Early spondyloarthritis: results from the pilot registry ESPIDEP

OBJECTIVES

Studies on the incidence of spondyloarthritis (SpA) are scarce. Early SpA clinics should facilitate the detection of new cases as well as to decrease the diagnosis and treatment delay. However, the workload of such clinics has not been estimated.

METHODS

ESPIDEP is a pilot registry of patients with early SpA performed in Madrid, Spain. General practitioners (GPs) agreed and were trained to refer all patients under 45 with either inflammatory back pain or asymmetric arthritis of lower limbs with 3 to 24 month duration of symptoms to a specialised unit during 6 consecutive months. Case definition of SpA was based on the ESSG criteria. The success of the program was measured by: the satisfaction of the GPs regarding the referral process, the percentage of patients correctly derived according to the rheumatologist, the expected incidence of AS.

RESULTS

From a population of 111,941, the unit attended 52 patients, of whom 43 (83%) had been derived correctly and 35 were diagnosed with SpA (49% women; mean age 33+/-8; mean duration of symptoms 11+/-6 months; 46% HLA-B27 positive). The annual estimated incidence of SpA was 62.5 cases per 100,000 (95% CI: 45-87). Only 20/35 (57%) had radiological sacroiliitis and 4 (11.8%) fulfilled the modified New York criteria for ankylosing spondylitis (annual estimated incidence 7.2 per 100,000 (IC95%: 3.1-14.1)).

CONCLUSIONS

Around 60 cases of early SpA are expected annually in an area of 100,000. A referral based upon clinical parameters seems efficient. The planning of early SpA clinics may be based upon these figures.

Androgen deprivation therapy and cognitive decline in the NEON-PC study

Background/Objective

Androgen deprivation therapy (ADT) has been associated with cognitive decline, but results have been heterogenous. We describe changes in cognitive performance in patients with prostate cancer (PCa), according to treatment with ADT, during the 1st year after PCa diagnosis.

Methods

Between February 2018 and March 2021, 348 patients with PCa treated at the Instituto Português de Oncologia do Porto were evaluated with the Montreal Cognitive Assessment (MoCA), before treatment and after one year (1y). ADT was used in 183 participants, and 165 were treated without ADT (total prostatectomy, radiotherapy, brachytherapy, active surveillance). Cognitive decline was defined as the decrease in MoCA from baseline to the 1y-evaluation below 1.5SD of the distribution of the MoCA variation in the whole cohort. Participants scoring below age- and education-based normative reference values in MoCA were considered to have probable cognitive impairment (PCI). Multivariate logistic regression was used to estimate age- and education-adjusted OR (aOR) of the association between ADT and cognitive decline/incident PCI.

Results/Discussion

PCI was observed in 12.4% of the patients at baseline. Mean MoCA scores increased from baseline to the 1y-evaluation (22.4 vs. 22.9, p = 0.001), and 51.2% of PCI cases at baseline had normal MoCA scores at 1y. Cognitive decline was most frequent in the ADT group (9.3% vs. 3.6%, p = 0.034), although the aOR was 2.44 (95%CI:0.89-6.71). The 1yr cumulative incidence of PCI was 10.4% (95%CI:6.2%-16.2%) in the ADT-group and 2.8% (95%CI:0.8-%-7.1%) in the non-ADT group [aOR=3.15 (95%CI:0.97-10.25)].

Conclusions

ADT was associated with a decrease in the cognitive performance of PCa patients during the 1st year after diagnosis. The completion of the 1y-evaluation in the whole cohort (n = 600) is needed to confirm these preliminary results.

Funding

POCI-01-0145FEDER-032358;PTDC/SAU-EPI/32358/2017; UIDB/4750/2020;SFRH/BD/119390/2016

Key messages

Half of the cases with cognitive impairment at baseline improved at one-year. Patients treated with ADT seem to be affected by cognitive decline more frequently.

Disproportionate functional mitral regurgitation: clinical validation of a new conceptual framework

Background

Disproportionate functional mitral regurgitation (FMR) is a novel concept that tries to identify hemodynamically significant FMR by readjusting the effective regurgitant orifice area (EROA) and regurgitant volume (RegVol) cut-offs according to left ventricular end-diastolic volume (LVEDV) and left ventricular ejection fraction (LVEF). However, this theoretical concept lacks clinical validation. The aim of this study was to assess the clinical significance of disproportionate FMR.

Methods

Patients with at least mild FMR and reduced LVEF (<50%) who underwent transthoracic echocardiography between 2010 and 2014 were retrospectively identified in our laboratory database. Optimal medical therapy (including cardiac resynchronization when indicated) for ≥3 months was a prerequisite for inclusion. Hemodynamically significant FMR was defined as regurgitant fraction >50% and the patient-specific theoretical RegVol cut-off was calculated according to the formula presented in Fig. 1a. The difference between the estimated RegVol by the PISA method and the theoretical RegVol cut-off was considered to represent the haemodynamic burden of MR. The primary endpoint was all-cause death. Patients were censured if mitral intervention or heart transplant was undertaken. Survival analysis was used to assess the effect of disproportionate FMR on mortality in 2 subgroups (LVEF <30% and 30–49%).

Results

A total of 289 patients (median age 69 years [IQR 60–77], 75% male, 53% of ischemic aetiology) were included. More than 90% were on beta-blockers and renin-angiotensin inhibitors, 44% on aldosterone receptor antagonists, and 73% had implanted devices. The median LVEF and LVEDV were 34% (IQR 27–41) and 170mL (IQR 128–220), respectively. Median EROA was 10mm2 (IQR 3–21) and RegVol was 15 mL (IQR 4–30). RegVol distribution across the cohort was: <10mL: 41%; 10–20mL: 18%; 20–30mL: 15% and >30mL: 26%. Disproportionate FMR was present in 83 patients (29%). These patients had significantly higher SPAP values (41mmHg [IQR 33–50] vs. 33mmHg [IQR 29–40]; p<0.001).

During a median follow-up of 44 months (IQR 19–73), 106 patients died. In the LVEF <30% subgroup, age (HR 1.05 per year [1.02–1.08]; p<0.001), LVEF (HR 0.94 per 1% [0.89–0.99]; p=0.042) and TAPSE (HR 0.92 per mm [0.86–0.99]; p=0.030) were independent predictors of mortality. In the LVEF 30–49% subgroup, age (HR 1.05 per year [1.02–1.08]; p=0.003), LVEF (HR 0.94 per 1% [0.89–0.99]; p=0.020) and disproportionate FMR (HR 1.02 per mL [1.01–1.03]; p=0.01) were independently associated with increased mortality.

Conclusions

Disproportionate FMR proved to be an important independent predictor of mortality in patients with LVEF between 30–49%. These findings were not replicated in those with LVEF<30%, where the degree of biventricular dysfunction seems to outweigh all other echocardiographic parameters, leaving FMR as a bystander.

Figure 1

Funding Acknowledgement

Type of funding source: None

Looking beyond left ventricular ejection fraction – a new multiparametric CMR score to refine the prognostic assessment of HF patients

Background

Cardiac magnetic resonance (CMR) is recommended in Heart Failure (HF) to assess myocardial structure and function. Recently, the quantification of pulmonary congestion and skeletal muscle mass using CMR have been shown to predict adverse events in HF, but a tool integrating this information is currently unavailable. The purpose of this study was to develop and test a new multiparametric CMR-derived score.

Methods

We conducted a single-center retrospective study of consecutive HF patients with left ventricular ejection fraction (LVEF) <50% who underwent CMR. Several CMR parameters with known prognostic value were assessed, including: LVEF, Lung Water Density (LWD), Pectoralis Major Muscle (PMM) area, and presence of Late Gadolinium Enhancement. PMM area was outlined at the level of the carina – Figure 1A, B – and LWD was defined as the lung-to-liver signal ratio multiplied by 0.7, as previously described. Both parameters were measured in standard HASTE images - Figure 1C. The primary endpoint was a composite of all-cause death or HF hospitalization. Using the Cox regression Hazard Ratios of designated variables, a risk score was developed.

Results

Overall, 436 patients were included. During a median follow-up of 27 (17–37) months, 43 (9.9%) patients died and 57 (13.2%) had at least one hospitalization for HF. LVEF, LWD and PMM were independent predictors of the primary endpoint and were included in the CMR-HF score – Figure 2. The annual rate of events increased from 4.7 to 7.5 and 20.0% from lowest to highest tertile of the score. Roughly half of the events (54%) occurred in patients in the highest tertile of the CMR-HF score. In multivariate analysis, the new score independently predicted the primary endpoint (HR per 5 points: 1.54; 95% CI: 1.21–1.97; p<0.001) even after adjustment for age, body mass index, NYHA class, NT-proBNP, estimated glomerular filtration rate, presence of implantable cardioverter-defibrillator, and ischemic etiology.

Conclusions

This novel multidimensional CMR-HF score, combining easily obtainable data on left ventricular pump failure, lung congestion and muscular wasting, is a promising tool identifying HF patients with an LVEF <50% at higher risk of death or HF hospitalization.

Funding Acknowledgement

Type of funding sources: None.

[Superficial siderosis of the central nervous system]

We report five cases of superficial siderosis of the central nervous system. All patients developed progressive deafness and cerebellar ataxia associated with pyramidal tract signs or mental deterioration. The cerebrospinal fluid examinations usually revealed an elevated protein level, without other abnormalities. Magnetic resonance imaging typically showed a hypointense rim around the cerebral and cerebellar hemispheres, the brainstem and the spinal cord on T2-weighted images. A definite source of bleeding was only found in two patients. The literature on superficial siderosis is reviewed. The etiologies and the pathogenesis are discussed.

Tc45, a dimorphic Trypanosoma cruzi immunogen with variable chromosomal localization, is calreticulin

We demonstrate that Tc45, a polypeptide described as an immunogenetically restricted Trypanosoma cruzi antigen in mice, is calreticulin, a dimorphic molecule encoded by genes with variable chromosomal distribution. Previously we showed that IgG from A.SW (H2s) mice immunized with T. cruzi trypomastigotes or epimastigotes and sera from infected humans recognize Tc45, a 45 kD parasite polypeptide. Herein we describe the cloning, sequencing, and expression of the Tc45 gene. A 98% homology in the deduced amino acid sequence was found with a T. cruzi calreticulin-like molecule and 41% with Leishmania donovani and human calreticulin. In the T. cruzi CL Brener clone and in the Tulahuén strain, the gene is located in two and four chromosomes, respectively. Calreticulin was detected in several T. cruzi clones, in the Tulahuén strain, and in T. rangeli, displaying alternative 43 and 46 kD forms.

Mechanism of escape of exoerythrocytic forms (EEF) of malaria parasites from the inhibitory effects of interferon-gamma

We have studied the mechanism of inhibition by interferon-gamma (IFN-gamma) of the development of exoerythrocytic forms (EEF) of Plasmodium berghei in the livers of rats. At the time corresponding to the maximum development of EEF (44 hr after injection of sporozoites), the livers of the IFN-gamma-treated rats contained less parasite DNA as compared with controls. Twenty-four to 72 hr later, the livers of both groups of animals were free of parasites; that is, IFN-gamma treatment does not delay the development of the EEF. The decrease in parasite DNA observed in the IFN-gamma-treated rats was due to a diminution in the number, but not the size, of EEF. It appears, therefore, that treatment with the lymphokine either destroys the parasites or does not affect their replication. To study the mechanism of resistance to IFN-gamma of a small population of EEF, we subjected the parasites to four cycles of selection by IFN-gamma. The parasites from the "selected" and "nonselected" populations were equally susceptible to inhibition by IFN-gamma, indicating that the escape from IFN-gamma activity is not inherited.

P955Non-invasive mapping: what is the minimal number of electrodes needed to obtain a good spatial resolution of the activation map?

Introduction and aims

The 12-lead ECG is highly inaccurate for localization of the site of origin of supraventricular and ventricular arrhythmias.  Non-invasive mapping systems (ECGI) based on a high number of electrodes recording the electrical activity on the surface of the torso have already proven good accuracy for mapping different arrhythmic substrates. The aim of this study was to assess what is the minimal number of leads needed to obtain a precise mapping with the ECGI.

Methods

This study enrolled 14 patients (9 male, median age 50 (44-58) years) referred to our center for catheter ablation of premature ventricular contractions (PVC). Patients underwent pre-procedural ECGI using the epicardial and endocardial mapping system . This system uses the DICOM images from contrast computed tomography of the heart and up to 28 adhesive electrodes with 8 leads each, adding up to 224 body-surface leads. All patients underwent invasive electroanatomical mapping and ablation with the magnetic navigation system. We analysed the number of recording leads used to construct the non-invasive activation map of the PVCs and the accuracy and the spatial resolution of the map when comparing to the invasive map. We then reprocessed the exam, using progressively less leads until we only left the leads placed in the standard 12 lead ECG positions and evaluated the concordance with the invasive map as well as the spatial resolution. We considered an earliest activation site (EAS) area of 1 cm2 a good spatial resolution and using a ROC curve we calculated the minimal number of leads necessary to obtain a good spatial resolution.

Results

The median number of electrodes used for the initial map was 170 (138-177). Concordance between non-invasive and invasive site of origin occurred in 11 out of 14 patients. The results are presented in the Table. The minimal number of electrodes to have a good spatial resolution was 100. The area of EAS was significantly lower when using more than 100 leads, respectively 0.65 (0.5-1) cm2 versus 3 (1.6-5) cm2, p < 0.001.

Conclusions

The minimal number of leads to achieve a good spatial resolution was high.  Reducing the number of leads resulted in a significant decrease in spatial resolution and a lower concordance rate.

ECGI data Number of adhesive electrodes Median number of leads Amycard/Carto concordance Median area of EAS in the ECGI (cm2) Maximal nº electrodes 170 (138-177) 11/14 0.64 (0.5-0.9) 12 electrodes 76 (61-80) 11/14 1.6 (1.4-2.6) 6 electrodes (2 Ant, 2 Lat ,2 Post) 38 (32-44) 9/14 4.3 (3.2-5.4) 12 leads 12 0/14 - Ant anterior; Lat: lateral; Post: posterior; EAS: early activation site.

Abstract Figure. Area of EAS according to the N of leads