AB0411 CHALLENGES IN THE MANAGEMENT OF MIXED CONNECTIVE TISSUE DISEASE: A RETROSPECTIVE ANALYSIS OF THE MCTD COHORT IN A TERTIARY REFERRAL CENTRE

Background:

As a rare, complex, and heterogeneous disease, mixed connective tissue disease (MCTD) represents a challenge for clinical practice.

Objectives:

We aimed to unravel potential pitfalls including correct referral diagnosis, fulfilment of diagnostic criteria, distinction from other CTDs, disease course and activity, and treatment modalities.

Methods:

We analysed the prospectively collected MCTD cohort at our tertiary referral centre. The patients’ medical histories were investigated for fulfilment of Sharp’s (1), Kasukawa’s (2), and Alarcón-Segovia’s (3) diagnostic MCTD criteria. We defined overlap syndromes as simultaneous fulfilment of clinical as well as immunological criteria of two defined rheumatic diseases. Disease conversion was defined as emergence of new symptoms and autoantibodies consistent with another rheumatic disease. Remission was defined by simultaneous systemic lupus erythematosus disease activity index 2000 (SLEDAI-2 K) of 0 and European League Against Rheumatism scleroderma trial and research (EUSTAR) activity index <2.5. Disease phenotype and disease activity were monitored over time and all patients were evaluated for fulfilment of classification criteria of various connective tissue diseases.

Results:

Out of 85 patients initially referred as MCTD, only one third fulfilled the diagnostic MCTD criteria. Most of the remaining patients had undifferentiated CTD (29%) or overlap syndromes (20%). In our final cohort of 33 MCTD patients, 6 (48%) also met the classification criteria of systemic sclerosis, 13 (39%) those of systemic lupus erythematosus (SLE), 6 (18%) those of rheumatoid arthritis, and 3 (9%) those of primary myositis. Over the median observation period of 4.6 (1.6, 9.9) years, only two patients (6%) underwent disease conversion from MCTD to SLE and no patient converted towards other diseases. The number of patients in remission increased from 6 (18%) to 15 (45%) due to introduction of immune modulatory treatment. Combination therapy was favoured in most cases (17 patients, 52%), whereas monotherapy was less frequent (12 patients, 36%), and only 4 (12%) patients remained without immune modulators until the end of the follow-up period. Hydroxychloroquine, prednisone, and methotrexate were the most frequently used medications in our cohort.

Conclusion:

Our study showed a high risk for misdiagnosis for patients with MCTD. Phenotype conversion was a very rare event. As a multi-organ disease, MCTD required prolonged (combined) immunosuppressive therapy to achieve remission. The establishment of an international registry with longitudinal data from observational multi-centre cohorts might represent a first step to address the many unmet needs of MCTD.

References:

[1]Sharp GC. Diagnostic criteria for classification of MCTD. In: Kasukawa R, Sharp GC, editors. Mixed connective tissue disease and anti-nuclear antibodies: proceedings of the International Symposium on Mixed Connective Tissue Disease and Anti-nuclear Antibodies, Tokyo, 29-30 August 1986. no. 719. Amsterdam: Elsevier Science Publishers B.V. (Biomedical Division); 1987. p. 23-30.

[2]Kasukawa R, Tojo T, Miyawaki S, Yoshida H, Tanimoto K, Nobunaga M, et al. Preliminary diagnostic criteria for classification of mixed connective tissue disease. In: Kasukawa R, Sharp GC, editors. Mixed connective tissue disease and anti-nuclear antibodies: proceedings of the International Symposium on Mixed Connective Tissue Disease and Anti-nuclear Antibodies, Tokyo, 29-30 August 1986. no. 719. Amsterdam: Elsevier Science Publishers B.V. (Biomedical Division); 1987. p. 41-7.

[3]Alarcón-Segovia D, Villarreal M. Classification and diagnostic criteria for mixed connective tissue disease. In: Kasukawa R, Sharp GC, editors. Mixed connective tissue disease and anti-nuclear antibodies: proceedings of the International Symposium on Mixed Connective Tissue Disease and Anti-nuclear Antibodies, Tokyo, 29-30 August 1986. no. 719. Amsterdam: Elsevier Science Publishers B.V. (Biomedical Division); 1987. p. 33-40.

Disclosure of Interests:

Adrian Wanzenried: None declared, Alexandru Garaiman: None declared, Suzana Jordan: None declared, Oliver Distler Consultant of: O.D. had consultancy relationship and/or has received research funding from Abbvie, Actelion, Acceleron Pharma, Amgen, AnaMar, Baecon Discovery, Blade Therapeutics, Bayer, Boehringer Ingelheim, Catenion, Competitive Drug Development International Ltd, CSL Behring, ChemomAb, Curzion Pharmaceuticals, Ergonex, Ga-lapagos NV, Glenmark Pharmaceuticals, GSK, Inventiva, Italfarmaco, iQone, iQvia, Lilly, medac, Medscape, Mitsubishi Tanabe Pharma, MSD, Novartis, Pfizer, Roche, Sanofi, Target Bio Science and UCB in the area of potential treatments of scleroderma and its complications., Britta Maurer Consultant of: Boehringer-Ingelheim, Grant/research support from: AbbVie, Protagen, and Novartis Biomedical Research as well as congress support from Pfizer, Roche, Actelion, mepha, and MSD.

POS0861 EFFECTIVENESS AND SAFETY OF TOCILIZUMAB IN PATIENTS WITH SYSTEMIC SCLEROSIS: A PROPENSITY SCORE CONTROL MATCHED OBSERVATIONAL STUDY OF THE EUSTAR COHORT

Background:

Tocilizumab (TCZ) showed trends for improving skin fibrosis and prevented progression of lung fibrosis in patients with systemic sclerosis (SSc) in placebo-controlled randomised clinical trials (RCTs). However, safety and effectiveness of TCZ beyond these selected and enriched clinical trial populations in SSc is still unknown.

Objectives:

To assess safety and effectiveness of TCZ treatment compared to standard of care in SSc patients from the large, multicentre, observational, real-life EUSTAR network/database using propensity score matching.

Methods:

SSc patients from the EUSTAR network/database, who fulfilled the ACR/EULAR 2013 classification criteria, with a baseline and a follow-up visit at 12±3 months, receiving TCZ or standard of care (controls), were selected. The following variables were used for the propensity score matching (1:1): age at diagnosis, gender, disease subtype, baseline modified Rodnan skin score (mRSS), forced vital capacity (FVC), and diffusing capacity for carbon monoxide (DLCO), co-therapy with immunosuppressives, disease duration, and year of treatment. Primary endpoints were mRSS and FVC at 12±3 months follow-up compared between the groups, using paired t-tests. Secondary endpoints were the percentage of progressive/regressive patients for skin and lung at 12±3 months follow-up according to standard definitions (1,2). Sensitivity analyses assessed pre-processing decisions (selection of most recent vs. random observation for control patients with multiple suitable time intervals), as well as the matching method (optimal vs. exact matching). Missing values were addressed with 100-fold multiple imputation using chained equations. Safety data were analysed in all patients. The study including the statistical analysis plan was pre-registered at www.drks.de (DRKS-ID: DRKS00015537).

Results:

We identified 93 SSc patients treated with TCZ and 2370 SSc patients with standard of care who fulfilled the inclusion criteria. Forty nine (57.7%) of the TCZ treated patients were diffuse, eight patients were not classified, disease duration was (mean±SD) 6.35±5.40 years, their baseline mRSS was 15.05±10.85, and 76 (81.7%) received immunosuppressive therapy in addition to TCZ.Through multiple imputation and propensity score matching, 100 imputed sets of 93 pairs of TCZ/controls were generated. Comparison between groups showed consistent effects of TCZ across all pre-defined primary and secondary endpoints: mRSS was lower in the TCZ group (mean difference (95% confidence interval (CI)) -1.8 (-4.79 to 1.19), p=0.24, Figure 1A). Similarly, FVC % predicted was higher in the TCZ group mean difference (2.25, 95% CI -4.57 to 9.06), p=0.51, Figure 1B). Considering secondary endpoints, the percentage of skin progressors as well as lung progressors at follow up was lower in the TCZ group (odds ratio OR 0.67 (95% CI 0.07 to 6.41), p=0.74 and OR 0.53 (95% CI 0.16 to 1.7); p=0.2, respectively. Consistently, the percentage of regressors for skin (OR 1.6 (95% CI 0.56 to 4.54), p=0.38) and for lung (OR 1.74 (95% CI 0.66 to 4.58), p=0.26) was higher in TCZ. These results were robust regarding the sensitivity analyses. Safety analysis confirmed previously reported adverse event profiles.

Conclusion:

In this large, observational, controlled, real-life EUSTAR study, effectiveness of TCZ did not reach statistical significance compared to standard of care treatment but showed consistent positive effects of TCZ on skin and lung fibrosis across all pre-defined primary and secondary endpoints confirming data from recent RCTs.

References:

[1]Prediction of improvement in skin fibrosis in diffuse cutaneous systemic sclerosis: a EUSTAR analysis. Ann Rheum Dis 2016:1743-8.

[2]Progressive interstitial lung disease in patients with systemic sclerosis-associated interstitial lung disease in the EUSTAR database. Ann Rheum Dis 2021:219-227.

Disclosure of Interests:

Simon Kuster: None declared, Suzana Jordan: None declared, Muriel Daniele Elhai: None declared, Ulrike Held: None declared, Klaus Steigmiller: None declared, Cosimo Bruni: None declared, Florenzo Iannone: None declared, Serena Vettori: None declared, Elise Siegert: None declared, Simona Rednic: None declared, Veronica Codullo: None declared, Paolo Airò Consultant of: Dr. Airo’ reports personal fees (consultancies) from Bristol Myers Squibb, Bohringer Ingelheim, non-financial support from CSL Behring, SOBI, Janssen, Roche, Sanofi, Pfizer, Yolanda Braun-Moscovici: None declared, Nicolas Hunzelmann: None declared, Maria Joao Salvador: None declared, Valeria Riccieri: None declared, Ana Maria Gheorghiu: None declared, Juan Jose Alegre Sancho: None declared, Katarzyna Romanowska-Prochnicka: None declared, Ivan Castellví: None declared, Ina Koetter: None declared, Marie-Elise Truchetet Consultant of: Marie-Elise Truchetet has had consultancy relationships and/or has received research funding from Boehringer Ingelheim, Genentech/Roche, and Sanofi in the area of potential treatments of scleroderma and its complications., Grant/research support from: Marie-Elise Truchetet has had consultancy relationships and/or has received research funding from Boehringer Ingelheim, Genentech/Roche, and Sanofi in the area of potential treatments of scleroderma and its complications., Francisco J López-Longo: None declared, Pavel Novikov: None declared, Alessandro Giollo: None declared, Yuichiro Shirai: None declared, Laura Belloli: None declared, Elisabetta Zanatta: None declared, Eric Hachulla: None declared, Vanessa Smith: None declared, Christopher Denton: None declared, Ruxandra Ionescu: None declared, Tim Schmeiser: None declared, Jörg H.W. Distler: None declared, Armando Gabrielli: None declared, Anna-Maria Hoffmann-Vold Consultant of: AMHV has received research funding and/or consulting fees and/or other remuneration from Actelion, Boehringer Ingelheim, Roche, Bayer, Merck Sharp & Dohme, ARXX, Lilly and Medscape, Grant/research support from: AMHV has received research funding and/or consulting fees and/or other remuneration from Actelion, Boehringer Ingelheim, Roche, Bayer, Merck Sharp & Dohme, ARXX, Lilly and Medscape. Masataka Kuwana: None declared, Yannick Allanore: None declared, Oliver Distler Speakers bureau: Oliver Distler has/had consultancy relationship and/or has received research funding in the area of potential treatments for systemic sclerosis and its complications from (last three years): Abbvie, Acceleron Pharma, Amgen, AnaMar, Arxx Therapeutics, Baecon Discovery, Blade Therapeutics, Bayer, Boehringer Ingelheim, ChemomAb, Corbus Pharmaceuticals, CSL Behring, Galapagos NV, Glenmark Pharmaceuticals, GSK, Horizon (Curzion) Pharmaceuticals, Inventiva, iQvia, Italfarmaco, iQone, Kymera Therapeutics, Lilly, Medac, Medscape, Mitsubishi Tanabe Pharma, MSD, Novartis, Pfizer, Roche, Sanofi, Serodapharm, Topadur, Target Bioscience and UCB. Patent issued “mir-29 for the treatment of systemic sclerosis” (US8247389, EP2331143)., Consultant of: Oliver Distler has/had consultancy relationship and/or has received research funding in the area of potential treatments for systemic sclerosis and its complications from (last three years): Abbvie, Acceleron Pharma, Amgen, AnaMar, Arxx Therapeutics, Baecon Discovery, Blade Therapeutics, Bayer, Boehringer Ingelheim, ChemomAb, Corbus Pharmaceuticals, CSL Behring, Galapagos NV, Glenmark Pharmaceuticals, GSK, Horizon (Curzion) Pharmaceuticals, Inventiva, iQvia, Italfarmaco, iQone, Kymera Therapeutics, Lilly, Medac, Medscape, Mitsubishi Tanabe Pharma, MSD, Novartis, Pfizer, Roche, Sanofi, Serodapharm, Topadur, Target Bioscience and UCB. Patent issued “mir-29 for the treatment of systemic sclerosis” (US8247389, EP2331143)., Grant/research support from: The study was partially supported by a grant from Roche. Roche was not involved in analysis or interpretation of the results.

A novel murine model of pulmonary fibrosis: the role of platelets in chronic changes induced by bleomycin

Idiopathic pulmonary fibrosis (IPF) is a disease that causes scarring and destruction of lung tissue that is ultimately fatal. There is a need to develop improved treatments for IPF. One problem with identifying novel treatments of IPF is the poor predictability of current preclinical models. Few model investigate lung function changes, rather relying on histological changes which doesn't adequately reflect the complete clinical situation. The aim of this study was to establish a novel model of pulmonary fibrosis where we could investigate changes in lung function, and histology. We have also utilised this model to investigate the role of platelets in pulmonary fibrosis as platelets have been recognised as having a broader role than just facilitating haemostasis. Lung fibrosis was induced in male C57BL6/J mice by intranasal bleomycin on Days 0, 1, 2, 5, 6 and 7. Platelets were depleted by twice-weekly administration of anti-platelet antibodies. On Day 35 mice were assessed by examining lung function, platelet infiltration into lung tissues and bronchoalveolar lavage fluid (BAL), levels of BAL Tissue growth factor (TGF)-β levels, and the degree of fibrosis evaluated histologically. Repeated bleomycin administration caused loss of lung function associated with fibrosis assessed histologically. Platelet depletion resulted in a reduction in fibrosis and modest inhibition of lung function changes. We have established a novel model of pulmonary fibrosis that is associated with a decline in lung function similar to the clinical setting. Furthermore, platelet depletion resulted in a less severe fibrosis suggesting that targeting platelets maybe worth further investigation.

Assessment of the Utility of Kidney Histology as a Basis for Discarding Organs in the United States: A Comparison of International Transplant Practices and Outcomes

BACKGROUND

Many kidneys donated for transplant in the United States are discarded because of abnormal histology. Whether histology adds incremental value beyond usual donor attributes in assessing allograft quality is unknown.

METHODS

This population-based study included patients who received a deceased donor kidney that had been biopsied before implantation according to a prespecified protocol in France and Belgium, where preimplantation biopsy findings are generally not used for decision making in the allocation process. We also studied kidneys that had been acquired from deceased United States donors for transplantation that were biopsied during allocation and discarded because of low organ quality. Using donor and recipient characteristics, we fit multivariable Cox models for death-censored graft failure and examined whether predictive accuracy (C index) improved after adding donor histology. We matched the discarded United States kidneys to similar kidneys transplanted in Europe and calculated predicted allograft survival.

RESULTS

In the development cohort of 1629 kidney recipients at two French centers, adding donor histology to the model did not significantly improve prediction of long-term allograft failure. Analyses using an external validation cohort from two Belgian centers confirmed the lack of improved accuracy from adding histology. About 45% of 1103 United States kidneys discarded because of histologic findings could be accurately matched to very similar kidneys that had been transplanted in France; these discarded kidneys would be expected to have allograft survival of 93.1% at 1 year, 80.7% at 5 years, and 68.9% at 10 years.

CONCLUSIONS

In this multicenter study, donor kidney histology assessment during allocation did not provide substantial incremental value in ascertaining organ quality. Many kidneys discarded on the basis of biopsy findings would likely benefit United States patients who are wait listed.

Efficacy of Retreatment After Failed Direct-acting Antiviral Therapy in Patients With HCV Genotype 1-3 Infections

Hepatitis C virus infection is causing chronic liver disease, cirrhosis, and hepatocellular carcinoma. By combining direct-acting antivirals (DAAs), high sustained virologic response rates (SVRs) can be achieved. Resistance-associated substitutions (RASs) are commonly observed after DAA failure, and especially nonstructural protein 5A (NS5A) RASs may impact retreatment options.^1-3 Data on retreatment of DAA failure patients using first-generation DAAs are limited.^4-7 Recently, a second-generation protease- and NS5A-inhibitor plus sofosbuvir (voxilaprevir/velpatasvir/sofosbuvir [VOX/VEL/SOF]) was approved for retreatment after DAA failure.⁸ However, this and other second-generation regimens are not available in many resource-limited countries or are not reimbursed by regular insurance, and recommendations regarding the selection of retreatment regimens using first-generation DAAs are very important. This study aimed to analyze patients who were re-treated with first-generation DAAs after failure of a DAA combination therapy.

Successful Treatment of Severe COVID-19 Pneumonia With Clazakizumab in a Heart Transplant Recipient: A Case Report

BACKGROUND

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is characterized by an overwhelming cytokine response. Various treatment strategies have been attempted.

METHODS AND RESULTS

A 61-year-old man with heart transplantation in 2017 presented with fever, cough, and dyspnea, and was confirmed positive for coronavirus disease 2019 (COVID-19). Laboratory tests showed significant elevations in C-reactive protein and interleukin-6 (IL-6). Echocardiogram showed left ventricular ejection fraction 58% (with ejection fraction 57% 6 months prior). Given the lack of clear management guidelines, the patient was initially managed symptomatically. However, the patient subsequently had a rapid respiratory deterioration with worsening inflammatory markers on day 5 of admission. Tocilizumab (anti-IL-6R) was in low supply in the hospital. The patient was offered clazakizumab (anti-IL-6) for compassionate use. Patient received 25 mg intravenously × 1 dose. Within 24 hours, he showed significant improvement in symptoms, oxygen requirements, radiological findings, and inflammatory markers. There was a transient leukopenia that improved in 4 days. He was discharged home on day 11, with negative nasopharyngeal SARS-CoV-2 PCR as an outpatient on day 35, development of positive serum COVID-19 IgG antibody, and he continued to do well on day 60, with no heart-related symptoms.

CONCLUSION

Clazakizumab is a monoclonal antibody against human IL-6, which may be helpful in inhibiting the cytokine response to SARS-CoV-2 in COVID-19. Although not yet FDA approved, it is being investigated for treatment of renal antibody-mediated rejection. Clinical trials of clazakizumab for treatment of COVID-19 are underway worldwide.

Sex difference in left ventricular global longitudinal strain in patients with systemic sclerosis: association with outcomes

Background

Cardiac involvement is an important cause of hospitalization and mortality in patients with systemic sclerosis (SSc). Advanced echocardiographic measures such as global longitudinal strain (GLS) have already demonstrated to help identifying cardiac involvement and improve risk-stratification in these patients. However, possible sex differences in echocardiographic parameters including GLS have not been explored so far.

Purpose

To compare standard and advanced (GLS) echocardiographic parameters between male and female patients with SSc and evaluate their association with cardiovascular outcomes.

Methods

A total of 408 patients (345 females, 54±14 years old and 63 males 51±13 years old) were included in the study. The study endpoint was all-cause mortality combined with hospitalisations for heart failure, myocardial infarction, coronary interventions, device implantations, arrhythmias, cerebral infarction and peripheral ischemic disease.

Results

Males and females were comparable in terms of cardiovascular risk-factors and comorbidities but showed differences in terms of disease characteristics: greater modified rodnan skin score and higher creatine phosphokinase was observed in males as compared to females, although high NT-proBNP and deteriorated glomerular filtration rate was more prevalent in females. By standard echocardiography, male SSc patients were characterised by greater left ventricular (LV) volumes, but no difference was observed in LV ejection fraction. By advanced echocardiographic analysis, LV GLS was more preserved in female patients (−21% (IQR: −22% to −20%) as compared to males (−20% (IQR −21% to −19%), p&lt;0.001. After median follow-up of 39 months (IQR: 22–66), the combined endpoint occurred in 84 patients, males were affected significantly more frequently as compared to females (20 (32%) vs. 64 (19%), p=0.017). Kaplan-Meier survival analysis showed that impaired LV GLS (based on median value −20%) was associated with higher cumulative rates of all-cause mortality both in males and females with SSc (females: Chi-Square = 80.307 Log Rank &lt;0.001; males: Chi-Square = 4.493 Log Rank = 0.034) (Fig. 1). In univariate cox regression analyses, LV GLS was also significantly associated with the endpoint both in males and females (in males HR: 1.291, 95% CI: 1.033–1.612, p=0.025, in females HR: 1.386, 95% CI: 1.290–1.491, p&lt;0.001).

Conclusions

Our study shows that among patients with SSc, LV GLS is more impaired in males as compared to females but in both groups is associated with higher prevalence of death and cardiovascular hospitalization.

Funding Acknowledgement

Type of funding source: None

Radiological-pathological correlation of negative CT biopsy results enables high negative predictive value for thoracic malignancy

AIM

To evaluate multidisciplinary team (MDT) practice of radiological-pathological correlation of non-malignant biopsy results to examine the additive effect on the predictive values of computed tomography (CT) biopsy for malignancy and their subsequent management and outcomes.

MATERIALS AND METHODS

A service evaluation of the MDT management of non-malignant lung biopsy results (May 2014- May 2017) was undertaken.

RESULTS

Sixty patients had a non-malignant diagnosis on initial CT biopsy. Five patients were lost to follow-up leaving 55 in the final cohort. Forty-eight of the 55 patients had biopsy results classified as potentially non-specific, of which 26 were classified as concordant with radiology (e.g., organising pneumonia with compatible CT features), and 22 were classified as discordant (e.g., non-specific inflammation and yet sufficiently suspicious CT features). Patients with concordant negative pathology showed resolution (n=19) or stability (n=6) on imaging follow-up. One lesion demonstrated growth and was proven malignant on surgical resection. Discordant lesions were managed with repeat biopsy (n=8) or surgical resection (n=13), with 12 final benign diagnoses and nine malignancies. The negative predictive value of CT biopsy alone was 44/55 (80%), following repeat biopsy was 44/50 (88%), and following radiological-pathological assessment was 32/33 (97%). No patients underwent a shift in stage from time of biopsy to resection.

CONCLUSION

Combining radiological-pathological interpretation of negative biopsy results offers superior negative predictive value for lung malignancy without delayed diagnosis of lung cancer.

Diuretic lounge and the impact on hospital admissions for treatment of decompensated heart failure

BACKGROUND

Heart failure is a prevalent condition associated with frequent and costly hospital admissions. Hospitalizations are primarily related to worsening fluid retention and often require admission for decongestion with intravenous diuretics.

OBJECTIVE

To assess the safety of an outpatient intravenous diuresis service for heart failure patients, and its impact on emergency admissions and the cost of treatment.

METHODS

We conducted a prospective observational cohort registry study on patients referred to the diuretic lounge at our acute hospital between May 2017 and April 2018.

RESULTS

We analysed 245 patients treated in the diuretic lounge, of which 190 (77.6%) avoided hospitalization or any adverse events during the 60 days of follow up (77.6% vs. 22.4%; P < 0.001). The diuretic lounge service resulted in a significant decrease in emergency heart failure admissions compared to the previous 12 months (823 vs. 715 per annum; 68.6 ± 10.1 vs. 59.6 ± 14 per month; P = 0.04), and a numerical reduction in readmission rates (17.3% vs. 16.2%). The 13.1% decrease in admissions lead to financial savings of £315 497 per annum and £2921 per admission avoided. During the same time period, at the other acute hospital site in our trust, where no diuretic lounge service is available, the number of admissions did not significantly change (457 vs. 450 per annum; 37.5 ± 7.0 vs. 38.1 ± 7.6 per month; P = 0.81).

CONCLUSION

Ambulatory administration of intravenous diuretics reduces emergency admissions and is a safe and cost-effective alternative to treat acute decomposition in heart failure patients.

FRI0240 HOSPITAL ANXIETY AND DEPRESSION SCALE AND SENSE OF COHERENCE 13-ITEM SCALE IN A SWISS COHORT OF SYSTEMIC SCLEROSIS PATIENTS: VALIDITY, RELIABILITY AND SENSITIVITY TO CHANGE

Background:

Depression, anxiety and distress affect the quality of life of patients with systemic sclerosis (SSc) [1]. The Hospital Anxiety and Depression Scale (HADS) and Sense of Coherence 13-item scale (SOC-13, measuring comprehensibility, manageability and meaningfulness) are screening tools used in patients with different medical conditions. However, their validity, reliability and sensitivity to change in SSc patients has not been evaluated yet.

Objectives:

To examine the psychometric properties of HADS and its subscales HADS-A and HADS-D (measuring anxiety and depression symptoms, respectively), and unidimensional SOC-13 in a large cohort of Swiss SSc patients.

Methods:

Consecutive patients fulfilling the ACR/EULAR 2013 classification criteria for SSc who completed the HADS, SOC-13, Short Form-36 Health Survey (SF-36) and Scleroderma Health Assessment Questionnaire (SHAQ) were included in a cross-sectional and longitudinal analysis. Cronbach’s α, split-half reliability and construct validity were measured. Sensitivity to change (Cohen’s d coefficient) was assessed in patients who worsened within 12±3 months, defined as occurrence of any of the following events: decline in forced vital capacity (FVC)≥10%, new diagnosis of interstitial lung disease (ILD) on high-resolution computed tomography (HRCT), progression of known ILD to >20% lung involvement on HRCT (ILD20), new-onset pulmonary hypertension (PH), increase in European Scleroderma Study Group activity index (EScSG-AI) >3 points, new active digital ulcers, increase in modified Rodnan skin score (mRSS) > 7 points.

Results:

Of 345 patients (aged 59.34±14.17, 82.9% female, 18.8% with diffuse cutaneous SSc, 47.6% anti-centromere Ab-positive, 23.5% anti-Scl-70 Ab-positive, 13% anti-U1RNP Ab-positive and 11.3% anti-RNA polymerase III Ab-positive) 85 participated with a second visit to the sensitivity to change analysis.

Internal consistency was excellent for the HADS (Cronbach’s α=0.91; split-half reliability r=0.92), and very good for HADS-A, HADS-D and SOC-13 (Cronbach’s α=0.85-0.89; split-half reliability r=0.86-0.89).

Regarding construct validity, all four scales showed a strong to very strong correlation to each other, as well as with the mental components of SF-36 (Spearman’s r=0.63-0.85). There was a moderate to strong correlation with the SHAQ (Spearman’s r=0.45-0.64).

Regarding sensitivity to change: HADS-A showed a large to very large effect size (ES) for progression of ILD as assessed on HRCT and increase in EScSG-AI (Cohen’s d=1-1.63), and a very small to small ES for changes in FVC, DU and mRSS (Cohen’s d=0.02-0.45). HADS-D showed a large ES for changes in the ILD20, mRSS and EScSG-AI (Cohen’s d=0.82-1), and moderate ES for changes of FVC, ILD, PH, DU (Cohen’s d=0.1-0.49). SOC-13 showed generally a very small to small EF, except for change in mRSS (Cohen’s d=0.56).

Conclusion:

The HADS(A/D) and SOC-13 are valid and easy-to-use tools to detect depression, anxiety and distress in SSc. However, their sensitivity to change might be limited by the respective type of organ involvement and its impact on the patients’ psychological wellbeing.

References:

[1]Legendre C, Allanore Y, Ferrand I, Kahan A. Evaluation of depression and anxiety in patients with systemic sclerosis. Joint Bone Spine. 2005;72(5):408–411.

Disclosure of Interests:

Alexandru Garaiman: None declared, Carina Mihai: None declared, Rucsandra Dobrota: None declared, Suzana Jordan: None declared, Britta Maurer Grant/research support from: AbbVie, Protagen, Novartis, congress support from Pfizer, Roche, Actelion, and MSD, Speakers bureau: Novartis, Oliver Distler Grant/research support from: Grants/Research support from Actelion, Bayer, Boehringer Ingelheim, Competitive Drug Development International Ltd. and Mitsubishi Tanabe; he also holds the issued Patent on mir-29 for the treatment of systemic sclerosis (US8247389, EP2331143)., Consultant of: Consultancy fees from Actelion, Acceleron Pharma, AnaMar, Bayer, Baecon Discovery, Blade Therapeutics, Boehringer, CSL Behring, Catenion, ChemomAb, Curzion Pharmaceuticals, Ergonex, Galapagos NV, GSK, Glenmark Pharmaceuticals, Inventiva, Italfarmaco, iQvia, medac, Medscape, Mitsubishi Tanabe Pharma, MSD, Roche, Sanofi and UCB, Speakers bureau: Speaker fees from Actelion, Bayer, Boehringer Ingelheim, Medscape, Pfizer and Roche, Mike-Oliver Becker: None declared

FRI0265 IS AN IMPROVEMENT IN SKIN FIBROSIS ASSOCIATED WITH BETTER OUTCOME IN PATIENTS WITH SYSTEMIC SCLEROSIS? A EUSTAR ANALYSIS

Background:

In previous studies, we showed that in patients with diffuse cutaneous systemic sclerosis (dcSSc), worsening of skin fibrosis predicts later decline in lung function and worse survival. However, in many patients, an improvement of skin fibrosis is the natural course of dcSSc, and many current clinical trials are designed to show improvement of skin fibrosis rather than prevention of skin fibrosis progression.

Objectives:

To investigate whether an improvement in skin fibrosis is associated with less progression of visceral organ involvement and better overall-survival during follow-up.

Methods:

We evaluated patients from the European Scleroderma Trials and Research Group (EUSTAR) database with diffuse cutaneous systemic (dcSSc), baseline modified Rodnan skin score (mRSS) ≥7, valid mRSS at 12±3 months after baseline and ≥1 follow-up visit. Regression of skin fibrosis was defined as a decrease in mRSS >5 and ≥25% and progression as increase by the respective numbers from baseline to 12±3 months. Outcomes were pulmonary progression, cardiac progression, intestinal progression, new onset of scleroderma renal crisis and all-cause death using recently specified definitions (1). Associations between skin changes and outcomes were evaluated by Kaplan-Meier analysis and multivariable Cox regression.

Results:

Of 1257 included patients, 282 (22.4%) showed a regression of skin fibrosis, 883 (70.2%) were categorized as stable patients and 92 (7.3%) showed progression of skin fibrosis at 12±3 months. Median long-term follow-up for organ involvement/death was 4.2 years. Cox regression analyses indicated that skin fibrosis regression had a significantly lower probability of later FVC decline ≥10% than non-regressive (stable and progressive) patients when controlled for baseline mRSS (p=0.013). No significant association of skin fibrosis regression was found with other organ manifestations or all-cause death. Conversely, associations of skin fibrosis progression were found for later FVC decline ≥10% with a more significant p-value (p<0.001, Figure 1), and there was also an association with all cause death (p=0.026).

Conclusion:

Progression of skin fibrosis is stronger associated with organ changes and all-cause death at follow up than improvement of skin fibrosis. These data suggest a prevention of progression paradigm for clinical practice. They also suggest that clinical trials designed for prevention of skin fibrosis progression are more meaningful for long-term outcome of SSc patients than trials designed to show improvement of skin fibrosis

References:

[1]Progressive skin fibrosis is associated with a decline in lung function and worse survival in patients with diffuse cutaneous systemic sclerosis in the European Scleroderma Trials and Research (EUSTAR) cohort. Wu W, Jordan S, Graf N, de Oliveira Pena J, Curram J, Allanore Y, Matucci-Cerinic M, Pope JE, Denton CP, Khanna D, Distler O; EUSTAR Collaborators. Ann Rheum Dis. 2019 May;78(5):648-656

Disclosure of Interests:

Anja Wyss: None declared, Suzana Jordan: None declared, Nicole Graf: None declared, Elise Siegert Grant/research support from: Actelion, Consultant of: AEC, Speakers bureau: NA, László Czirják Consultant of: Actelion, BI, Roche-Genentech, Lilly, Medac, Novartis, Pfizer, Bayer AG, Andrea Doria Consultant of: GSK, Pfizer, Abbvie, Novartis, Ely Lilly, Speakers bureau: UCB pharma, GSK, Pfizer, Janssen, Abbvie, Novartis, Ely Lilly, BMS, Alessandro Giollo: None declared, Edoardo Rosato: None declared, Anna-Maria Hoffmann-Vold Grant/research support from: Boehringer Ingelheim, Consultant of: Boehringer Ingelheim, Actelion, Bayer, GlaxoSmithKline, Speakers bureau: Boehringer Ingelheim, Actelion, Roche, Armando Gabrielli: None declared, Oliver Distler Grant/research support from: Grants/Research support from Actelion, Bayer, Boehringer Ingelheim, Competitive Drug Development International Ltd. and Mitsubishi Tanabe; he also holds the issued Patent on mir-29 for the treatment of systemic sclerosis (US8247389, EP2331143)., Consultant of: Consultancy fees from Actelion, Acceleron Pharma, AnaMar, Bayer, Baecon Discovery, Blade Therapeutics, Boehringer, CSL Behring, Catenion, ChemomAb, Curzion Pharmaceuticals, Ergonex, Galapagos NV, GSK, Glenmark Pharmaceuticals, Inventiva, Italfarmaco, iQvia, medac, Medscape, Mitsubishi Tanabe Pharma, MSD, Roche, Sanofi and UCB, Speakers bureau: Speaker fees from Actelion, Bayer, Boehringer Ingelheim, Medscape, Pfizer and Roche

THU0331 INTERSTITIAL LUNG DISEASE IN SYSTEMIC SCLEROSIS: DECLINE IN FORCED VITAL CAPACITY DOES NOT PREDICT FURTHER PROGRESSION IN THE FOLLOWING PERIOD

Background:

In systemic sclerosis (SSc) patients with interstitial lung disease (ILD) approximately 30% show progressive ILD. It is unknown whether a progressive ILD period is followed by further lung function decline. In clinical practice, treatment is frequently initiated after observation of lung function decline over 6-12 months and lung function stabilization at follow up is often interpreted as treatment effect.

Objectives:

Assess the predictive ability of lung function decline over 12 months for further deterioration adjusted for known risk factors for ILD and treatment in two large and well characterized SSc cohorts.

Methods:

Patients with SSc-ILD by HRCT, fulfilling SSc classification criteria, from the Oslo and Zurich University Hospital were included. The first period with three consecutive annual forced vital capacity (FVC) measurements (i.e. at 0, 12 and 24 months, +/- 3 months) was used. Lung function decline was assessed by absolute changes in FVC% predicted. Moderately progressive ILD was defined as FVC decline of >5-<10% and significantly progressive ILD as FVC decline ≥10% in 12 months. Candidate predictors by experts (including SSc subtype, autoantibodies, disease duration, baseline and FVC decline in the first period, extent of lung and skin (mRSS) fibrosis, CRP, reflux, tendon friction rubs, O2 desaturation, dyspnea) for FVC decline in the second period were tested using logistic regression analysis. Treatment included low dose corticosteroids, mycophenolate mofetil; and other immunosuppressive treatment (cyclophosphamide, Rituximab and Tocilizumab).

Results:

In total, 240 SSc-ILD patients met the inclusion criteria (table). Of these 69 (29%) SSc-ILD patients showed progressive ILD in the first 12 months period; 34 (14%) with moderate (5-10%) and 35 (15%) with significant FVC decline (≥10%). Independent of FVC changes in the first period, 77 (32%) showed progressive ILD in the second period; 44 (18%) moderate and 33 (14%) significant FVC decline. Only 21 (9%) SSc-ILD patients had two progressive periods, and 115 (48%) were stable in the two 12 month’s periods; all independent of treatment. In multivariable logistic regression, progressive ILD in the first period (moderate, significant or combined FVC decline) was not predictive for progression in the following period. Of all applied risk factors, only mRSS was significantly predictive for further FVC decline, also when adjusted for age, gender and treatment (OR 1.03, 95%CI 1.00-1.08, p=0.035).

Conclusion:

Decline of FVC in one 12 months period did not predict further ILD progression in the following 12 months independent of treatment. These results have important clinical implications. Firstly, a decline of lung function in one period seems not to be the right indicator for initiating treatment. Secondly, stabilization of lung function under treatment initiated after ILD progression cannot necessarily be interpreted as a treatment response on the individual patient level.

Table:

First periodBoth periodsSSc-ILD (n=240)ILD progression (n=69)ILD progression (n=21)Stable ILD (n=115)Age, years (SD)48 (14.7)49 (13.8)50 (14.3)46 (15.3)Male, n (%)57 (24)18 (26)5 (24)27 (24)Disease duration yrs, mean (SD)10.2 (11.4)9.8 (10.2)8.8 (11.0)10.8 (12.3)Disease duration <3 years, n (%)68 (28)22 (32)8 (38)29 (25)Diffuse cutaneous SSc, n (%)95 (40)30 (44)11 (52)43 (27)Anti-topoisomerase I Ab, n (%)84 (35)27 (40)9 (43)42 (37)mRSS, mean (SD)10 (9.3)11 (10.2)16 (13.0)8 (8.3)CRPml, mean (SD)3.6 (7.2)3.3 (6.2)4.4 (9.1)3.1 (5.1)GERD, n (%)148 (62)44 (64)15 (74)70 (61)FVC % predicted90 (20.3)90 (21.9)92 (21.7)89 (19.3)DLCO% predicted64 (17.9)64 (16.6)70 (11.3)65 (17.5)Lung fibrosis >20%, n (%)55 (23)16 (23)4 (19)27 (24)Mycophenolate Mofetil, n (%)47 (20)15 (22)5 (24)23 (20)Other immunosuppression, n (%)79 (33)22 (32)9 (43)42 (37)Corticosteroids, n (%)62 (26)18 (26)8 (38)28 (24)

Disclosure of Interests:

Anna-Maria Hoffmann-Vold Grant/research support from: Boehringer Ingelheim, Consultant of: Boehringer Ingelheim, Actelion, Bayer, GlaxoSmithKline, Speakers bureau: Boehringer Ingelheim, Actelion, Roche, Håvard Fretheim: None declared, Britta Maurer Grant/research support from: AbbVie, Protagen, Novartis, congress support from Pfizer, Roche, Actelion, and MSD, Speakers bureau: Novartis, Mike Durheim Grant/research support from: BI, Consultant of: BI, Speakers bureau: BI, Øyvind Midtvedt: None declared, Mike O. Becker: None declared, Rucsandra Dobrota: None declared, Øyvind Molberg: None declared, Suzana Jordan: None declared, Oliver Distler Grant/research support from: Grants/Research support from Actelion, Bayer, Boehringer Ingelheim, Competitive Drug Development International Ltd. and Mitsubishi Tanabe; he also holds the issued Patent on mir-29 for the treatment of systemic sclerosis (US8247389, EP2331143)., Consultant of: Consultancy fees from Actelion, Acceleron Pharma, AnaMar, Bayer, Baecon Discovery, Blade Therapeutics, Boehringer, CSL Behring, Catenion, ChemomAb, Curzion Pharmaceuticals, Ergonex, Galapagos NV, GSK, Glenmark Pharmaceuticals, Inventiva, Italfarmaco, iQvia, medac, Medscape, Mitsubishi Tanabe Pharma, MSD, Roche, Sanofi and UCB, Speakers bureau: Speaker fees from Actelion, Bayer, Boehringer Ingelheim, Medscape, Pfizer and Roche

OP0252 CIRCULATING COLLAGEN TURNOVER MARKERS ARE SPECIFICALLY CHANGED IN VERY EARLY SYSTEMIC SCLEROSIS

Background:

Timely diagnosis of patients with very early systemic sclerosis (veSSc) is essential for their personalized and optimal management. We hypothesise that changes in serum-based extracellular matrix (ECM) turnover biomarkers are already detectable in patients with veSSc, even before occurrence of specific clinical signs.

Objectives:

To investigate circulating ECM turnover markers as potential biomarkers for veSSc.

Methods:

Patients with veSSc, n=42, defined as presence of Raynaud’s syndrome and at least one of puffy fingers, positive antinuclear antibodies or pathological nailfold capillaroscopy, who did not meet any classification criteria for SSc, were compared to healthy controls (HC, n=29). Longitudinal assessment, data and sera collection were conducted by EUSTAR standards. ECM-degradation (BGM, C3M, C4M, C6M) and ECM-formation biomarkers (PRO-C3, PRO-C4, PRO-C5) were measured in serum using ELISA assays. The statistical analyses included Mann-Whitney U, Spearman correlation and ROC analysis. Using Kaplan-Meier plots and univariable Cox regression, we explored if biomarkers can predict progression towards definite SSc (fulfillment of ACR/EULAR criteria or minimum two points increase in the criteria score) during the longitudinal follow-up.

Results:

Compared to HC, veSSc patients showed a deregulated turnover of type III and IV collagen, with higher degradation (higher C3M, C4M, both p<0.0001 and PRO-C3, p=0.004, Figure 1a, resulting in lower turnover ratios PRO-C3/C3M and PRO-C4/C4M, both p<0.0001). The biglycan degradation biomarker BGM was also higher in veSSc (p=0.006), whereas the degradation biomarker for type VI collagen, C6M, was lower than in HC (p=0.002). In the ROC analysis, biomarkers of type III and IV collagen distinguished between veSSc and HC: C3M, AUC=0.95, p<0.0001; C4M, AUC=0.97, p<0.0001; turnover ratios PRO-C3/C3M, AUC=0.80, p<0.0001; PRO-C4/C4M, AUC=0.97; p<0.0001 (Figure 1b).

Median follow up was 4.5 years (range 0.5-7.9 years), mean age was 50±2.2 years, 88% female gender, 24% with puffy fingers, 92% were ANA positive, 64% had an abnormal capillaroscopy, none had organ involvement or skin fibrosis. 14/42 veSSc patients fulfilled the ACR/EULAR classification criteria at follow-up (time to fulfilment of criteria ranged between 0.5 and 6.8 years from inclusion) and in addition, 18/42 veSSc patients gained at least two classification criteria-points. This resulted in 14, respectively 18 progressors for the longitudinal analysis. However, in univariable Cox regression, the baseline levels of the markers did not predict progression over time.

Conclusion:

ECM turnover is already altered in veSSc patients compared to HC. Biomarkes of type III and IV collagen distinguished between veSSc patients and HC, which may indicate them as potential biomarkers for the detection of veSSc in addition to the established immunological and capillaroscopic criteria.

Disclosure of Interests:

Rucsandra Dobrota: None declared, Suzana Jordan: None declared, Pernille Juhl Employee of: Nordic Bioscience, Britta Maurer Grant/research support from: AbbVie, Protagen, Novartis, congress support from Pfizer, Roche, Actelion, and MSD, Speakers bureau: Novartis, Mike O. Becker: None declared, Carina Mihai: None declared, Anne-Christine Bay-Jensen Shareholder of: Nordic Bioscience A/S, Employee of: Full time employee at Nordic Bioscience A/S., Morten Karsdal Shareholder of: Nordic Bioscience A/S., Employee of: Full time employee at Nordic Bioscience A/S., Anne Sofie Siebuhr Employee of: Nordic Bioscience, Oliver Distler Grant/research support from: Grants/Research support from Actelion, Bayer, Boehringer Ingelheim, Competitive Drug Development International Ltd. and Mitsubishi Tanabe; he also holds the issued Patent on mir-29 for the treatment of systemic sclerosis (US8247389, EP2331143)., Consultant of: Consultancy fees from Actelion, Acceleron Pharma, AnaMar, Bayer, Baecon Discovery, Blade Therapeutics, Boehringer, CSL Behring, Catenion, ChemomAb, Curzion Pharmaceuticals, Ergonex, Galapagos NV, GSK, Glenmark Pharmaceuticals, Inventiva, Italfarmaco, iQvia, medac, Medscape, Mitsubishi Tanabe Pharma, MSD, Roche, Sanofi and UCB, Speakers bureau: Speaker fees from Actelion, Bayer, Boehringer Ingelheim, Medscape, Pfizer and Roche

SAT0310 ANTI-CENTROMERE ANTIBODY ISOTYPE LEVELS AS BIOMARKER FOR DISEASE PROGRESSION IN SUBJECTS AT RISK TO DEVELOP SYSTEMIC SCLEROSIS

Background:

Presence of anti-centromere antibodies (ACA) generally associates with a better prognosis than many other systemic sclerosis (SSc) associated autoantibodies. However, presentation of the disease can be very heterogeneous and prediction of the disease course is challenging. Some older studies suggest a possible association between clinical characteristics and isotypes of ACA in patients with SSc. It is unknown whether ACA can serve as biomarker for future SSc development.

Objectives:

To evaluate the clinical course of very early SSc and to assess whether ACA isotype levels can identify subjects that will progress to definite SSc.

Methods:

ACA IgG+ patients with very early SSc (defined as presence of ACA IgG AND Raynaud and/or puffy fingers and/or abnormal nailfold capillaroscopy but not fulfilling ACR 2013 criteria) from five prospective SSc cohorts (Leiden, Zurich, Oslo, Bordeaux, Ghent) were included. Presence and levels of ACA IgG, IgM and IgA were determined at first clinical assessment and clinical course was evaluated annually. Disease progression to definite SSc, which was defined as fulfillment of the ACR 2013 criteria for SSc, and included any development of: digital ulcers (DU), interstitial lung disease (ILD) assessed by high resolution chest tomography, pulmonary arterial hypertension assessed by right heart catheterization, gastro-intestinal involvement, renal crisis or myocardial involvement was determined. ACA response characteristics were compared between very early SSc patients that progressed to definite SSc and those who did not. Logistic regression was performed to determine whether ACA response characteristics can predict progression to definite SSc, with adjustment for age and follow-up duration.

Results:

In total 92 subjects were included with median follow-up (FU) of 3 years (table 1); 39% progressed to definite SSc, mostly based on the development of skin involvement (77%). Twenty-three percent of patients developed lung involvement, 11% DU, 17% gastro-intestinal involvement and 4% myocardial involvement. Progression on more than one organ system was present in 31% of the very early SSc patients. In the multivariable logistic regression, with adjustment for age and follow-up duration, ACA IgG levels at baseline were significantly associated with progression to definite SSc (OR 3.0 (1.1-8.8)). Likewise, a trend was observed for higher ACA IgM levels (OR 1.8 (0.9-3.5)) in the very early SSc patients progressing to definite SSc (figure 1).

Table 1.

Baseline characteristics and ACA isotype levels in patients with very early SSc, and between progressors and non-progressors. * p value < 0.05.

Progressors(n=35)Non-progressors(n=57)Female, n(%)32 (91)50 (91)Age, mean (SD)56 (14)53 (13)Disease duration since non Raynaud phenomenon, median(IQR) in years3 (0.8-10)2 (0.6-7)Follow-up duration in years, median (IQR)4 (2-6)2 (1-3)*Abnormal Nailfold videocapillaroscopy, n(%)17 (65)27 (60)IgA level [aU/mL], median (IQR)63 (34-120)75 (35-144)IgM level [aU/mL], median (IQR)131 (32-585)79 (18-391)IgG level [U/mL], median (IQR)342 (162-720)195 (93-488)*

Conclusion:

In this study we illustrate that 39% of the ACA positive very early SSc subjects progress to definite SSc within median 4 years. We identified higher ACA IgG level as a predictive biomarker for progression to definite SSc indicating that it might be a useful biomarker for risk stratification in clinical practice.

Disclosure of Interests:

Nina van Leeuwen: None declared, Jaap Bakker: None declared, Annette Grummels: None declared, Corrie Wortel: None declared, Suzana Jordan: None declared, Sophie Liem: None declared, Oliver Distler Grant/research support from: Grants/Research support from Actelion, Bayer, Boehringer Ingelheim, Competitive Drug Development International Ltd. and Mitsubishi Tanabe; he also holds the issued Patent on mir-29 for the treatment of systemic sclerosis (US8247389, EP2331143)., Consultant of: Consultancy fees from Actelion, Acceleron Pharma, AnaMar, Bayer, Baecon Discovery, Blade Therapeutics, Boehringer, CSL Behring, Catenion, ChemomAb, Curzion Pharmaceuticals, Ergonex, Galapagos NV, GSK, Glenmark Pharmaceuticals, Inventiva, Italfarmaco, iQvia, medac, Medscape, Mitsubishi Tanabe Pharma, MSD, Roche, Sanofi and UCB, Speakers bureau: Speaker fees from Actelion, Bayer, Boehringer Ingelheim, Medscape, Pfizer and Roche, Anna-Maria Hoffmann-Vold Grant/research support from: Boehringer Ingelheim, Consultant of: Boehringer Ingelheim, Actelion, Bayer, GlaxoSmithKline, Speakers bureau: Boehringer Ingelheim, Actelion, Roche, Karin Melsens: None declared, Vanessa Smith Grant/research support from: The affiliated company received grants from Research Foundation - Flanders (FWO), Belgian Fund for Scientific Research in Rheumatic diseases (FWRO), Boehringer Ingelheim Pharma GmbH & Co and Janssen-Cilag NV, Consultant of: Boehringer-Ingelheim Pharma GmbH & Co, Speakers bureau: Actelion Pharmaceuticals Ltd, Boehringer-Ingelheim Pharma GmbH & Co and UCB Biopharma Sprl, Marie-Elise Truchetet: None declared, Hans Ulrich Scherer Grant/research support from: Bristol Myers Squibb, Sanofi, Pfizer, Speakers bureau: Pfizer, Lilly, Roche, Abbvie, Rene Toes: None declared, Thomas Huizinga Grant/research support from: Ablynx, Bristol-Myers Squibb, Roche, Sanofi, Consultant of: Ablynx, Bristol-Myers Squibb, Roche, Sanofi, Jeska de Vries-Bouwstra: None declared

FRI0267 CLINICAL CORRELATES AND RELEVANCE OF UCLA GIT 2.0 FOR ESOPHAGITIS AND INDICATION FOR ESOPHAGOGASTRODUODENOSCOPY IN REAL-LIFE PATIENTS WITH SYSTEMIC SCLEROSIS

Background:

The gastrointestinal (GI) tract is frequently involved in systemic sclerosis (SSc). The University of California Los Angeles Scleroderma Clinical Trial Consortium Gastrointestinal Tract Instrument 2.0 (UCLA GIT 2.0) is validated to capture GI morbidity in patients with SSc (1). The routine clinical investigation of GI involvement in these patients is not standardized and there is no consensus about when and how frequently an esophagogastroduodenoscopy (EGD) should be performed.

Objectives:

The main aim of this study was to analyze the capacity of UCLA GIT 2.0 to identify patients with erosive esophagitis in an unselected, real-life SSc patients’ cohort. Secondary aim was to determine whether the UCLA GIT 2.0 could discriminate SSc patients for whom an expert rheumatologist would recommend an EGD.

Methods:

We selected patients fulfilling the ACR/EULAR 2013 criteria for SSc from the Zurich cohort, having completed at least once the UCLA GIT 2.0 questionnaire. We reviewed the medical charts of SSc patients from 2013 to 2019 and recorded data on EGD. We analyzed by univariable logistic regression several parameters, including UCLA GIT 2.0, considered as potentially associated with 1) the referral to EGD and 2) macroscopic esophagitis according to the Los Angeles criteria.

Results:

We identified 346 patients (82.7% female, median age 63 years, median disease duration 10 years, 23% with diffuse cutaneous SSc) satisfying the inclusion criteria, who filled in 940 UCLA GIT 2.0 questionnaires.

From 940 visits, 31 were excluded because EGD was done within 3 months before completing the UCLA GIT 2.0. In the 909 remaining visits, EGD was recommended by the expert rheumatologists in 128 cases. In logistic regression, UCLA GIT 2.0 total score and some of its subscales, but also the modified Rodnan skin score (mRSS) and esophageal and stomach symptoms by past medical history, associated with the referral to EGD (Table 1).

Table 1.

Logistic regression of factors associated with referral to EGD

OR (95% CI)p-valuemRSS1.04 (1.01 - 1.06)0.009Hemoglobin (Hb)1.00 (0.96 - 1.04)0.978Proton pump inhibitor (PPI)0.37 (0.12 - 1.15)0.086Esophageal symptoms3.37 (2.28 - 4.96)<0.001Stomach symptoms2.93 (2.02 - 4.26)<0.001Reflux subscale2.04 (1.52 - 2.73)<0.001Distention/bloating subscale1.53 (1.24 - 1.89)<0.001Social functioning2.20 (1.57 - 3.07)<0.001Emotional wellbeing1.42 (1.03 - 1.97)0.034Total score of UCLA GIT 2.02.27 (1.55 - 3.32)<0.001

We found data on 177 EGD performed in 150 patients, meaning that 49 EGD were performed on indication by another physician. In logistic regression, mRSS and esophageal symptoms correlated with esophagitis, while neither the total ULCA GIT 2.0 score nor the reflux subscale or any of the other subscales showed an association with esophagitis (Table 2).

Table 2.

Logistic regression of factors associated with esophagitis

OR (95% CI)p-valuemRSS1.09 (1.03 - 1.15)0.001Hb1.03 (0.99 - 1.06)0.126PPI0.52 (0.27 - 1.03)0.059Esophageal symptoms2.92 (1.29 - 6.61)0.010Stomach symptoms1.60 (0.80 - 3.21)0.183Reflux subscale1.07 (0.60 - 1.93)0.816Distention/Bloating subscale0.63 (0.39 - 1.01)0.054Social functioning0.65 (0.31 - 1.35)0.245Emotional wellbeing0.77 (0.36 - 1.61)0.483Total score of UCLA GIT 2.00.67 (0.28 - 1.60)0.367

Conclusion:

In a real-life setting, UCLA GIT 2.0 subscales (reflux, distention/bloating, social functioning, emotional wellbeing) and total score strongly associated with expert interpretation of gastroesophageal symptoms and consecutive referral to EGD. However, they showed no correlation with esophagitis on EGD. The main clinical association of esophagitis was the presence of esophageal symptoms.

References:

[1]Khanna D, et al. Reliability and validity of the University of California, Los Angeles Scleroderma Clinical Trial Consortium Gastrointestinal Tract Instrument. Arthritis Rheum. 2009;61(9):1257-63.

Disclosure of Interests:

Norina Zampatti: None declared, Alexandru Garaiman: None declared, Suzana Jordan: None declared, Mike O. Becker: None declared, Britta Maurer Grant/research support from: AbbVie, Protagen, Novartis, congress support from Pfizer, Roche, Actelion, and MSD, Speakers bureau: Novartis, Rucsandra Dobrota: None declared, Oliver Distler Grant/research support from: Grants/Research support from Actelion, Bayer, Boehringer Ingelheim, Competitive Drug Development International Ltd. and Mitsubishi Tanabe; he also holds the issued Patent on mir-29 for the treatment of systemic sclerosis (US8247389, EP2331143)., Consultant of: Consultancy fees from Actelion, Acceleron Pharma, AnaMar, Bayer, Baecon Discovery, Blade Therapeutics, Boehringer, CSL Behring, Catenion, ChemomAb, Curzion Pharmaceuticals, Ergonex, Galapagos NV, GSK, Glenmark Pharmaceuticals, Inventiva, Italfarmaco, iQvia, medac, Medscape, Mitsubishi Tanabe Pharma, MSD, Roche, Sanofi and UCB, Speakers bureau: Speaker fees from Actelion, Bayer, Boehringer Ingelheim, Medscape, Pfizer and Roche, Carina Mihai: None declared

Combined Heart and Kidney Transplantation: Clinical Experience in 100 Consecutive Patients

Background

Combined heart and kidney transplantation (HKTx) is performed in patients with severe heart failure and advanced renal insufficiency. We analyzed the long‐term survival after HKTx, the influence of age and dialysis status, the rates of cardiac rejection, and the influence of sensitization.

Methods and Results

From June 1992 to December 2016, we performed 100 HKTx procedures. We compared older (≥60 years, n=53) with younger (<60 years, n=47) recipients, and recipients on preoperative dialysis (n=49) and not on dialysis (n=51). We analyzed actuarial freedom from any cardiac rejection, acute cellular rejection, and antibody‐mediated rejection, and survival rates by sensitized status with panel‐reactive antibody levels <10%, 10% to 50%, and >50%, and compared these survival rates with those from the United Network for Organ Sharing database. There was no difference in 15‐year survival between the 2 age groups (35±12.4% and 49±17.3%, ≥60 versus <60 years; P=0.45). There was no difference in 15‐year survival between the dialysis and nondialysis groups (44±13.4% and 37±15.2%, P=0.95). Actuarial freedom from any cardiac rejection (acute cellular rejection>0 or antibody‐mediated rejection>0) was 92±2.8% and 84±3.8%, acute cellular rejection (≥2R/3A) 98±1.5% and 94±2.5%, and antibody‐mediated rejection (≥1) 96±2.1% and 93±2.6% at 30 days and 1 year after HKTx. There was no difference in the 5‐year survival among recipients by sensitization status with panel‐reactive antibody levels <10%, 10% to 50%, and >50% (82±5.9%, 83±10.8%, and 92±8.0%; P=0.55). There was no difference in 15‐year survival after HKTx between the United Network for Organ Sharing database and our center (38±3.2% and 40±10.1%, respectively; P=0.45).

Conclusions

HKTx is safe to perform in patients 60 years and older or younger than 60 years and with or without dialysis dependence, with excellent outcomes. The degree of panel‐reactive antibody sensitization did not appear to affect survival after HKTx.

Association between pelvic inflammatory disease, infertility, ectopic pregnancy and the development of ovarian serous borderline tumor, mucinous borderline tumor and low-grade serous carcinoma

OBJECTIVE

Risk factors for ovarian borderline tumors and low-grade serous carcinoma (LGSC) are poorly understood. The aim of this study was to examine the association between infertility, pelvic inflammatory disease (PID), endometriosis, ectopic pregnancy, hysterectomy, tubal ligation and parity and the risk of serous borderline tumor (SBT), mucinous borderline tumor (MBT) and LGSC.

METHODS

This was a population-based cohort study using linked administrative and hospital data. Participants were 441,382 women born between 1945 and 1975 who had been admitted to hospital in Western Australia between 1 January 1980 and 30 June 2014. We used Cox regression to estimate hazard ratios (HRs).

RESULTS

We observed an increased rate of SBT associated with infertility, PID and ectopic pregnancy (HRs and 95% CIs were, respectively, 1.98 (1.20-3.26); 1.95 (1.22-3.10) and 2.44 (1.20-4.96)). We did not detect an association between any of the factors under study and the rate of MBT. A diagnosis of PID was associated with an increased rate of LGSC (HR 2.90, 95% CI 1.21-6.94).

CONCLUSIONS

The association with PID supports the hypothesis that inflammatory processes within the upper gynaecological tract and/or peritoneum may predispose to the development of SBT and LGSC.

Co-Creation in participatory epidemiology

Background

Participatory epidemiology aims to involve public health professionals, health activists, and community representatives in epidemiological studies. Paramount are equitable research partnerships for identifying the causes of health problems, generating data, and finding ways to address health related issues. Alongside the research process, co-creation informs various aspects of participatory epidemiology.

Methods

A scoping review was conducted to develop the conceptual foundations of participatory epidemiology. Workshops with staff from public health administration and public health practitioners were held to check feasibility of the concept for public health monitoring, policy making and the development of relevant public health recommendations. From this research, principles and practices of co-creation were identified.

Results

Co-creation is of importance for participatory epidemiology. 1) Methodologically: Co-creation asks to apply multiple perspectives (research, practice, communities) in data collection and synthesis, what may require the adaption of a given study design. 2) Research practice: Co-creation in participatory epidemiology means producing epidemiologic evidence while contributing to concrete public health interventions, two goals that have to be balanced. 3) Personal attitudes: In participatory epidemiology academic researchers, practitioners, and community representatives are requested to acknowledge each other as co-researching partners, which can be challenging for each of them.

Conclusions

Co-creation is a prerequisite for establishing equitable research partnerships. In participatory epidemiology, co-creation offers ways to produce meaningful knowledge for research and practice.

Main messages

Participatory epidemiology offers ways of producing epidemiologic evidence while contributing to public health practice. Co-creation is a prerequisite, way, and attitude to conduct meaningful research, hopefully for all of those who are involved.