), cocaine-induced vasculopathy, moyamoya disease, and radiation-induced arteriopathy), aneurysms, and post-thrombectomy changes. The authors will also discuss the potential pitfalls of VWI and helpful cues to avoid being tricked.

A multicentre observational study on the epidemiology, risk factors, management and outcomes of mucormycosis in India

OBJECTIVES

To describe the epidemiology, management and outcome of individuals with mucormycosis; and to evaluate the risk factors associated with mortality.

METHODS

We conducted a prospective observational study involving consecutive individuals with proven mucormycosis across 12 centres from India. The demographic profile, microbiology, predisposing factors, management and 90-day mortality were recorded; risk factors for mortality were analysed.

RESULTS

We included 465 patients. Rhino-orbital mucormycosis was the most common (315/465, 67.7%) presentation followed by pulmonary (62/465, 13.3%), cutaneous (49/465, 10.5%), and others. The predisposing factors included diabetes mellitus (342/465, 73.5%), malignancy (42/465, 9.0%), transplant (36/465, 7.7%), and others. Rhizopus species (231/290, 79.7%) were the most common followed by Apophysomyces variabilis (23/290, 7.9%), and several rare Mucorales. Surgical treatment was performed in 62.2% (289/465) of the participants. Amphotericin B was the primary therapy in 81.9% (381/465), and posaconazole was used as combination therapy in 53 (11.4%) individuals. Antifungal therapy was inappropriate in 7.6% (30/394) of the individuals. The 90-day mortality rate was 52% (242/465). On multivariate analysis, disseminated and rhino-orbital (with cerebral extension) mucormycosis, shorter duration of symptoms, shorter duration of antifungal therapy, and treatment with amphotericin B deoxycholate (versus liposomal) were independent risk factors of mortality. A combined medical and surgical management was associated with a better survival.

CONCLUSIONS

Diabetes mellitus was the dominant predisposing factor in all forms of mucormycosis. Combined surgical and medical management was associated with better outcomes. Several gaps surfaced in the management of mucormycosis. The rarer Mucorales identified in the study warrant further evaluation.